Zusammenfassung
Die operative Behandlung ist der Grundpfeiler der Therapie des Endometriumkarzinoms.
Neben der Entfernung des Uterus und der Adnexe setzt sich zunehmend auch die pelvine
und paraaortale Lymphonodektomie (LNE) durch, die als Staging-Prozedur den gezielten
Einsatz adjuvanter Maßnahmen wie der Strahlentherapie ermöglicht und wahrscheinlich
gleichzeitig einen wichtigen therapeutischen Benefit erbringt. Da bisher keine randomisierten
Studien vorliegen und die Durchführung der LNE bei den häufig multimorbiden und adipösen
Patientinnen ein kompetentes Team erfordert, wird die Indikation hierfür von einigen
Autoren zurückhaltend gestellt und von dem Vorliegen diverser prä- und intraoperativ
erhobener Befunde abhängig gemacht. Auf der anderen Seite fordert z. B. das National
Comprehensive Cancer Network der USA für alle Patientinnen mit Endometriumkarzinom
die Durchführung einer kompletten pelvinen und paraaortalen Lymphonodektomie. Lediglich
im Stadium IA G1 ist diese Maßnahme optional. Der Nutzen einer adjuvanten perkutanen
Teletherapie des Beckens im Stadium I ist durch mehrere randomisierte Studien infrage
gestellt worden. Bei komplett operativ gestagten Patientinnen kann wahrscheinlich
häufig auf diese Maßnahme verzichtet und stattdessen lediglich eine vaginale Brachytherapie
durchgeführt werden. Die Abdomenganzbestrahlung ist einer systemischen Chemotherapie
bei fortgeschrittenem Endometriumkarzinom unterlegen. Neue multimodale Konzepte aus
operativem Staging, adjuvanter Chemo- und gezielter Strahlentherapie müssen evaluiert
werden. In der palliativen Situation werden neben der etablierten Gestagentherapie
innovative endokrine Maßnahmen evaluiert. Die Effektivität der bisherigen Standardchemotherapie
mit Adriamycin und Cisplatin konnte durch Hinzunahme von Paclitaxel etwas verbessert
werden, allerdings um den Preis einer deutlichen Toxizitätssteigerung. Frauen mit
Endometriumkarzinom sollten - wie es beim Mamma- und Ovarialkarzinom Standard ist
- ebenfalls möglichst im Rahmen von zertifizierten Studien behandelt werden.
Abstract
Surgical therapy is the mainstay of the treatment of endometrial cancer. Apart from
total abdominal hysterectomy und bilateral salpingo-oophorectomy, complete pelvic
and paraaortic lymphadenectomy has become an integral part of the primary surgical
procedure, allowing for definite surgical/histopathological staging. In surgically
staged patients, adjuvant measures including external radiotherapy can be applied
with a clear indication and unnecessary toxicity can be avoided. In addition complete
lymphadenectomy has probably a relevant therapeutic effect. As so far no randomized
trials have been completed and lymphadenectomy in the often multimorbid and obese
endometrial cancer patients requires a certain amount of expertise, it is not accepted
by all experts or is accepted only if a variety of parameters obtained pre- and intraoperatively
are present. On the other hand, the National Comprehensive Cancer Network of the USA
recommends a complete pelvic and paraaortic lymphadenectomy for all patients with
endometrial cancer, except for those with Stage IA, Grade 1 disease where this procedure
is optional. The efficacy of an adjuvant pelvic teletherapy in Stage I patients has
been questioned by several randomized trials. In patients having a complete surgical
staging, external radiotherapy is often not necessary and can be replaced by vaginal
brachytherapy. In advanced stages of endometrial cancer chemotherapy has been shown
to be superior to whole abdominal radiotherapy. New multimodal concepts including
surgical staging, adjuvant chemo- and targeted radiotherapy have to be evaluated.
In the palliative setting novel endocrine strategies are being assessed in addition
to the well established progestagen therapy. The efficacy of the standard chemotherapy
with adriamycin/cisplatin could be somewhat improved by adding paclitaxel, at the
expense of a markedly increased toxicity. Women with the diagnosis of endometrial
cancer should be treated in the context of certified clinical trials as it has become
the standard for patients with breast or ovarian cancer.
Schlüsselwörter
Endometriumkarzinom - operative Therapie - Strahlentherapie - systemische Therapie
Key words
endometrial cancer - surgical therapy - radiotherapy - systemic therapy
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Prof. G. Emons
Klinik für Gynäkologie und Geburtshilfe
Robert Koch-Str. 40
D-37075 Göttingen
