Epidemiologie,Diagnostik und chirurgische Therapie des Nierenzellkarzinoms

Epidemiology

Renal tumors make up about 3–4?% of all malignant tumors of the adults, and approximately 80–90?% of all malignant tumors of the kidney are renal cell carcinomas.

Diagnosis

Sonography is the leading examination for early detection of kidney tumors.

Therapy

The treatment of renal cell carcinoma has been enriched in recent years by new therapeutic options for localized and metastatic cancer. The classification of renal cell carcinoma is based on TNM and UICC criteria. The current standard medicinal therapy includes the use of tyrosine kinase inhibitors, antiangiogenic substances, such as VEGF receptor antagonists (VEGF: vascular endothelial growth factor) or mTOR inhibitors (mTOR: mammalian target of rapamycin). Improvement in clinical response is to be expected when surgical tumor debulking by nephrectomy or metastasectomy is performed before systemic therapy is started and should be considered especially in patients with a good performance status. In addition, complete resection of solitary or at least a limited number of metastases can potentially be done with curative intent.

Prognosis

At the time of diagnosis, 25–30?% of all patients with renal cell carcinoma already present with metastatic disease. Furthermore, 20–30?% of patients with renal cell carcinoma will have progressive disease despite radical nephrectomy with complete tumor resection. Metastatic renal cell carcinoma has a poor prognosis with a median overall survival rate of approximately 2 years.     

Die Rolle der Chirurgie bei Diagnostik und Therapie des Analkarzinoms

The treatment of carcinomas of the anal canal and the anal margin has changed in the last 20 years: primary radiochemotherapy now yields 5-year survival rates of up to 90%. Surgery is reserved for the primary excision of biopsy specimens or the excision of small tumors and for salvage abdominoperineal resection in patients with persisting tumor or local recurrence after radiochemotherapy. Systematic inguinal lymphadenectomy is not indicated.     

Klinische Diagnostik und Therapie des oberflächlichen Harnblasenkarzinoms

Jedes Jahr erkranken etwa 15.700 Menschen in Deutschland an einer b?sartigen Neubildung der Harnblase. M?nner sind dabei doppelt so h?ufig betroffen wie Frauen. In der H?ufigkeit der Tumorerkrankungen stehen maligne Tumoren der Harnblase beim Mann an 4., bei der Frau an 6. Stelle. Die Harnblase z?hlt damit zu den h?ufigsten Krebslokalisationen beim Mann. Das mittlere Erkrankungsalter liegt für M?nner bei 69, für Frauen bei 74 Jahren. Im europ?ischen Vergleich liegen die in Deutschland ermittelten Neuerkrankungsraten für Harnblasenkrebs bei Frauen im oberen und für M?nner im mittleren Bereich. Die h?chsten Raten findet man bei M?nnern in Italien und Spanien, bei Frauen in D?nemark. Die niedrigsten Raten werden bei M?nnern in ?sterreich und Irland, bei Frauen in Frankreich und in den Niederlanden gefunden.     

Pathologie und pathomorphologische Diagnostik des Analkarzinoms

Die “Analregion” wird in den Analkanal und in die Perianalregion unterteilt. 80% aller malignen Tumoren der Analregion liegen im Analkanal. Die Tumoren der Perianalregion unterscheiden sich von denen des Analkanals. In der Klassifikation werden sie den Hauttumoren zugerechnet und im Folgenden nicht behandelt. In der Literatur wurden Therapieergebnisse für Patienten mit Analkanal- und Analrandkarzinomen vielfach zusammengefasst, was die Auswertung für die einzelnen Karzinome der beiden Regionen schwierig macht. Die Karzinome des Analkanals müssen gegen von anderen Ausgangsorten eingewachsene Karzinome, gegen sekund?re Tumoren (Metastasen) und gegen nichtepitheliale Tumoren wie das maligne Melanom oder gro?zellige Non-Hodgkin-Lymphome abgegrenzt werden. Einige besondere Aspekte der Pathologie, der histomorphologischen Diagnose und Differenzialdiagnose und besondere Aspekte der Klassifikationen der Karzinome des Analkanals sollen nachfolgend besprochen werden.     

Therapie des Analkarzinoms

Anal cancer is a rare tumor, which should be considered in patients with risk factors, e.g., HIV (human immunodeficiency virus) infection, immunosuppression, and history of cervical carcinoma. Based on recent published data, the principles of diagnosis, treatment, and follow-up are presented. Concurrent chemoradiotherapy with 5-FU (5-flurouracil) and mitomyin C is the treatment of choice for anal cancer, which can provide sphincter preservation in most cases. In patients with persistent tumor after chemoradiotherapy or local recurrence, cure can still be provided with abdominoperineal resection as salvage treatment. Thus, there is need of regular follow-up examinations to diagnose this indication at an early stage. The use of new substances and the addition of induction or maintenance chemotherapy could not improve the results in randomized trials and could not replace the established protocol. Achieving good treatment results requires close cooperation of all involved medical specialties.     

