Zusammenfassung
Die heutige Behandlung kolorektaler Karzinome erfordert die intensive Zusammenarbeit von Chirurgen, Strahlentherapeuten und Internisten und den stadienabhängigen Einsatz unterschiedlicher Verfahren. Nach R0-Resektion eines Kolonkarzinoms im Stadium III ist eine adjuvante Therapie ohne Altersbeschränkung indiziert. Dabei sollte eine 6-monatige Oxaliplatin-Fluoropyrimidin-Chemotherapie mit Beginn innerhalb von 6 Wochen postoperativ durchgeführt werden. Patienten über 70 Lebensjahren sollten eine Fluoropyrimidinmonotherapie erhalten. Diese Monotherapie kann auch bei fortgeschrittenen Kolonkarzinomen ohne regionäre Lymphknotenmetastasen (Stadium II) erwogen werden, wenn die Tumoren keine Mikrosatelliteninstabilität aufweisen. Eine oxaliplatinbasierte Chemotherapie sollte bei Stadium-II-Tumoren nur bei Hochrisikokonstellation durchgeführt werden. Rektumkarzinome im Stadium II und III sollten mit einer neoadjuvanten Radiochemotherapie gefolgt von einer adjuvanten Chemotherapie behandelt werden. Die Therapie mit VEGF- oder EGFR-Antikörpern hat weder in der adjuvanten Therapie des Kolonkarzinoms noch in der neoadjuvanten Radiochemotherapie des Rektumkarzinoms einen Stellenwert. Die Prognose bei primär resektablen Lebermetastasen wird durch Chemotherapien tendenziell verbessert, während irresektable Leberfiliae nach einer neoadjuvanten Chemotherapie oft potenziell kurativ reseziert werden können.
Abstract
Adjuvant chemotherapy for resected stage III colon cancer is indicated for all patients, including elderly patients >70 years. In general, adjuvant oxaliplatin-fluoropyrimidine chemotherapy should be started within 6 weeks after tumor resection and should be given for a period of 6 months. However, patients aged >70 should receive fluoropyrimidine mono-chemotherapy. This mono-therapy, but not an oxaliplatin-based combination, can also be considered for patients with standard risk stage II tumors without microsatellite instability. In stage II patients with a high risk constellation adjuvant oxaliplatin-fluoropyrimidine combination therapy should be considered. Patients with stage II and III rectal cancer require neoadjuvant radiochemotherapy with fluoropyrimidine followed by adjuvant fluoropyrimidine treatment. There is no role for the use of VEGF- or EGFR-antibodies in the adjuvant therapy of colon cancer or in neoadjuvant therapy of rectal cancer. The prognosis of patients with primary resectable colorectal liver metastases may be improved by adjuvant or perioperative chemotherapy, while neoadjuvant systemic chemotherapy frequently facilitates potential curative resection of initially non-resectable liver metastases.
Literatur
Adam R, Delvart V, Pascal G et al (2004) Rescue surgery for unresectable colorectal liver metastases downstaged by chemotherapy: a model to predict long-term survival. Ann Surg 240:644–657
Albert SR, Sargent DJ, Smyrk TC et al (2010) Adjuvant mFOLFOX with or without cetuximab (Cmab) in KRAS wild-type (WT) patients (pts) with resected stage III colon cancer (CC): Results from NCCTG Intergroup Phase III Trial N0147. J Clin Oncol 28 (Suppl):18s (abstr CRA3507)
André T, Boni C, Navarro M et al (2009) Improved overall survival with oxaliplatin, fluorouracil, and leucovorin as adjuvant treatment in stage II or III colon cancer in the MOSAIC trial. J Clin Oncol 27:3109–3116
André T, Sargent D, Tabernero J et al (2006) Current issues in adjuvant treatment of stage II colon cancer. Ann Surg Oncol 13:887–898
Aschele C, Pinto C, Cordio S et al (2009) Preoperative fluorouracil (FU)-based chemoradiation with and without weekly oxaliplatin in locally advanced rectal cancer: Pathologic response analysis of the Studio Terapia Adiuvante Retto (STAR)-01 randomized phase III trial. J Clin Oncol 27 (Suppl):18s (abstr CRA4008)
Bosset JF, Collette L, Calais G et al (2006) Chemotherapy with preoperative radiotherapy in rectal cancer. N Engl J Med 355:1114–1123
Bujko K, Nowacki MP, Nasierowska-Guttmejer A et al (2006) Long-term results of a randomized trial comparing preoperative short-course radiotherapy with preoperative conventionally fractionated chemoradiation for rectal cancer. Br J Surg 93:1215–1223
Collette L, Bosset JF, den Dulk M et al (2007) Patients with curative resection of cT3–4 rectal cancer after preoperative radiotherapy or radiochemotherapy: does anybody benefit from adjuvant fluorouracil-based chemotherapy? A trial of the European Organisation for Research and Treatment of Cancer Radiation Oncology Group. J Clin Oncol 25:4379–4386
