辅助内分泌配合放射性粒子组织间植入治疗局限性前列腺癌

目的探讨辅助内分泌配合放射性粒子组织间植入治疗局限性前列腺癌的安全性和有效性。方法22例T1-T24前列腺癌患者在采用直肠超声引导经会阴穿刺放射性^125I粒子组织间植入治疗前后，给予辅助内分泌治疗4—7（平均5．7）个月。术前2—4（平均3．2）个月，术后1—4（平均2．1）个月。结果22例手术均顺利完成，手术时间60-120（平均90）min，植入^125I粒子数40-75（平均56）枚，术后随访12—48个月，血PSA≤1ng／mL15例，1ng／mL≤PSA≤2ng／mL2例，PSA≥2ng／mL5例。结论辅助内分泌配合放射性粒子组织间植入治疗局限性前列腺癌安全有效。     

局限性前列腺癌近距离照射治疗的有效性研究

目的 研究近距离照射治疗局限性前列腺癌的效果及其影响因素.方法 回顾性分析2001年4月至2011年3月于北京大学第一医院泌尿外科接受近距离照射治疗的61例局限性前列腺癌患者资料,其中联合外放疗11例.患者年龄57～84岁,平均75.2岁.肿瘤临床分期:T1c 12例,T2a 18例,T2b 17例,T2c 14例.Gleason评分平均7分(范围5～9分).随访术后前列腺特异抗原(PSA)变化及不良反应发生情况,绘制Kaplan-Meier生化无复发生存曲线,并以单因素Cox回归分析和Log-rank检验分析治疗效果的影响因素.结果 61例患者获得随访,随访时间9～126个月,中位随访时间49个月.术前PSA平均为(17.80±14.44) μg/L,术后PSA最低值平均为(1.16±1.15) μg/L.58例(95.1％)患者最低PSA＜4.0μg/L,37例(60.7％)患者最低PSA＜1.0μg/L,达最低PSA时间平均为术后11.6个月,术后短期不良反应少见(发热、血尿、便血等),长期不良反应主要为尿路刺激症状.近距离照射治疗后平均生化无复发生存时间的估计值为41.0个月.接受联合外放疗的11例患者治疗后PSA最低值平均为1.32 μg/L,平均生化无复发生存时间为38个月.PSA所达最低值是否＜1.0μg/L对生化无复发生存时间有显著影响(x2=4.445,P=0.035).结论 近距离照射治疗对局限性前列腺癌疗效肯定,严重不良反应少见;治疗后PSA最低值是否＜1.0μg/L有助于判断预后.     

间歇内分泌治疗联合~（125）I放射性粒子植入治疗局限性前列腺癌的临床观察

目的探讨间歇性内分泌治疗（IHT）联合125I放射性粒子组织间植入治疗局限性前列腺癌的临床价值。方法 56例局限性前列腺癌患者在采用直肠超声引导植入125I放射性粒子前后,分别给予间歇内分泌治疗（全雄激素阻断）,术前为2～3（平均2.8）个月及术后3～5（平均3.6）个月,以后依据每月监测PSA的值决定是否再次启动内分泌治疗。结果 56例手术均顺利完成,手术时间30～62（平均52）min,术中使用穿刺针21～30根,植入125I放射性粒子数40～82枚,平均58枚。术后随访6～68个月,平均48个月。术后2～4个月所有患者的PSA都降到0.2ng/mL以下,其中20例的PSA值降到0ng/mL。对随访中16例再次出现PSA升高的患者,给予间歇内分泌治疗,2例同时加用外放疗,其中12例患者PSA维持0.2ng/mL以下,4例转变为雄激素非依赖性,并发生骨转移,其中2例术后4年死亡。术后出现血尿14.28%（8/56）,轻至中度尿路刺激症状及会阴部不适28.57%（16/56）,直肠刺激征10.71%（6/56）,血便1.78%（1/56）,多数患者症状随访1年后缓解。无尿道狭窄及尿失禁等并发症出现。目前52例患者的PSA值在0.2ng/mL以下,处于脱离治疗期。2年、3年和5年PSA无进展生存率分别是96.43%（54/56）、94.64%（53/56）、92.86%（52/56）。结论间歇性内分泌治疗联合125I放射性粒子植入是治疗局限性前列腺癌的安全有效方案。     

