Die Radiochemotherapie im multimodalen Behandlungskonzept des Pankreaskarzinoms

Zusammenfassung

Wegen seiner nach wie vor schlechten Prognose bleibt das duktale Pankreaskarzinom weiterhin eine Herausforderung an multimodale Therapiekonzepte. Hierbei hat die Strahlentherapie, heute für gewöhnlich als simultane Radiochemotherapie (RCT) appliziert, ihren Platz zu definieren und zu behaupten. Dies verlangt nach interdisziplinär sorgfältig geplanten Therapiestudien, welche die Möglichkeiten der einzelnen Therapiebausteine sinnvoll einsetzten. Bisher ist leider die Datenlage bei der adjuvanten bzw. neoadjuvanten Therapie unbefriedigend. Nach einer R0-Resektion werden die Patienten in Europa überwiegend der adjuvanten Chemotherapie zugeführt. In Nordamerika ist aufgrund der GITSG- Daten die Radiochemotherapie Standard. Diese ist eine sinnvolle Behandlungsoption insbesondere bei Patienten mit Pankreaskopfkarzinom, pN1-Status und einem maximalen Tumordurchmesser von > als 3 cm. Zusätzlich sollte sie nach einer R1-Resektion empfohlen werden. Aufgrund des Fehlens prospektiv randomisierter Studien kann zur neoadjuvanten Radiochemotherapie derzeit noch nichts Abschließendes gesagt werden. Es ist jedoch zu erwarten, dass die neoadjuvante RCT zu einer Verbesserung des Gesamtüberlebens führt durch Steigerung der R0-Resektabilität, eine erhöhte ypN0-Rate und eine verbesserte lokale Tumorkontrolle. Bei lokal fortgeschrittenen Karzinomen ohne Fernmetastasen sind wohl die Überlebensraten nach RCT tendenziell besser als nach alleiniger Chemotherapie. Der wichtigste Punkt dabei ist, dass die RCT in 15 - 20 % der Fälle sekundär eine kurativ intendierte Tumorresektion ermöglicht. Mehr als bei anderen Tumoren bestimmt das Bestrahlungsvolumen die Verträglichkeit und damit Durchführbarkeit einer simultanen RCT. Das Zielvolumen umfasst den Primärtumor und die Lymphabflussgebiete peripankreatisch, trunkal, hepatoduodenal, mesenterial und interaortocaval bis zum Abgang der A. mesenterica inferior. Eine Gesamtdosis von 50 - 55 Gy wird in Einzelfraktionen von 1,8 - 2,0 Gy fraktioniert. Ungewöhnliche Toxizität tritt immer dann auf, wenn diese Regeln nicht ausreichend beachtet werden.

Summary

Ductal pancreatic carcinoma remains a challenge for multimodal therapeutic concepts because of its still dismal prognosis. Within this context the role of radiotherapy - usually administered as concurrent chemoradiation - has to be defined and to stand the test of time. This requires carefully planned trials that use the inherent power of each of the respective therapeutic modalities in a reasonable way. To date, the data for adjuvant and neoadjuvant therapy are unfortunately insufficient. After clear resection (R0) patients in Europe are preferentially treated with adjuvant chemotherapy. In northern America chemoradiation (CRT) is standard based upon the GITSG data. CRT is a reasonable option for patients with cancer of the pancreatic head, with positive nodes and with a maximal tumor diameter > 3 cm. Additive CRT should be recommended after non-curative resection (R1). The value of neoadjuvant CRT has not yet been proven on the highest level of evidence since prospectively randomized trials have not been completed yet. However, we expect longer survival after neoadjuvant CRT through higher rates of R0-resections, lower rates of nodal spread (ypN1) and higher local tumor control. Survival of patients with locally advanced pancreatic cancer (LAPC) without distant metastasis has a tendency to be longer after CRT compared to chemotherapy alone. It should always be kept in mind that CRT allows secondary tumor resection with curative intent. More than in other tumors, volume of radiation directly corresponds to tolerability and feasibility of concurrent CRT. The clinical target volume contains the primary tumor and the regional lymphatic areas (peripancreatic, celiac trunk, hepatoduodenal, mesenteric, and interaortocaval between the celiac trunk and the inferior mesenteric artery). A total dose of 50 - 55 Gy is given in fractions of 1.8 to 2.0 Gy. Unexpected toxicity has repeatedly been described when these technical aspects have been neglected.

Schlüsselwörter

Pankreaskarzinom - Radiochemotherapie

Key words

pancreatic cancer - chemoradiation

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