Aktuelle Therapieansätze beim malignen Melanom mit leptomeningealer Metastasierung

best practice onkologie - Trotz fundamentaler Fortschritte im Bereich der Dermatoonkologie bleibt die Prognose einer leptomeningealen Metastasierung (LMM) mit einer durchschnittlichen...     

Metastasentherapie bei malignem Melanom mit unbekanntem Primärtumor

Malignant melanoma from unknown primary tumor is always a metastatic tumorous disease. The clinical presentation is often regional tumor manifestations in skin, subcutis, soft tissue or lymph nodes but may also show visceral metastases in lungs, liver, brain, bones, spleen or gastrointestinal manifestations. Diagnosis and treatment cannot always be separated. As multiple sites are frequently involved the individual treatment plan should be devised by an interdisciplinary tumor board after whole body staging. Documented local metastases in skin, soft tissue or lymph nodes are classified as stage III melanoma and treated accordingly. The prognosis has been shown to be equal to or even better than in cases with known primary tumor. Even after curative resection further recurrences are common but can often be re-resected with curative intent. Palliative treatment options, such as interventional procedures, radiotherapy, chemotherapy, novel kinase inhibitors and immunotherapy depend on tumor extent and the sites of the metastases.     

Prä- und postoperative Ernährungstherapie beim Magenkarzinom

Context

Many patients with gastric cancer suffer from serious nutritional problems in the perioperative setting. The main symptom is an unexpected weight loss, which increases the risks of malnutrition, therapy, associated complications and leads to higher perioperative morbidity and mortality rates.

Objective

The aim of this article was an overview of evidence-based nutrition intervention as an integrative part of the treatment for gastric cancer.

Material and methods

Literature research in PubMed, MED-LINE and manual searches.

Results

The impact of malnutrition on the course of the disease in cancer patients has been described in many studies. A review of the literature showed that patients, especially with a high-risk and/or pre-existing malnutrition, can benefit from adequate nutrition intervention. In order to adequately treat malnutrition, a systematic survey of the nutritional status is necessary (e.g. using NRS). The treatment of malnutrition reduces treatment-related complications and thus contributes to an improved quality of life for patients.

Conclusions

An evaluation of the nutritional status should be done at the moment of the diagnosis and throughout the course of treatment. The result should be integrated into the treatment concept, both preoperatively and postoperatively. After gastrectomy, there should always be a nutritional therapeutic treatment. The altered anatomy leads to changes in nutrient intake and absorption. In the long term, there is an increased risk of anemia, osteoporosis and malnutrition. This can be positively influenced by the correct use of pancreatic enzymes and adapted eating habits. To avoid nutrient deficiency, related complications, a regular monitoring of the relevant nutrients is necessary.     

Chronische lymphatische Leukämie beim alten Patienten

Background

The majority of patients with chronic lymphocytic leukemia (CLL) are of advanced age and over 70 years old when the disease is diagnosed or requires therapy. Recently, new treatment options have emerged.

Objective

This article gives a review of current diagnostics and therapy of CLL in elderly patients.

Methods

A literature search was carried out in PubMed and in congress abstracts.

Results

The development and approval of new CD20 antibodies (e.g. ofatumumab, and obinutuzumab) as well as kinase inhibitors (e.g. ibrutinib and idelalisib) have broadened the therapeutic arsenal for elderly patients with CLL. Benefits from these advances have been mainly demonstrated for elderly patients with increased comorbidities and for elderly patients with high risk features (e.g. 17p deletion, p53 mutation and early relapse).

Conclusion

For the former group of patients immunochemotherapy and no longer chemotherapy alone is the standard first-line treatment. In the latter group of patients early use of kinase inhibitors which block B-cell receptor signaling and can be taken orally are indicated. Studies are currently being carried out with further agents for targeted therapy (e.g. venetoclax, lenalidomide) as well as with tools for assessing patient fitness in elderly patients with CLL.

     

Aktuelle immuntherapeutische Ansätze beim multiplen Myelom

best practice onkologie - Antikörper gegen CD38 („cluster of differentiation 38“) und SLAM-F7 („signaling lymphocytic activation molecule F7“) sind für die...     

Erkrankungs- und therapiebedingte Spätfolgen beim Hodgkin-Lymphom

Die Onkologie - Angesichts eindrucksvoller Remissionsraten in den letzten Jahren in der Therapie des Hodgkin-Lymphoms (HL) erlangen späte Folgen nach Diagnose und Therapie einen zunehmenden...     

Strategien beim rezidivierten/refraktären multiplen Myelom

Context

Multiple myeloma is a malignant lymphoproliferative B-cell disease of the bone marrow characterized by proliferation of monoclonal plasma cells. Approximately 95?% of patients develop recurrent disease.

Objective

A structured review of the treatment options for relapsed multiple myeloma is summarized using current publications.

Results

Novel agents, such as thalidomide, bortezomib and lenalidomide have improved the outcome in patients with recurrent/relapsed myeloma and resulted in prolongation of overall survival. High-dose therapy followed by autologous hematopoietic stem cell transplantation (ASCT) should be considered as a treatment option for patients in a good general condition and with a prolonged disease control (at least 12–24 months) after upfront ASCT.

Conclusion

Treatment strategies for myeloma patients depend on the general physical condition and response as well as side effects of previous therapies. Carfilzomib and pomalidomide should be considered as new treatment options for patients with recurrent/relapsed myeloma refractory to bortezomib and/or lenalidomide. Further drugs are currently being evaluated in several clinical trials. Allogeneic haematopoetic stem cell transplantation is still debateable and should only be considered as a treatment option within clinical trials.     