高能聚焦超声治疗激素非依赖性前列腺癌

目的探讨高能聚焦超声（HIFU）治疗激素非依赖性前列腺癌的临床效果。方法对本组12例激素非依赖性前列腺癌行HIFU治疗，术后随访3—20个月，平均14个月。结果治疗前后血清前列腺特异性抗原（PSA）值分别为（42．5±20．2）ng／mL、（10．4±6．6）ng／mL；前列腺体积为（45．2±12．5）mL、（3．5±1．1）mL；国际前列腺症状评分为19．5±5．5、8．5±4．5，治疗前后比较具有显著差异（P〈0．05）；治疗并发症：轻度血尿2例。结论HIFU治疗激素非依赖性前列腺癌近期疗效确切、并发症少。     

综合治疗中晚期前列腺癌132例

目的评估中晚期前列腺癌患者的综合治疗效果。方法对1995年1月-2004年6月收治的132例中晚期前列腺癌患者行经尿道前列腺切除术＋双侧睾丸切除术，术后口服氟他胺（250mg，3次／日）综合治疗。结果经尿道前列腺切除后患者排尿困难、血尿症状明显改善，血PSA由（70．8±50．6）ng／mL下降至（38．9±28．1）ng／mL；48例术前发现有骨转移者，术后3个月35例行ECT扫描，均提示骨转移灶减少、缩小，浓集影部分变淡，46例骨关节疼痛减轻；12例患者术后1—2年出现PSA升高，全身骨转移灶加重，病情加重死亡。结论经尿道前列腺切除术＋双侧睾丸切除术＋术后口服氟他胺的综合方案，治疗中晚期前列腺癌疗效较好。     

前列腺癌患者去势术后的睾酮水平

目的 探讨进展期前列腺癌患者去势术后平均睾酮水平，以指导内分泌治疗。方法 进展期前列腺癌患者40例，去势术后，未用任何抗雄激素药物，分别于术前、术后1周及1、3、6、9、12个月，观察血清总睾酮和PSA变化。结果 去势术后6个月，40例患者血清睾酮平均水平〈1．9nmol／L（95％可信区间1．2～1．9nmol／L）；13例患者睾酮〉1．9nmol／L，平均Gleason评分为6．8分。术后6个月，36例患者PSA〈1ng／ml，平均Gleason评分为6．3分；4例患者PSA〉1ng／ml，平均Glcason评分为8．0分。结论 前列腺癌患者去势术后，平均血清睾酮水平〈1．9nmol／L，部分患者需继续抗雄激素药物治疗。术后PSA逐渐下降，6个月降至最低值。     

超声引导下经直肠系统性12＋1针前列腺穿刺活检术

目的探讨超声引导下经直肠系统性12＋1针前列腺穿刺活检术诊断前列腺癌的临床价值。方法回顾性分析816例经直肠前列腺系统性12＋1针穿刺活检的可疑前列腺癌患者。其中PSA＜4ng／ml、直肠指诊发现结节者66例;PSA介于4～10ng／ml、f／tPSA值异常、PSAD值异常者190例;PSA〉10ng／ml、任何f／tPSA、PSAD值者560例。结果816例患者中活检病理确诊为前列腺癌者358例,总阳性率为43．9％（358／816）。其中位于前列腺尖部阳性者235例,占确诊病例总数的65．6％（235／358）。术后发热9例（1．0％,9／816）,并发血尿49例（6．0％,49／816）。几乎所有患者皆有短时大便带血。无其他严重并发症发生。结论超声引导下经直肠系统性前列腺12＋1针穿刺活检术定位准确,创伤较小,并发症较少。可以随机增加穿刺点,利于提高前列腺癌检出率。     

