Laryngeale intraepitheliale Neoplasien

 

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Zusammenfassung

Die Bezeichnung „Carcinoma in situ” ist in den letzten Jahren zunehmend zugunsten des Begriffs „Intraepitheliale Neoplasie” aufgegeben worden. Intraepitheliale Neoplasien unterscheiden sich in diagnostischer, therapeutischer und prognostischer Hinsicht zum Teil erheblich von den infiltrierenden Karzinomen des Larynx. Für die dysplastischen Epithelveränderungen des Larynx sind verschiedene Klassifikationssysteme vorgeschlagen worden (Kleinsasser-Klassifikation, Ljubljana-Klassifikation, WHO-Klassifikation), die hier kurz dargestellt werden. Laryngeale intraepitheliale Neoplasien entwickeln sich als Folge langjähriger Exposition gegenüber Inhalationsschadstoffen, von viralen Infektionen und möglicherweise einer Refluxerkrankung. Eine multifaktorielle Genese ist wahrscheinlich. Die Früherkennung und klinische Diagnostik stützt sich auf Lupenlaryngoskopie, flexible transnasale Laryngoskopie und Stroboskopie. Die wesentlichen Therapieoptionen sind die mikrolaryngoskopische Laserchirurgie und die Strahlentherapie. Die Strahlentherapie weist höhere lokale Kontrollraten nach initialer Behandlung auf. Im Rezidivfall ist aber eine Wiederholung der Strahlentherapie in der Regel nicht möglich und eine kehlkopferhaltende Operation kann erschwert sein. Wegen der Möglichkeit wiederholter kurativer Eingriffe und der sehr guten Endergebnisse hat sich mittlerweile die transorale Laserchirurgie als Therapieoption der Wahl für die meisten Patienten durchgesetzt. Die funktionellen Ergebnisse (Stimmqualität) nach transoraler Laserchirurgie und nach Strahlentherapie scheinen nicht wesentlich voneinander abzuweichen und sind als gleichwertig zu beurteilen. Lokalrezidive sind häufiger als nach chirurgischer oder strahlentherapeutischer Behandlung von infiltrierenden Karzinomen. Daher ist eine intensive Nachsorge erforderlich und die Möglichkeit späterer Lokalrezidive bereits bei der Wahl der initialen Therapie zu berücksichtigen.

Abstract

Precancer (carcinoma in situ) or laryngeal intraepithelial neoplasia (LIN) is a non-invasive lesion that has genetic abnormalities, loss of cellular control functions, and some phenotypic characteristics of invasive cancer and that predicts for a substantial likelihood of developing invasive cancer. Several classifications have been proposed but none has received a total agreement. With regard to diagnosis, treatment and prognosis, these lesions differ substantially from infiltrating carcinoma. Known risk factors include cigarette smoking, viral infection with subtypes of the human papilloma virus, exposure to asbestos, and probably the gastro-oesophageal reflux disease. The diagnostic work-up usually includes indirect laryngoscopy with rigid telescopes, microlaryngoscopy and biopsies for histological evaluation. Therapeutic options include wait-and-see-strategies, radiotherapy, transoral laser surgery, vocal cord stripping with cold instruments, and open partial laryngectomy. Data from the literature suggest highest local control rate with radiotherapy as initial treatment compared to other standard methods of management of dysplasia. However, transoral laser surgery can be applied repeatedly and yields excellent final results. Therefore it is now considered the treatment of choice for these lesions in the majority of patients. Local recurrences are observed more frequently than with small infiltrative carcinoma, and second primaries may arise within the upper aero-digestive tract following initial treatment. Therefore systematic follow-up is recommended for these patients.

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Prof. Dr. Hans E. Eckel

Landeskrankenhaus Klagenfurt

St. Veiter Straße 47

A-9020 Klagenfurt

Österreich

Email: hans.eckel@kabeg.at