Management der Axilla beim primär operablen Mammakarzinom

Context

Operative treatment of the axillae is an essential component in the treatment of breast cancer. During the course of the past century axillary lymphadenectomy was initially carried out continuously more extensively as a therapeutic intervention in order to achieve higher rates of curing. As this hope was not realized and even ultraradical axillary interventions could not prevent the occurrence of distant metastases, the radicality of this operation clearly decreased from the 1990s onwards so that its importance nowadays is mostly of a diagnostic nature. Palpation and sonography are the standards for preoperative diagnostics of the axillae. Sentinel lymph node biopsy (SNLB) has developed into the standard method for a clinically negative lymph node status. The morbidity of SLNB is significantly reduced in comparison to axillary dissection.

Conclusion

In which situations axillary lymphadenectomy can be completely dispensed with, is currently the objective of running clinical studies.     

Therapieansätze beim Nierenzellkarzinom aus der Sicht der Strahlentherapie

Der Stellenwert der Bestrahlung ist als effektive Palliativtherapie bei metastasierter Erkrankung unbestritten. Hingegen wird die Rolle der Strahlentherapie im Rahmen der Prim?rbehandlung des Nierenzellkarzinoms unterschiedlich beurteilt. Standardtherapie des nicht metastasierten Hypernephroms ist die Operation. Adenokarzinome der Niere erwiesen sich bei In-vivo-Untersuchungen als durchaus strahlensensibel [1]; es besteht somit zumindest ein experimentell begründeter Ansatz zur Durchführung einer Radiotherapie bei dieser Erkrankung. Bislang haben jedoch klinische Studien keinen gesicherten Vorteil für Patienten aufzeigen k?nnen, die mit einer Kombination aus Operation des Prim?rtumors und zus?tzlicher Bestrahlung behandelt wurden.     

Molekulare Marker zur Responseprädiktion beim lokal fortgeschrittenen Rektumkarzinom

Based on the results of the CAO/ARO/AIO-94 trial of the German Rectal Cancer Study Group preoperative 5-FU-based radiochemotherapy (RCTx) is recommended as the standard treatment of locally advanced rectal cancers (UICC stages II and III) of the middle and lower third of the rectum (0-12 cm above the anocutaneous margin). Unfortunately, tumor response to neoadjuvant RCTx is very heterogeneous ranging from complete pathological response (pCR) to total resistance. To fulfill the clinical requirement of an individualized and risk-adapted multimodal treatment, progress has been made in genomic and proteomic analyses of cellular signaling pathways. Compared with postoperatively determined clinicopathological parameters of local response, complex phenotypes, such as tumor responsiveness to RCTx do not depend on the expression levels of just one or a few genes and proteins. Therefore, methods which allow comprehensive interrogation of genetic pathways and networks hold great promise in delivering tumor-specific signatures, because expression levels of tens of thousands of genes can be monitored simultaneously. During the past few years microarray technology has emerged as the key tool in addressing pertinent clinical questions, the answers to which are critical for the realization of personalized genomic medicine, in which patients will be treated based on the biology of the tumor and the genetic profile.     

Prophylaktische Schädelbestrahlung und Überleben beim kleinzelligen Bronchialkarzinom

Das kleinzellige Bronchialkarzinom ist durch eine hohe Disseminationstendenz einerseits und eine gute Chemotherapieempfindlichkeit andererseits gekennzeichnet. Mit heutigen Chemotherapieregimen werden komplette Remissionsraten von 50% bis 80% erreicht. Daraus resultieren im Stadium “Limited disease” mediane überlebenszeiten von etwa 14 Monaten und 2-Jahres-überlebenszeiten von 20 bis 30%. Mit zunehmender überlebenszeit steigt das Risiko für Hirnmetastasen. Dies ist als Folge verringerter Zytostatikawirkung im ZNS durch die Blut-Hirn-Schranke erkl?rbar. Bereits seit den 70er Jahren wird deshalb in Analogie zur Leuk?mietherapie die prophylaktische Sch?delbestrahlung (prophylactic cranial irradiation, PCI) eingesetzt. Deren Effektivit?t im Hinblick auf die Verhinderung von Hirnmetastasen ist umstrittig. Ein m?glicher überlebensgewinn wird kontrovers beurteilt.     

Stellenwert der Hochdosischemotherapie (HDCT) beim männlichen Keimzelltumor

Context

As a consequence of the unsatisfactory results of conventional dose regimens (CDCT), particularly in patients with poor prognostic features at the time of first-line therapy or at relapse, high-dose chemotherapy (HDCT) was introduced into clinical practice in the late 1980s.

Material and methods

Research of literature and analysis of clinical trials.

Results

The combination of carboplatin and etoposide (CE) remains the backbone of most high-dose salvage regimens. With improved expertise in supportive care and the use of peripheral blood stem cells, hematopoietic recovery time was significantly shortened and the initially high treatment-related mortality was reduced from more than 10?% to about 3?%. Since the incorporation of HDCT even patients with unfavorable prognostic features or patients with a second or subsequent relapse can achieve long-term remission. However, the role of HDCT as first-line treatment in selected patients with “poor prognosis” metastatic disease as well as first salvage treatment in relapsed patients with favorable prognostic characteristics remains controversial. To avoid overtreatment HDCT should only be administered at a few experienced centers and only be recommended for patients with unfavorable prognostic factors or for patients with a second or subsequent relapse. However, current data now allow a better assessment and limitation of its role. In addition an international prospective randomized phase III study (TIGER) is planned which will compare a conventional salvage regimen with sequential HDCT for the first relapse.