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Strahlentherapie und Onkologie

, Volume 174, Issue 5, pp 231–236 | Cite as

Lokal fortgeschrittenes prostatakarzinom (T2b-T4 N0) ohne und lokoregionär fortgeschrittenes Prostatakarzinom (Tx N+) mit Lymphknotenmetastasen

Ist eine Strahlentherapie der pelvinen Lymphabflußwege indiziert oder nicht indiziert?
  • Thomas Wiegel
  • Wolfgang Hinkelbein
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Zusammenfassung

Hintergrund

Die Indikation zur Bestrahlung der pelvinen Lymphabflußwege bei Patienten mit vermutetem okkulten Befall bei lokal fortgeschrittenem Prostatakarzinom (T2b-4 N0) und auch mit gesichertem Lymphknotenbefall bei lokoregionär fortgeschrittenem Prostatakarzinom (Tx N+) wird sehr kontrovers diskutiert. Das betrifft sowohl die definitive Strahlentherapie als auch die adjuvante Bestrahlung nach radikaler Prostatektomie. Die vorliegende Arbeit untersucht die möglichen Indikationen zur Bestrahlung der pelvinen Lymphabflußwege anhand der Literaturdaten.

Patienten und Methoden

Weil retrospektive Untersuchungen ein therapeutisches Benefit durch die Radiotherapie der Lymphabflußwege erwarten ließen, wurde in zwei Studien der RTOG (75-06, 77-06) die Frage der elektiven Bestrahlung der pelvinen Lymphabflußwege und teilweise der paraaortalen Lymphabflußwege untersucht. Da, sich hierbei keine Verlängerung des Überlebens oder des tumorfreien Überlebens fand, wurde daraus vorschnell die fehlende Wirksamkeit der Radiotherapie der Lymphabflußwege postuliert. Reanalysen von RTOG 77-06 haben gezeigt daß die Studie diese Frage nicht valide prüfen konnte. Da sich RTOG 77-06 nur auf Patienten mit T1b/T2-Karzinomen bezog, existiert keine prospektiv randomisierte Studie zur Frage der elektiven Radiotherapie der Lymphabflußwege bei T3-Karzinomen, die eine hohe Wahrscheinlichkeit pelviner Lymphknotenmetastasen haben.

Ergebnisse

Es gibt keine Standardtherapieempfehlung bei lokal fortgeschrittenem Prostatakarzinom über die Bestrahlung der pelvinen Lymphabflußwege im Gegensatz zur Radiotherapie der paraaortalen Lymphabflußwege, die heute obsolet ist. Viele Strahlentherapeuten setzen die Radiotherapie der pelvinen Lymphabflußwege bei einer Wahrscheinlichkeit des Befalls über 20 bis 30% ein, da es Hinweise auf die Wirksamkeit in retrospektiven Untersuchungen gibt. Andere Strahlentherapeuten lehnen sie jedoch wegen der nicht bewiesenen Wirksamkeit und einer erhöhten Dünndarmmorbidität ab. Eine Lösung bietet die laparoskopische pelvine Lymphadenektomie bei geringer Morbidität, da bei pN0 auf die Bestrahlung der Lymphabflußwege verzichtet werden kann. Wo die laparoskopische pelvine Lymphadenektomie nicht durchführbar ist, gibt es Modelle, den warhscheindlichen Befall der Lymphknoten anhand des klinischen Tumorstadiums, des Gleason-Score und des PSA-Wertes zu berechnen. Bei gesichertem Befall finden sich Hinweise, daß Patieten mit mikroskopischen Lymphknotenmetastasen von einer aggressiven Therapie profitieren. Bei gesichertem Befall und Existirpation durch pelvine Lymphadenektomie scheinen Patienten mit Radiotherapie und hormoneller Therapie im Sinne eines verlängerten tumorfreien Intervalls zu profitieren, es existieren jedoch keine randomisierten Studien.

