Zusammenfassung
Die unbefriedigenden Ergebnisse konventionell dosierter Salvagechemotherapien besonders bei Patienten mit ungünstigem Risikoprofil im Rezidiv und/oder multiplen Rezidiven führten Ende der 1980er Jahre zur Einführung der Hochdosischemotherapie (HDCT). Bis heute bleibt die Kombination von Carboplatin und Etoposid (CE) das Grundgerüst aller HDCT-Kombinationen. In der Vergangenheit wurden vielfache Therapiemodifikationen mit Dosissteigerungen oder Hinzunahme von weiteren Substanzen untersucht, ohne dass das Nutzen-Nebenwirkungs-Profil des Verfahrens dadurch gesteigert werden konnte. Durch verbesserte supportive Therapie und dem Einsatz autologer peripherer Blutstammzellen (PBSC) wurden die hämatopoetischen Rekonstitutionszeiten signifikant verkürzt und somit die initial hohe behandlungsbedingte Letalität von >10% auf etwa 3% gesenkt. Durch den Einsatz der HDCT konnten bei Patienten mit ungünstigen Prognosemerkmalen oder mehrfachen Rezidiven regelhaft anhaltende Remissionen erzielt werden. Einen hohen Stellenwert dabei hat die Resektion der Tumorresiduen, z. T. in multiplen Lokalisationen. Der Anteil residuellen vitalen Tumors ist dabei wesentlich höher als bei der Residualtumorresektion (RTR) nach primärer konventioneller Chemotherapie. Umstritten ist bis heute v. a. der Stellenwert einer HDCT in der Primärbehandlung metastasierter Poor-prognosis-Patienten aber auch der Einsatz als erste „Salvagebehandlung“ rezidivierter und refraktärer Patienten. Eine HDCT außerhalb von Studien findet aktuell nur bei Patienten mit ungünstigen Prognosemerkmalen im 1. Rezidiv sowie bei Patienten mit 2. oder nachfolgendem Rezidiv breite Akzeptanz.
Abstract
As a consequence of the unsatisfactory results of conventional dose salvage regimens, in particular for patients with poor prognostic features at the time of relapse or in patients with refractory disease, high-dose chemotherapy (HDCT) was introduced into clinical practice in the late 1980s. The combination of carboplatin and etoposide (CE) still remains the backbone of most high-dose regimens. Multiple modifications with more dose escalations or addition of further drugs have been explored, most often with increased toxicity. With improved expertise in supportive care and the use of peripheral blood stem cells, hematopoetic recovery has been significantly shortened and the initial high treatment-related mortality reduced from more than 10% to about 3%. Since the incorporation of HDCT, even patients with unfavorable prognostic features or patients with second or subsequent relapses can achieve long-term remission. Following HDCT residual tumor resection plays a major role in achieving these long-term results. The proportion of vital residual tumor after HDCT is much higher than in patients after conventional chemotherapy. The role of HDCT remains controversial particularly as a first-line treatment and less so in the first salvage setting. As these patients are rare HDCT and residual tumor resection should only be be provided by high-volume centers with sufficient expertise in performing these complex procedures.
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Lorch, A., Albers, P., Winter, C. et al. Hochdosischemotherapie und Residualtumorresektion bei Patienten mit Hodentumor. Urologe 50, 1047–1054 (2011). https://doi.org/10.1007/s00120-011-2683-7
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DOI: https://doi.org/10.1007/s00120-011-2683-7