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Neuroendocrine neoplasias comprise a heterogenous group of malignant tumours, mostly arising from the gastro-entero-pancreatic system (GEP). Most of these tumours develop from the small intestine and pancreas and the liver is the predominant site for distant metastases. Patients may be asymptomatic for a long time and liver metastases are frequently diagnosed by chance or during operations for bowel obstruction, for example, during emergency surgery. The only curative therapy consists in complete removal of primary and metastases. In case of metastatic disease, various treatment modalities need to be discussed in interdisciplinary tumour boards comprised of specialists from gastroenterology, (liver-)surgery, radiology, nuclear medicine, radiotherapy, pathology and endocrinology. By combining different therapies, even patients with progressive disease may reach long-term overall survival with good quality of life. The most important factors for decisions on therapy are individual factors like tumour grading, hormonal functionality, type of metastases and evolution of the disease. Adequate treatment of liver metastases comprises various surgical strategies as well as locally ablative radiological interventions and nuclear medical therapies, in complement to systemic treatments.Neuroendokrine Neoplasien (NEN) bilden eine heterogene Gruppe maligner Tumoren, die überwiegend dem gastro-entero-pankreatischen System (GEP) zuzuordnen sind. Hierbei sind Dünndarm und Pankreas die häufigsten Organe für Primärtumoren, die Leber stellt den dominanten Metastasierungsort dar. Da viele Patient*innen lange asymptomatisch bleiben, führen oftmals zufällig diagnostizierte Lebermetastasen oder ein Ileus zur Diagnose. Die einzige kurative Therapieoption stellt die komplette Entfernung von Primarius und Metastasen dar. Besonders im Falle der metastasierten Erkrankung sollten die vorhandenen Therapieoptionen immer im interdisziplinären Tumorboard mit Spezialisten*innen aus Gastroenterologie, (Leber-)Chirurgie, Radiologie, Nuklearmedizin, Radiotherapie, Pathologie und Endokrinologie evaluiert werden. Durch die Kombination der verschiedenen Therapieverfahren kann auch für Patient*innen mit fortgeschrittener Erkrankung eine jahrelange Prognose bei guter Lebensqualität erreicht werden. Wichtig für die Therapieentscheidung sind neben patientenindividuellen Faktoren der Differenzierungsgrad des Tumors, dessen hormonelle Sekretion, das Metastasierungsmuster und der Erkrankungsverlauf. Die Behandlung von Lebermetastasen umfasst neben den unterschiedlichen chirurgischen Strategien die lokal-ablativen radiologischen und nuklearmedizinischen Verfahren, die als Ergänzung zu den systemischen Therapien zur Verfügung stehen.

Ziel/Aim: In patients with non-small cell lung cancer (NSCLC) undergoing treatment with curative intent, the asphericity (ASP) of the primary tumor’s metabolic tumor volume (MTV) has been demonstrated as a prognostic factor. This study aimed at validation in an independent cohort with sufficient sample size. Methodik/Methods: Retrospective study in 313 NSCLC patients (203 men; median age, 67 [41-87] a) undergoing FDG-PET/CT with the same scanner prior to treatment in curative intent (always including resection of the primary tumor). 137 patients had UICC stage I, 79 patients stage II and 97 patients stage III disease (adenocarcinoma [ADC], 153; squamous cell carcinoma [SCC], 143, other, 17). Delineation of primary tumor MTV with semiautomated background-adapted threshold relative to its SUVmax. Univariable Cox regression for progression-free (PFS) and overall survival (OS) for PET parameters (MTV, ASP, SUVmax, SUVmean), clinical (UICC stage I vs. II vs. III), histological (SCC vs. ADC) and treatment variables (Rx/1 vs. R0 resection, chemotherapy yes/no, radiotherapy yes/no). Multivariable Cox of parameters significant in univariate Cox. Ergebnisse/Results: Events (progression, relapse, death) occurred in 169/313 patients, 139 patients died (median follow-up in survivors, 37 months). In multivariable Cox for OS, ASP >33.3% (hazard ratio [HR], 1.53 [95%-confidence interval, 1.02-2.3]), Rx/1 vs. R0 resection (HR, 2.47 [1.5-4.2]) and SCC vs. ADC (HR, 1.53 [1.1-2.2]) were significant. Log-rank test for ASP was significant at any cut-off from 18% upwards. Among separate UICC stages, ASP was only prognostic for OS in stage II (optimal, >19.5%; median OS, 33 vs. 59 months; p21.2% (HR, 1.75 [1.2-2.5]) and Rx/1 vs. R0 (HR, 2.48 [1.5-4.1]) were significant. Log-rank test for ASP was significant at any cut-off from 10-60%. Schlussfolgerungen/Conclusions: ASP was validated as an independent predictor of PFS and OS in NSCLC patients with curative treatment intent. Subdividing UICC stages, ASP remained prognostic in stage II.

Die Leitlinie soll medizinisches Fachpersonal und onkologisch tätige Ärzte bei der Auswahl geeigneter Patienten, der Planung, Vorbereitung und Durchführung einer SIRT zur Behandlung primärer und sekundärer maligner Lebertumoren unterstützen. Schwerpunkte sind personelle, technische und organisatorische Anforderungen an das Therapiezentrum einschließlich Strahlenschutz, d. h. insbesondere die Notwendigkeit einer interdisziplinären Patientenselektion in Tumorboards und die Anforderungen an das Team, das die Therapie durchführt und einen Medizinphysikexperten einbeziehen muss. Die Zielsetzung der Therapie, die erforderlichen Daten und Voruntersuchungen für die Indikationsstellung und Therapieplanung und ihre Implikationen für die Vermeidung von Komplikationen werden dargestellt, ebenso Anforderungen an die Aufklärung des Patienten. Die Nachsorge wird beschrieben und auf die Notwendigkeit einer interdisziplinären Zusammenarbeit auch mit heimatnahen behandelnden Ärzten hingewiesen.