耻骨后前列腺癌根治术（附27例报告）

目的总结经耻骨后前列腺癌根治术的治疗体会。方法2000年-2005年27例局限性前列腺癌患者，年龄60-71岁，平均66岁，术前PSA值4．8—37．5ng／mL。B期21例，G1期6例。采用开放性前列腺癌根治术治疗。结果本组患者高分化癌7例，中分化癌15例，低分化癌5例，术中出血300—1200mL，平均560mL，无周围脏器损伤及围手术期死亡病例，无吻合口漏尿。无吻合口狭窄、排尿困难，6例出现暂时性尿失禁，分别于术后1—2月恢复。9例术后1个月PSA降为0，随访未见升高，无需服用抗雄激素药物；其余18例患者间断性服用抗雄激素药物PSA下降至0．2ng／mL。术后16例维持阴茎勃起功能，所有病例均无瘤存活。结论耻骨后前列腺癌根治术中保留耻骨前列腺韧带及耻骨直肠悬带有助于减少并发症，取得较好的疗效。     

经会阴前列腺癌根治术28例报告

目的 探讨经会阴前列腺癌根治术在早期局限性前列腺癌治疗中的应用价值。方法 总结28例临床分期T1a～T2b前列腺癌患者经会阴前列腺癌根治术临床资料。经直肠B超引导下前列腺穿刺活检，证实为前列腺腺癌，Gleason评分2～4分13例，5～7分15例。血清PSA2．3～16．6ng／ml，平均9．2ng／ml。术前CT或MRI检查确定前列腺癌局限于前列腺包膜内，胸部、脊椎与骨盆X线平片、ECT均未发现远处转移灶。临床分期T1a～Tb3例，T1a5例，T213例，T2b7例。结合血清PSA、临床分期和GMason评分预测临床早期前列腺癌的病理分期均在T2内，28例均行经会阴前列腺癌根治术，未行盆腔淋巴结切除。结果 术后保留导尿5d，拔除导尿管后，23例患者控尿良好，4例患者有3～7d短暂的尿失禁。发生尿道直肠瘘1例，术后2个月瘘道自行愈合。术后病理：肿瘤局限于前列腺包膜内27例，有单侧包膜外浸润（T3a）1例。28例术后随访6～30个月。术后3个月PSA〈0．04ng／ml24例，1例〈0．01ng／ml，2例未检测到PSA。1例切缘阳性（T3a）、术后PSA持续升高者，行双侧睾丸切除。术后6个月20例同时复查胸部X线片和全身骨扫描，未发现远处转移病灶。结论 经会阴前列腺癌根治术治疗早期局限性前列腺癌在肿瘤控制和排尿控制方面有突出优势，结合PSA、临床分期和Gleason评分选择的病例，不需行盆腔淋巴结切除。     

125I 放射性粒子植入术联合间歇性内分泌疗法治疗局部中高危前列腺癌

目的 探讨¹²⁵I放射性粒子植入术联合间歇性内分泌疗法治疗局部中高危前列腺癌的临床价值。方法 前列腺癌患者25例，年龄 64～85 岁，平均年龄75岁，前列腺特异性抗原（PSA）：10.3～354.8 ng/mL，Gleason 评分：7～9 分，临床分期T2～T3N0M0。椎管内麻醉，截石位，直肠超声从前列腺基底到尖部进行扫描，图像传送至计算机计划系统进行三维重建和术中计划，根据计划行直肠超声引导下经会阴¹²⁵I放射性粒子植入术，术后联合全部雄激素阻断疗法。当PSA达到0 ng/mL，并稳定2个月后停止内分泌治疗，当PSA连续3次上升，则重新开始内分泌治疗。结果所有患者手术均顺利，植入粒子85～110粒，平均93粒。术后随访8～20个月，平均12个月。术后3～6个月所有患者的PSA都降到正常范围，其中10例患者PSA未达到0 ng/mL，未停药。5例患者术后5～16个月，出现PSA反弹，再次用药3～5个月PSA值达到0 ng/mL。2例患者转变为激素非依赖性并出现骨转移。目前17例患者的PSA值在0～1.2 ng/mL之间，其中10患者PSA< 0.2 ng/mL。近期出现的并发症有轻至中度尿路刺激征24%（6/25），急性尿潴留8%（2/25），直肠刺激征和血便16%（4/25），多数患者症状随访1年后缓解。结论 对于局部晚期中高危前列腺癌，¹²⁵I放射粒子植入术联合间歇性内分泌疗法是一种安全有效的治疗方法。     

