Zusammenfassung
Die Behandlung von Patienten mit einem Plattenepithelkarzinom des Oropharynx (OPSCC) erfordert eine interdisziplinäre Zusammenarbeit. Therapieziel ist neben der Tumorkontrolle der Funktions- und Organerhalt. Hierzu wird die primäre gleichzeitige Radiochemotherapie (RCT) v. a. bei lokal fortgeschrittenen Kopf-Hals-Tumoren eingesetzt. Alternativ erfolgt die sequenzielle RCT, zunächst als Induktionschemotherapie durchgeführt und dann von einer alleinigen Radiatio oder einer RCT ergänzt. Zu beachten sind bei diesen Therapieansätzen die Funktionseinschränkungen im Bereich des Schluckapparats, die insbesondere durch radiogene Fibrosen bedingt sind, sowie die Toxizitäten, die durch eine cisplatinbasierte Chemotherapie entstehen. Der chirurgische Therapieansatz versucht, offen chirurgische Zugänge durch die Verwendung der transoralen Chirurgie zu vermeiden. Ein weiteres, weitaus wichtigeres Ziel ist es, die adjuvante R(C)T komplett zu vermeiden oder eine relevante Dosisreduktion zu ermöglichen. In Fällen, in denen eine adjuvante Therapie erforderlich wird, verringert sich der Vorteil einer primären Chirurgie gegenüber einer primären RCT, ist aber nicht notwendigerweise komplett eliminiert. Für die Gruppe der auf humanes Papillomvirus (HPV) positiven OPSCC sollte nicht übersehen werden, dass das primär chirurgische Vorgehen für HPV-bedingte Kopf-Hals-Karzinome gleichwertige, wenn nicht sogar größere Überlebensvorteile bietet und es keine eindeutigen Hinweise gibt, dass eine RCT gegenüber der primären Operation in dieser Patientengruppe einen klaren Vorteil bringt. Bei Einsatz der RCT werden deeskalierte Therapienansätze favorisiert, die durch die Verwendung einer Radioimmuntherapie sowie Dosisreduktion einer primären oder adjuvanten R(C)T langfristig Therapiemorbiditäten vermindern sollen.
Abstract
Treatment of patients with oropharyngeal squamous cell carcinoma (OPSCC) requires interdisciplinary collaboration. Besides oncologic control, organ and function preservation are important priorities. One treatment option is primary concomitant chemoradiotherapy (CRT), particularly for locally advanced head and neck cancer. Another option is sequential CRT, where induction chemotherapy may be followed either by radiation alone or by CRT. An important aspect of these modalities is the development of functional sequelae with regards to swallowing as a direct consequence of radiogenic fibrosis, as well as tissue ctoxicity associated with cisplatin-based chemotherapy. Conventional open surgical approaches are being increasingly replaced by transoral surgical modalities with less treatment-related morbidity. As a further, equally important goal of appropriately indicated surgery, adjuvant (C)RT may be omitted or the dose significantly reduced. The advantages of primary surgery over primary CRT may be less obvious in cases still requiring adjuvant treatment, although not necessarily completely eliminated. For patients with human papillomavirus (HPV)-driven OPSCC, it is important to note that primary surgery may provide comparable or even increased survival benefit. To date, there is no evidence for a clear advantage of primary CRT over primary surgery in this group. In these cases, a de-escalated treatment package may be the preferred option. Here, the application of radioimmunotherapy as well as a reduced radiation dose may minimize long-term treatment-related morbidities.
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L. Bussmann und N. Möckelmann geben an, dass kein Interessenkonflikt besteht. B.B. Lörincz ist Proctor und Trainer für Intuitive Surgical, Inc. R. Knecht ist Mitglied des Advisory Boards von Astra Zeneca, Merck Serono, Sanofi Aventis, Boehringer Ingelheim und Bayer Healthcare Leverkusen.
Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.
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Knecht, R., Bussmann, L., Möckelmann, N. et al. Ist Radio(chemo)therapie wirklich der zukünftige Standard für die Behandlung von Oropharynxkarzinomen?. HNO 64, 221–226 (2016). https://doi.org/10.1007/s00106-016-0147-5
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DOI: https://doi.org/10.1007/s00106-016-0147-5