Diagnostik und Therapie des Magenkarzinoms

Gastric cancer is a very aggressive tumor. Due to the late onset of symptoms most tumors are diagnosed in an advanced stage. For early gastric cancer endoscopic resection is a well-established treatment. In case of locally advanced tumor stage several studies have shown a significant survival benefit for perioperative chemotherapy. Surgical treatment includes subtotal or total gastric resection with radical lymphadenectomy of lymph node groups of both compartments 1 and 2. An additional splenectomy or distal pancreatic resection should be avoided to reduce postoperative morbidity. In case of non-resectable tumor palliative chemotherapy can improve the prognosis (combined with trastuzumab in case of a positive HER2 status). For improvement of quality of life endoscopic or surgical procedures can be offered. Follow-up is only clinically oriented with the need for regular vitamin B12 substitution.     

Chirurgische Therapie des Analkarzinoms

The primary therapy of anal cancer is curative radiochemotherapy. Following a confirmed diagnosis the role of the surgeon is the treatment of local complications of anal cancer by securing bowel passage and protection of the perineum by laparoscopic placement of a preternatural anus or stoma. For patients with a persistent or recurrent tumor following radiochemotherapy a clear improvement in the oncological process can be achieved by surgical salvage therapy using an abdominoperineal rectum extirpation. However, this is accompanied by a high morbidity of up to 80%. Of particular importance here are disturbances in wound healing in the perineum; therefore, a primary myocutaneous flap surgery can be used to cover the perineal resection wound and the rate of disturbances in wound healing can be substantially reduced.     

Diagnostik und Therapie des Hodgkin-Lymphoms

Hodgkin lymphoma is the most frequent hematologic neoplasia in young adults. Most patients (>80?%) can be healed with risk-adapted chemo- and/or radiotherapy. The staging into early favorable, early unfavorable, and advanced stages depends on tumor burden and other risk factors. A thorough and complete diagnosis is important for risk classification. State-of-the-art first-line therapies for early favorable and early unfavorable Hodgkin lymphoma are combined radiochemotherapies: In early favorable stages with two cycles of ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) and in early unfavorable with two cycles of BEACOPP_esc (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, prednisolone, procarbazine) therapy followed by two cycles of ABVD. In advanced stages, radiotherapy after six cycles of BEACOPP_esc therapy depends on residual metabolic activity after chemotherapy. With curative intent, first choice in relapse is high-dose chemotherapy. The special needs of young adults with cancer must be taken into consideration.     

Diagnostik und Therapie des Glioblastoms

Zusammenfassung Das Glioblastom ist der häufigste Hirntumor. Die mediane Überlebenszeit liegt unter 12 Monaten. Etwa 40% der Glioblastompatienten sind älter als 65 Jahre. Die Diagnose lässt sich nur histologisch stellen. Der Stellenwert der möglichst kompletten neurochirurgischen Resektion wird nicht mehr in Frage gestellt. Die postoperative Strahlentherapie der erweiterten Tumorregion mit 54–60 Gy bleibt die wichtigste Therapiemaßnahme. Für jüngere Patienten in gutem Allgemeinzustand hat sich die Chemotherapie mit Temozolomid während und nach der Strahlentherapie als neuer Standard etabliert. Insbesondere Patienten, deren Tumor eine Methylierung der Promoterregion des O⁶-Methylguanin-DNA-Methyltransferase-(MGMT-)Gens aufweist, scheinen von der Chemotherapie mit Temozolomid zu profitieren. Zahlreiche neue Ansätze der systemischen und lokalen Therapie befinden sich derzeit in klinischer Erprobung bei Patienten mit rezidivierten Glioblastomen.     

Diagnostik und Therapie des Zervixkarzinoms

best practice onkologie - Während sich in den Industrienationen die Inzidenz des Zervixkarzinoms seit Jahren rückläufig zeigt, ist die durch eine persistierende Infektion mit HPV...     

Diagnostik und Therapie des Zervixkarzinoms

Background

Cervical cancer is the third most common genital cancer in women in Germany. The choice of treatment depends on tumor stage, risk factors and individual patient characteristics.

Diagnostics and classification

Cervical cancer is clinically classified according to the Fédération Internationale de Gynécologie et d’Obstétrique (FIGO) stage. For this a clinical examination is necessary with the use of a speculum, bimanual vaginal and rectal examination, a gynecological examination with removal of material for cytological diagnostics and human papillomavirus (HPV) testing as well as a targeted biopsy by colposcopy or conization. Additionally, special diagnostics include an obligatory gynecological ultrasound investigation and renal sonography and further imaging methods can be helpful in uncertain situations and high-grade tumor stages.

