Radiochemotherapeutische Optionen beim Harnblasenkarzinom

Zusammenfassung

Die Standardbehandlung des muskelinvasiven Harnblasenkarzinoms ist die radikale Zystektomie, während beim oberflächlichen „high-risk”-Karzinom zunächst die organerhaltende Therapie mit einer Kombination aus transurethraler Resektion (TUR) gefolgt von einer intravesikalen Instillation empfohlen wird. Der Übersichtartikel fasst die radiochemotherapeutischen (RCT) Optionen bei oberflächlichen und muskelinvasiven Urothelkarzinomen – als Alternative zu oder als neoadjuvante Ergänzung der rein operativen Therapieverfahren – zusammen: Die Kombination von TUR und moderner RCT ermöglicht bei „high-risk”-T1-Tumoren Rezidiv- und Progressionsraten in einer Größenordnung von 30 % bzw. 15 %. Für muskelinvasive Tumoren sind die Überlebensraten im nicht-randomisierten Vergleich denen der primären Zystektomie vergleichbar. Etwa 80 % der überlebenden Patienten behalten jedoch ihre eigene Blase. Voraussetzung ist jedoch ein eingespieltes interdisziplinäres Team, das die jeweiligen Bausteine der multimodalen Behandlung mit hoher Qualität und zeitlich aufeinander abgestimmt einsetzt. Integraler Bestandteil ist dabei die Salvage-Zystektomie bei Nonrespondern und bei invasiven Rezidiven. Ideale Kandidaten für den Organerhalt sind Patienten mit frühen Tumorstadien (T1/2) und unifokalen Tumoren. Bei lokal weit fortgeschrittenen Tumoren (≥ T3b/T4) ist das Konzept der präoperativen Radiochemotherapie vor geplanter Zystektomie Erfolg versprechend.

Abstract

Radical cystectomy remains the standard of care for muscle-invasive bladder cancer, while for high-risk superficial carcinoma an organ-preserving approach, including transurethral resection (TUR) and intravesical therapy, is recommended. This review summarizes the radiochemotherpeutic options for high risk T1 or muscle-invasive bladder cancer – as an alternative for/or neoadjuvant therapy before radical surgery. Multimodality therapy, including TUR, radiation, and chemotherapy, is associated with recurrence and progression rates of 30 % and 15 %, respectively, in high-risk T1 bladder cancer. For muscle-invasive disease, five-year survival rates in the range of 50 % to 60 % have been published, which is comparable to primary cystectomy series. Approximately 80 % of the surviving patients maintained their own, well functioning bladder. Close coordination among all disciplines is required to achieve optimal results. An integral part of the concept is salvage cystectomy for non-responders or muscle-invasive recurrences. Ideal candidates for the organ-preserving approach are those with early-stage unifocal tumours (T1/T2). Preoperative radiochemotherapy is likely to improve the results of cystectomy alone in patients with locally advanced bladder cancer (T3b, T4).

Schlüsselwörter

Harnblasenkarzinom - Organerhalt - Radiochemotherapie - Salvage-Zystektomie

Key words

bladder cancer - organ preservation - radiochemotherapy - salvage cystectomy

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