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Allgemein- und Viszeralchirurgie up2date 2017; 11(01): 67-80
DOI: 10.1055/s-0042-120308
Oberer Gastrointestinaltrakt
Georg Thieme Verlag KG Stuttgart · New York

Therapiekonzepte beim metastasierten Magenkarzinom

Thorsten O. Götze
,
Lars M. Schiffmann
,
Salah-Eddin Al-Batran
,
Stefan P. Mönig
Further Information

Publication History

Publication Date:
17 March 2017 (online)

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Die Chirurgie stellt die Behandlung der Wahl beim Magenkarzinom dar. Eine Systemtherapie prä- und/oder postoperativ kann die Heilungsraten verbessern. Für viele Patienten ist jedoch eine Heilung aufgrund des fortgeschrittenen Tumorstadiums nicht mehr möglich. In dieser palliativen Situation steht die Abwägung von Therapienutzen und Nebenwirkungen im Vordergrund; die Ziele sind Verlängerung der Lebenszeit und die Verbesserung der Lebensqualität.
Kernaussagen

Medikamentöse Therapie beim metastasierten Magenkarzinom

Systemische Chemotherapie versus „Best Supportive Care“:

  • signifikante Verbesserung der Überlebenszeit,

  • längerer Erhalt der Lebensqualität, bessere Symptomkontrolle.

Erstlinienchemotherapie:

  • In Kombinationschemotherapien sind in ihrer Wirkungspotenz Oxaliplatin und Cisplatin sowie intravenöse Fluoropyrimidine durch orale austauschbar.

  • Her2-Testung ist prädiktiv; bei Her2-positiven Tumoren (IHC3+ oder IHC2+ und FISH+) besteht die Indikation für den Einsatz von Trastuzumab in Kombination mit Cisplatin und Fluoropyrimidinen.

  • Wenn Chemo-Dreifachkombinationen möglich und sinnvoll sind, sollte als dritte Substanz Docetaxel eingesetzt werden (FLOT).

Zweitlinienchemotherapie:

  • Die Kombination Paclitaxel + Ramucirumab ist die zurzeit wirksamste Zweitlinientherapie.

  • Die Therapieauswahl orientiert sich an

    • der Vortherapie,

    • dem Allgemeinzustand (ECOG),

    • dem Alter des Patienten.


Chirurgische Therapie des metastasierten Magenkarzinoms

Resezierende versus nicht resezierende Verfahren:

  • Die palliative Gastrektomie zeigt gemäß retrospektiven Daten einen Überlebensvorteil gegenüber der Gastroenterostomie. Die Indikation bleibt mangels prospektiv randomisierten Daten zu Outcome, Morbidität und Lebensqualität eine Einzelfallentscheidung.

  • Eine interventionelle Stentanlage sollte nur bei Patienten mit stark limitierter Lebenserwartung erfolgen.

Radikale Chirurgie in der M1-Situation im Rahmen einer multimodalen Therapie:

  • Eine Subgruppe oligometastasierter Patienten profitiert möglicherweise von einer radikalen Resektion im Rahmen eines multimodalen Therapiekonzepts. Bei solchen Patienten kann im Rahmen klinischer Studien ein multimodales Therapieziel einschließlich der Tumor- und Metastasenresektion verfolgt werden (RENAISSANCE-Studie).

 

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