Schlußfolgerungen

Die Therapieentscheidung ist individuell zu treffen. Randomisierte Studien der ARO und der RTOG (RTOG 9413) rekrutieren derzeit Patienten. Während in der Studie der ARO Patienten mit gesichertem Lymphknotenbefall untersucht werden, prüft die Studie der RTOG unter anderem den Wert der Bestrahlung der pelvinen Lymphabflußwege, wenn das individuelle Risiko des Befalls größer als 15% ist. Wird eine Radiotherapie der pelvinen Lymphabflußwege durchgeführt, sollte die Dosis bei okkultem Befall 45 Gy, bei gesichertem Befall 50,4 Gy nicht überschreiten.

Schlüsselwörter

Prostatakarzinom Lymphknotenmetastasen Radiotherapie 

Is there an indication for radiotherapy of the pelvic lymphaties in patients with locally advanced prostate cancer (T2b-T4 N0) without clinical evidence of lymph node metastases or in patients with locoregional advanced prostate cancer (Tx N+) with lymph node metastases?

Abstract

Background

There is a greater controversy regarding the indication of radiotherapy of the pelvic lymphatics in patients with suspected lymph node metastases in locally advanced prostate cancer (T2b-4 N0) on the one hand and in patients with pathologically proven lymph node metastases in locoregional advanced prostate cancer (Tx pN+) on the other hand following definitive radiotherapy and radical prostatectomy. This paper investigates the possible indications for radiotherapy of the pelvic lymphatics in the light of data from the literature.

Patients and Methods

Because data from several retrospective studies concerning radiotherapy of the pelvic lymphatics indicated a better outcome, the RTOG conducted 2 prospective randomised studies (RTOG 75-06, 77-06) to address these questions. However, the results of these studies showed no better survival or cause specific survival for patients treated for the paraaortal or pelvic lymphatics and therefore, radiotherapy of the pelvic lymphatics was no more advocated. A reanalysis showed several problems of the study design and it was concluded that the studies couldn’t prove the question of elective radiotherapy of the pelvic lymphatics. In RTOG 77-06 patients with T1b/T2 tumors were investigated. Therefore, there is no prospetive study investigating the elective radiotherapy in patients with T3-tumors, who are at high risk of pelvic lymph node metastases.

Results

Today there is no indication for treating the paraaortal lymphatics in patients with locoregional advanced prostate cancer. Many radiotherapists perform the elective radiotherapy of pelvic lymphatics when the risk of metastases is above 15 to 20% because retrospective data indicate a better outcome. On the other hand, many others don’t treat them because RTOG 75-06 and 77-06 didn’t demonstrate a better outcome. Laparoscopic lymphadenectomy with low morbidity seems to be helpful as in pN0 patients radiotherapy is not necessary. Where performing laparoscopic pelvine lymphadenectomy is impossible the probability of the frequency of lymph node metastases can be estimated using the clinical tumor stage, the Gleason-score and the pretherapeutic PSA. In case of proven metastases (pN+) some retrospective data indicate that patients with micrometastasis could profit from aggressive treatment. In case of proven metastases tumor-free interval. However, there are no data from randomized trials.

Conclusions

Every radiotherapist has to make his own decision for radiotherapy of the pelvic lymphatics as there is no standard treatment. Two randomised studies are open and recrute patients. These are one study of the ARO, investigating patients with histologically proven lymph node metastases and one study of the TROG (RTOG 9413), investigating patients with an estimated risk of lymph node metastases >15%. In case of radiotherapy of the pelvic lymphatics a dose of 45 Gy for suspected metastases and 50.4 Gy for proven metastases is recommended.

Key Words

Prostate cancer Lymph node metastases Radiotherapy 

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Copyright information

© Urban & Vogel 1998

Authors and Affiliations

  • Thomas Wiegel
    • 1
  • Wolfgang Hinkelbein
    • 1
  1. 1.Abteilung Strahlentherapie, Universitätsklinikum Benjamin FranklinFreie UniversitätBerlin

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