Das zweite Primärmalignom beim Krebspatienten – Epidemiologie, Prognose und klinische Relevanz

Zusammenfassung

Hintergrund: Ansteigendes Alter der Bevölkerung sowie Fortschritte in der Therapie und damit ein verbessertes Überleben von Patienten mit Tumorerkrankungen haben dazu geführt, dass häufiger bei Überlebenden einer Krebsbehandlung im weiteren Verlauf ein zweiter maligner Primärtumor beobachtet wird. Die Konsequenzen sollen in dieser Übersicht dargestellt werden.

Methodik: Für die Literaturübersicht wurde die Datenbank Medline (PubMed) unter den Schlüsselwörtern „Multiple primary malignant tumors“ sowie „(Neoplasms, second primary) AND "Neoplasms, Second Primary"[Mesh]“ durchsucht. Es wurden primär Veröffentlichungen der letzten 7 Jahre (2005 – 2011) abgefragt.

Ergebnisse: Die Prävalenz an Patienten mit Zweitmalignomen wird in verschiedenen Krebsregistern mit 6,6 % bis 9 % angegeben. Dabei ist das Malignomrisiko des Krebspatienten, abhängig vom Alter, im Vergleich zu dem der Allgemeinbevölkerung wenigstens um 20 % erhöht, bei Überlebenden einer kindlichen Krebstherapie beträgt das Zweitmalignomrisiko sogar das 3 – 6-Fache. Die Inzidenz der Zweitmalignome ist entscheidend von der Prognose des Ersttumors abhängig: Bei Patienten mit prognostisch ungünstigen Karzinomen wie Pankreas- oder Magenkarzinom werden 15 Jahre nach Erstdiagnose bei weniger als 5 % der Patienten Zweitmalignome entdeckt, hingegen beträgt die Rate bei Patienten mit kolorektalem Karzinom oder Schilddrüsenkarzinom nach 25 Jahren ca. 15 %.

Schlussfolgerung: Auswirkungen aus diesen Daten ergeben sich für die Primärdiagnostik, die bei Karzinomen mit gehäufter Inzidenz synchroner Zweitkarzinome nach entsprechenden Tumoren vor Beginn der Therapie suchen muss. Beispiele sind das synchrone Kolon-Zweitkarzinom oder Karzinome in Mund und Rachen bei Patienten mit Speiseröhrenkarzinom. Eine weitere Konsequenz stellt ein gezieltes Follow-up bei entsprechenden Risikopopulationen dar. Hierzu gehört das Screening auf metachrone kolorektale Zweitkarzinome, der Ausschluss von gastrointestinalen Zweitmalignomen bei Patienten mit GIST oder das Brustkrebs-Screening bei jungen Patientinnen mit Schilddrüsenmalignom. Da eine Radiotherapie die Rate an Zweitmalignomen erhöht, sollte eine adjuvante Strahlentherapie gut begründet werden. Dies gilt allerdings nur für jüngere Patienten, das strahlenbedingte Zweitmalignomrisiko des älteren Patienten ist gering.

Abstract

Background: Rising population age and advances in treatment with improved survival from cancer have led to more frequent survivors of cancer treatment and subsequently to more patients with a second primary tumour. The consequences are presented in this overview.

Method: For the literature review, the Medline database (PubMed) was searched under the key words “multiple primary malignant tumors” and “(Neoplasms, second primary) AND "Neoplasms, Second Primary"[Mesh]”. Primarily, publications in the last 7 years (2005 – 2011) were sought.

Results: The prevalence of patients with second primary cancer is reported in various cancer registries with 6.6 % to 9 %. Here, the risk of developing new primary cancer in cancer survivors, depending on age, compared to the general population is increased at least by 20 %. Among childhood cancer survivors, the risk was even 3 – to 6-times higher than would have been expected in the general population. The incidence of second malignant neoplasms is crucially dependent on the prognosis of the first tumour. Fifteen years after initial diagnosis, in patients with prognostically unfavourable tumours such as pancreatic or gastric carcinoma, second primary malignancies are detected in less than 5 %. However, the cumulative incidence of all second cancers combined is approximately 15 % at 25 years in patients with colorectal or thyroid cancer.

Conclusion: Implications from these data arise for primary diagnostics which must look at cancers with frequent synchronous second malignancies for respective tumours before treatment. Examples are synchronous colorectal lesions in patients with colorectal carcinoma or synchronous cancers of the oral cavity and pharynx in patients with oesophageal carcinoma. Another consequence is a targeted follow-up of corresponding risk populations. This includes the screening for metachronous colorectal cancer, the exclusion of gastrointestinal second malignancies in patients with GIST, or the breast cancer screening in young female thyroid cancer survivors. Since radiotherapy increases the rate of second primary neoplasms, adjuvant radiotherapy should be well justified. Nevertheless, this is true only for young patients, mainly in childhood. The risk of a second cancer after irradiation in adults is small.

Schlüsselwörter

multiple primäre Malignome - Zweitmalignom - Häufigkeit - Prognose - Therapie

Key words

multiple primary malignancies - second primary neoplasms - frequency - prognosis - treatment

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