Therapy recommendations

Lymph node staging is carried out for all patients with tumor stage FIGO IA2 and higher. Up to tumor stages FIGO IB–IIB, radical hysterectomy combined with pelvic and if necessary para-aortic lymph node staging are performed. Chemoradiotherapy leads to similar results compared to open surgery regarding long-term survival but differs in the side-effect profile and recurrence pattern. Sentinel lymph node dissection is being tested in clinical trials. For patients suffering from locally advanced cancer FIGO stage III primary chemoradiotherapy is recommended and for patients with FIGO stage IV tumors individual treatment should be considered. Adjuvant chemoradiotherapy is conducted in high risk patients. In advanced FIGO stage IVb and recurrent cervical cancer primary chemotherapy represents the therapeutic option.

Conclusion

By adequate diagnostics and therapy decisions over-therapy and under-therapy can be avoided and the optimal treatment for each stage can be found. For the corresponding early tumor stage a fertility-retaining treatment is possible. In this way even comorbidities can be avoided as far as possible by a combination of therapeutic procedures.     

Palliative interventionelle und chirurgische Therapie des Pankreaskarzinoms

The majority of patients with pancreatic cancer are found to be unresectable due to infiltrative growth of the tumor into the celiac axis and the superior mesenteric vessels and/or due to distal metastases. Pancreatic cancer arises predominantly in the head of the pancreas. The patients come to medical attention when they develop jaundice secondary to obstruction of the distal common bile duct. Biliary decompression with stenting can be achieved by either endoscopic methods (ERC) or percutaneous transhepatic cholangiodrainage (PTCD) into the duodenum or outside. Plastic stents tend to occlude faster than metal stents and have to be exchanged after 3 months. Mechanical obstruction of the duodenum with nausea and vomiting requires gastrojejunostomy. In individual cases duodenal stents are used to bypass duodenal obstruction. The aim of these procedures is to guarantee quality of life for the patient. Endoscopic versus surgical palliation has to be balanced for each patient individually.     

Diagnostik und Therapie des Vulva- und des Vaginalkarzinoms

best practice onkologie - Das Vulvakarzinom ist mit einer standardisierten Erkrankungsrate von 4,4/100.000 Frauen in Deutschland das 4. häufigste Karzinom des weiblichen Genitales. Es...     

Diagnostik und Therapie des Vulva- und Vaginalkarzinoms

Both vulvar and vaginal carcinomas are rare malignancies in women. However, within the past decade a distinct increase in the incidence of vulvar intraepithelial neoplasia (VIN) as a precursor lesion, and an increase of vulvar cancer have been reported within Europe and the U.S. The most important factor in developing vulvar cancer is human papillomavirus (HPV) infections but prophylactic HPV vaccination has been proven to be highly effective. Surgery is the first choice in treating patients with vulvovaginal carcinoma, especially in the early stages. The operative treatment options depend on the localization and spread of the tumor. In an attempt to decrease the incidence of complications, research was made into surgical modifications without compromising the prognosis. For the treatment of vaginal cancer no approaches for reducing the degree of radical surgery are known. Radiation treatment remains a therapy option in advanced disease. As vulvovaginal cancer is relatively rare it is possible to give evidence-based treatment recommendations but usually on a low evidence level.     

Diagnostik und operative Therapie des Vulva- und Vaginalkarzinoms

Both vulvar and vaginal carcinomas are rare malignancies in women. However, within the past decade, a distinct increase in vulvar cancer as well as in vulvar intraepithelial neoplasia as a precursor lesion has been reported both in Europe and the United States. The most important factor in developing vulvar cancer is human papillomavirus (HPV) infection, but prophylactic HPV vaccination has proven to be a highly effective preventative measure. Surgery is the first choice in treating patients with vulvovaginal carcinoma, especially in its early stages. The operative treatment options depend on localization and spread of the tumor. In an attempt to decrease the incidence of complications, researchers are working to modify the surgical procedure without compromising the prognosis; replacing radical vulvectomy by less wide local excision is one of these modifications. For treating vaginal cancer, no approaches for reducing the radicality are known. Because vulvovaginal cancer is relatively rare, it is possible to give evidence-based treatment recommendations, but usually on a low-evidence level. The aim of this paper is to elucidate the diagnostics and surgical treatment options for managing vulvovaginal cancer.     

Endoskopische Diagnostik und Therapie des Magenkarzinoms

Die Onkologie - Goldstandard zur Diagnostik von Magenkarzinomen ist die Ösophagogastroduodenoskopie (ÖGD). Subtile Unterschiede in der Oberflächenstruktur der Schleimhaut...     

Stadiengerechte chirurgische Therapie des Nierenzellkarzinoms

Die zentrale Bedeutung der Chirurgie in der Behandlung des Nierenkarzinoms ist seit Jahrzehnten unumstritten. Neben dem kurativen Charakter der Nephrektomie bei organbegrenzten Nierentumoren, kann in einem selektionierten Patientengut ein chirurgischer Ansatz, z. T. eingebunden in ein multimodales Konzept auch bei lokal fortgeschrittenen und metastasierten Nierentumoren, eine Langzeitpalliation bewirken. Nachfolgend werden operative Strategien und Langzeitprognosen nach Chirurgie für unterschiedliche Stadien des Nierenkarzinoms beschrieben.