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DOI: 10.1055/s-2007-986245
© Georg Thieme Verlag KG Stuttgart · New York
Diagnostische und therapeutische Strategien bei rezidivierten Gliomen
Diagnostic and Therapeutic Strategies for Recurrent GliomasPublikationsverlauf
Publikationsdatum:
19. November 2007 (online)
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Zusammenfassung
Mit der Verfügbarkeit neuer Strategien für die Primärtherapie der Gliome, insbesondere Temozolomid als Standard in der Primärtherapie des Glioblastoms, haben sich die Herausforderungen für die Diagnostik und Therapie rezidivierter Gliome verändert. Die Differenzierung der Tumorprogression von therapieinduzierten Veränderungen (Pseudoprogression) ist komplexer geworden. Häufiger als früher wird die Indikation zu einer Rezidivoperation auch aus diagnostischen Gründen bejaht, um aufgrund molekularer Veränderungen im Tumor individualisierte Therapieentscheidungen zu treffen. Aktuell stehen zahlreiche Studien der Rezidivtherapie maligner Gliome vor der Publikation, Endauswertung oder Ende der Patientenrekrutierung. Die Rezidivtherapie der Gliome außerhalb klinischer Studien hängt wesentlich von der zuvor erfolgten Primärtherapie ab. Ob bei Gliomen der WHO-Grade II und III im Rezidiv eine maligne Progression nachweisbar ist, spielt bei der Wahl der Therapie eine untergeordnete Rolle. Bei allen Patienten sollte im Rezidiv im Rahmen einer interdisziplinären Abstimmung die Indikation zu einer erneuten Operation geprüft werden. Wurde in der Primärtherapie keine Strahlentherapie durchgeführt, so ist diese im Rezidiv fast immer indiziert. Wurde in der Primärtherapie keine Chemotherapie mit Temozolomid durchgeführt, so ist diese im Rezidiv ebenso fast immer indiziert, meist als Monotherapie in konvenzioneller Dosierung (150 - 200 mg/m2, D1 - D5 × 28 Tage). Wenn bereits Temozolomid eingesetzt wurde, kommen vor allem Nitrosoharnstoffe, eine nitrosoharnstoffhaltige Kombination, modifizierte „dosisintensivierte” Temozolomidschemata, eine erneute Strahlentherapie, der Einschluss in eine aktuelle Therapiestudie oder auch der Verzicht auf weitere Therapiemaßnahmen in Betracht. Patientenalter, Karnofsky-Index, Tumorlokalisation, frühere Verträglichkeit der Strahlen- und Chemotherapie, Intervall zum Abschluss der Primärtherapie und Patientenwunsch spielen bei dieser Therapieentscheidung eine wichtige Rolle.
Abstract
The development of novel approaches to newly diagnosed gliomas, notably of temozolomide as a new standard of care for glioblastoma, has resulted in new challenges for the diagnosis and treatment of recurrent gliomas. The differentiation of tumor progression from therapy-related changes (pseudoprogression) has become complex. Surgical procedures for recurrent disease are more commonly performed also for diagnostic purposes, e. g., to base therapeutic decisions on specific molecular alterations detected in the recurrent tumor tissue. Several current randomized clinical trials for recurrent glioma have completed accrual and await their final analysis and publication. The treatment of recurrent gliomas of WHO grades II - IV outside of clinical trials depends strongly on the type of treatment administered for newly diagnosed disease. Whether gliomas of grades II and III show histological evidence of malignant progression to higher grade lesions at recurrence, is less critical. Interdisciplinary brain tumor boards should help to decide whether a second surgical procedure is indicated. Patients with recurrent gliomas who have not had radiotherapy before are usually candidates for radiotherapy. Patients with recurrent gliomas who have had radiotherapy before, but no chemotherapy, should receive temozolomide in most instances, commonly at the conventional dose of 150 - 200 mg/m2 (D1 - D5 × 28 days). If temozolomide has already been administered for newly diagnosed disease, further options include nitrosoureas, nitrosourea-based combinations, modified „dose-dense” temozolomide regimens, a second course of radiotherapy, enrollment in an experimental trial or no further tumor-specific treatment. This choice depends on patient age, Karnofsky performance score, tumor localization, prior tolerance of radiotherapy and chemotherapy, interval from completion of primary treatment and patient preference.
Schlüsselwörter
Gliom - Rezidiv - Chemotherapie
Key words
glioma - recurrence - chemotherapy
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Prof. Dr. Michael Weller
Neurologische Klinik, Universitätsspital Zürich
Frauenklinikstr. 26
8091 Zürich, Schweiz
eMail: michael.weller@usz.ch