Falcone A, Ricci S, Brunetti I et al (2007) Phase III trial of infusional fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFOXIRI) compared with infusional fluorouracil, leucovorin, and irinotecan (FOLFIRI) as first-line treatment for metastatic colorectal cancer: the Gruppo Oncologico Nord Ovest. J Clin Oncol 25:1670–1676
Folprecht G, Gruenberger T, Bechstein WO et al (2010) Tumour response and secondary resectability of colorectal liver metastases following neoadjuvant chemotherapy with cetuximab: the CELIM randomised phase 2 trial. Lancet Oncol 11:38–47
Gerard JP, Azria D, Gourgou-Bourgade S et al (2010) Comparison of two neoadjuvant chemoradiotherapy regimens for locally advanced rectal cancer: results of the phase III trial ACCORD 12/0405-Prodige 2. J Clin Oncol 28:1638–1644
Gerard JP, Conroy T, Bonnetain F et al (2006) Preoperative radiotherapy with or without concurrent fluorouracil and leucovorin in T3–4 rectal cancers: results of FFCD 9203. J Clin Oncol 24:4620–4625
Haller D, Taberno J, Maroun J et al (2009) First efficacy findings from a randomized phase III trial of capecitabine + oxaliplatin vs. bolus 5-FU/LV for stage III colon cancer (NO16968/XELOXA study). Eur J Cancer Suppl 7:4
Heald RJ, Ryall RD (1986) Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1:1479–1482
Hofheinz R, Wenz F, Post S et al (2009) Capecitabine (Cape) vs. 5-fluorouracil (5-FU)-based (neo-)adjuvant chemoradiotherapy (CRT) for locally advanced rectal cancer (LARC): Safety results of a randomized, phase III trial. J Clin Oncol:4014
Jackson McCleary NA, Meyerhardt J, Green E et al (2009) The ACCENT Collaborative Group. Impact of older age on the efficacy of newer adjuvant therapies in >12,500 patients (pts) with stage II/III colon cancer: Findings from the ACCENT Database. J Clin Oncol 27 (Suppl):15s (abstr 4010)
Kapiteijn E, Marijnen CA, Nagtegaal ID et al (2001) Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 345:638–646
Kuebler JP, Wieand HS, O’Connell MJ et al (2007) Oxaliplatin combined with weekly bolus fluorouracil and leucovorin as surgical adjuvant chemotherapy for stage II and III colon cancer: results from NSABP C-07. J Clin Oncol 25:2198–2204
Mitry E, Fields AL, Bleiberg H et al (2008) Adjuvant chemotherapy after potentially curative resection of metastases from colorectal cancer: a pooled analysis of two randomized trials. J Clin Oncol 26:4906–4911
Nordlinger B, Sorbye H, Glimelius B et al (2008) Perioperative chemotherapy with FOLFOX4 and surgery vs. surgery alone for resectable liver metastases from colorectal cancer (EORTC Intergroup trial 40983): a randomised controlled trial. Lancet 371:1007–1016
O’Connell MJ (2009) Oxaliplatin or irinotecan as adjuvant therapy for colon cancer: the results are in. J Clin Oncol 27:3082–3084
Quasar Collaborative Group, Gray R, Barnwell J, McConkey C et al (2007) Adjuvant chemotherapy vs. observation in patients with colorectal cancer: a randomised study. Lancet 370:2020–2029
Rodel C, Arnold D, Hipp M et al (2008) Phase I-II trial of cetuximab, capecitabine, oxaliplatin, and radiotherapy as preoperative treatment in rectal cancer. Int J Radiat Oncol Biol Phys 70:1081–1086
Rodel C, Liersch T, Hermann RM et al (2007) Multicenter phase II trial of chemoradiation with oxaliplatin for rectal cancer. J Clin Oncol 25:110–117
Sauer R, Becker H, Hohenberger W et al (2004) Preoperative vs. postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351:1731–1740
Schmiegel W, Pox C, Adler G et al (2004) S3-Guidelines conference „colorectal carcinoma“ 2004. Z Gastroenterol 42:1129–1177
Schmiegel W, Reinacher-Schick A, Arnold D et al (2008) Update S3-guideline „colorectal cancer“ 2008. Z Gastroenterol 46:799–840
Twelves C, Wong A, Nowacki MP et al (2005) Capecitabine as adjuvant treatment for stage III colon cancer. N Engl J Med 352:2696–2704
Willett CG, Boucher Y, di Tomaso E et al (2004) Direct evidence that the VEGF-specific antibody bevacizumab has antivascular effects in human rectal cancer. Nat Med 10:145–147
Wolmark N, Yothers G, O’Connell JM et al (2009) A phase III trial comparing mFOLFOX6 to mFOLFOX6 plus bevacizumab in stage II or III carcinoma of the colon: Results of NSABP Protocol C-08. J Clin Oncol 27 (Suppl):18s (abstr LBA4)
Interessenkonflikt
Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.
Author information
Authors and Affiliations
Corresponding authors
Rights and permissions
About this article
Cite this article
Hacker, U., Hallek, M. & Kubicka, S. Multimodale Therapie des kolorektalen Karzinoms. Internist 51, 1366–1373 (2010). https://doi.org/10.1007/s00108-010-2671-9
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00108-010-2671-9