During the last years angiographic Selective Internal Radiotherapy (SIRT) with (90)Y-labelled microspheres has become a common technique for the local-ablative treatment of cancer patients. SIRT is a palliative therapy concept for the treatment of liver malignancies. As a result of (90)Y-decay as β(-)-emitter without a concomitant gamma radiation, Bremsstrahlung imaging is needed to validate the distribution achieved by radioembolisation. This article demonstrates the method of imaging through phantom measurement and shows the advantages of post-therapeutic tomography by means of a patient study. Approaches for further optimization of Bremsstrahlung imaging are discussed.

As far as the management of primary resectable liver metastases is concerned, three approaches are currently competing with each other: surgery alone, surgery with pre- and postoperative chemotherapy, and surgery with postoperative chemotherapy alone. The core of the argument for pre- and postoperative chemotherapy in these patients is the European Organisation for Research and Treatment of Cancer (EORTC) 40983 study, which concluded that, in comparison with surgery alone, perioperative chemotherapy improved the 3-year progression-free survival (PFS) by 7 months. In contrast to this, there are two smaller studies--at a somewhat lower strength of evidence-- indicating that adjuvant chemotherapy extends PFS by 9.1 months compared with surgery alone. In Germany, the adjuvant approach continues to be favored in many places; this can also be seen in the formulation of the S3 guideline. In patients with unresectable liver metastases--with the associated difficulty of classification due to the lack of clear and definitive criteria--preoperative systemic therapy to induce 'conversion' is indicated, in order to allow secondary resection. In KRAS wild-type tumors, high response rates (in terms of a reduction in size of the metastases, such as according to RECIST (Response Evaluation Criteria in Solid Tumors)) and a high conversion rate are achieved using a cetuximab/chemotherapy combination. Triple chemotherapy combinations with 5-fluorouracil (5-FU), oxaliplatin and irinotecan also produce high response rates. Bevacizumab/chemotherapy combinations have led to a high number of complete and partial pathohistological remissions in phase II studies; these seem to correlate with long survival times. In the absence of long-term survival data, it therefore seems to remain unclear as to what is the best parameter to use in order to assess the success of preoperative treatment. Lung metastases, too, or local peritoneal carcinomatosis can nowadays be operated on in selected patients with a good prospect of long-term remission or even cure. The surgery should, however, generally only be carried out in experienced centers, especially in the case of peritoneal carcinomatosis. For synchronous metastasization, the appropriate management depends on the size and extent of liver metastases and of the primary tumor. Small, peripherally lying and safely resectable liver metastases can be removed before or at the same time as the primary tumor, especially if a hemicolectomy is being carried out. If the metastases are unresectable and there is no bleeding or stenosis, the primary tumor can also be left in situ and systemic chemotherapy can be carried out first. However, it should be borne in mind that, according to current data, palliative resection of the primary tumor combined with systemic therapy leads to longer overall survival than does chemotherapy alone. Whether resection or chemotherapy should be done first therefore depends on the patient's clinical situation.

As far as the management of primary resectable liver metastases is concerned, three approaches are currently competing with each other: surgery alone, surgery with pre- and postoperative chemotherapy, and surgery with postoperative chemotherapy alone. The core of the argument for pre- and postoperative chemotherapy in these patients is the European Organisation for Research and Treatment of Cancer (EORTC) 40983 study, which concluded that, in comparison with surgery alone, perioperative chemotherapy improved the 3-year progression-free survival (PFS) by 7 months. In contrast to this, there are two smaller studies--at a somewhat lower strength of evidence-- indicating that adjuvant chemotherapy extends PFS by 9.1 months compared with surgery alone. In Germany, the adjuvant approach continues to be favored in many places; this can also be seen in the formulation of the S3 guideline. In patients with unresectable liver metastases--with the associated difficulty of classification due to the lack of clear and definitive criteria--preoperative systemic therapy to induce 'conversion' is indicated, in order to allow secondary resection. In KRAS wild-type tumors, high response rates (in terms of a reduction in size of the metastases, such as according to RECIST (Response Evaluation Criteria in Solid Tumors)) and a high conversion rate are achieved using a cetuximab/chemotherapy combination. Triple chemotherapy combinations with 5-fluorouracil (5-FU), oxaliplatin and irinotecan also produce high response rates. Bevacizumab/chemotherapy combinations have led to a high number of complete and partial pathohistological remissions in phase II studies; these seem to correlate with long survival times. In the absence of long-term survival data, it therefore seems to remain unclear as to what is the best parameter to use in order to assess the success of preoperative treatment. Lung metastases, too, or local peritoneal carcinomatosis can nowadays be operated on in selected patients with a good prospect of long-term remission or even cure. The surgery should, however, generally only be carried out in experienced centers, especially in the case of peritoneal carcinomatosis. For synchronous metastasization, the appropriate management depends on the size and extent of liver metastases and of the primary tumor. Small, peripherally lying and safely resectable liver metastases can be removed before or at the same time as the primary tumor, especially if a hemicolectomy is being carried out. If the metastases are unresectable and there is no bleeding or stenosis, the primary tumor can also be left in situ and systemic chemotherapy can be carried out first. However, it should be borne in mind that, according to current data, palliative resection of the primary tumor combined with systemic therapy leads to longer overall survival than does chemotherapy alone. Whether resection or chemotherapy should be done first therefore depends on the patient's clinical situation.