^125I粒子植入术联合手术去势治疗局部晚期前列腺癌40例报告

目的：探讨^125I粒子植入术联合手术去势治疗局部晚期前列腺癌的临床效果。方法：采用直肠B超引导下经会阴植入^125I粒子并同时行双侧睾丸切除术治疗晚期前列腺癌患者40例,年龄52～87岁,平均73岁;Gleason评分为3～9分,PSA检测为0．24～2736．46ng／ml,临床分期为T3N0M0。结果：所有患者手术过程顺利,平均植入粒子71±15粒。术后随访10～76个月,中位随访时间44．5个月。远期手术并发症（〉1年）尿失禁发生率为2．5％（1／40）,轻度血便发生率为10％（4／40）,尿道直肠瘘发生率为2．5％（1／40）。1例在术后69个月死亡,有5例在术后平均15．8个月出现PSA生化复发,累计PSA无进展患者生存率为86．9％。结论：运用^125I粒子植入术联合手术去势术治疗局部晚期前列腺癌患者长期并发症少,临床效果良好。     

局限高危前列腺癌患者接受全雄激素阻断联合近距离治疗后的PSA变化模式与其生存预后的临床关联分析

目的:探讨前列腺癌(PCa)患者治疗后PSA变化模式对其生存预后的临床影响。方法:回顾性总结近12年来114例接受全雄激素阻断(MAB)联合近距离治疗的PCa患者的临床资料,从PSA变化规律入手,初步分析患者生存预后的影响因素。结果:患者中位生存时间81(15~144)个月,1、3、5年生存率分别为91.23%、78.07%和68.42%。单因素分析显示:基线PSA水平、PSA最低值、PSA下降时间、PSA倍增时间以及PSA缓解幅度均是可能影响生存预后的临床因素。多因素分析显示:PSA最低值、PSA下降时间以及PSA缓解幅度是独立的预后因素,并分别提高了患者远期生存可能1.7、3.3和6.8倍。结论:局限高危PCa患者在接受MAB联合近距离治疗后,其PSA能否降至1μg/L以下、能否在3个月之内降至最低值,以及PSA最大缓解幅度能否达到96%等因素均是影响患者预后的独立风险因素。     

125I放射粒子植入治疗前列腺癌12例临床分析

目的探讨前列腺125I放射粒子植入内放疗在前列腺癌治疗中的意义。方法依据治疗计划,在直肠B超引导下,经会阴穿刺植入前列腺125I放射粒子对12例前列腺癌行三维适形内放疗。结果全组手术顺利,平均植入125I放射粒子58粒,平均手术时间80min,术后平均住院时间7．2d。随访12例术后3个月结果：平均PSA由19．8ng／mL降至0．74ng／mL;随访6例术后6个月结果：5例PSA进一步降低,平均降至0．11ng／mL;1例升高,由0．51ng／mL升高至1．65ng／mL;无1例出现严重的并发症。结论采用永久性放射粒子植入前列腺、三维适形内放疗是一种有效、微创的治疗前列腺癌的方法。     

High-dose rate iridium-192 brachytherapy and external beam radiation therapy for prostate cancer with or without androgen ablation

Aim: To report the results of our feasibility study incorporating iridium‐192 high‐dose‐rate (HDR) afterloading brachytherapy and external beam radiation therapy (EBRT) for the treatment of prostate carcinoma and to assess the role of androgen ablation in conjunction with this treatment option. Methods: From July 2000 to June 2002, 42 patients with clinically localized or locally extensive prostate carcinoma were treated with HDR iridium‐192 brachytherapy and EBRT with or without androgen ablation. The median follow up was 16.5 months. Results: The technique of HDR brachytherapy and EBRT proved to be feasible with acceptable morbidities. Continuous prostate‐specific antigen (PSA) reduction was noted in all patients and no PSA failure was noted during follow up. Within 1 year, the decline of PSA nadir values less than 1 ng/mL was faster in patients with the addition of androgen blockade (P = 0.001). However, within 1 year, PSA nadir values less than 1.0 ng/mL can be achieved in all patients whose initial PSA is less than 20 ng/mL, with or without hormone blockade. Conclusions: The need for hormonal therapy in favorable‐risk brachytherapy patients (PSA < 20 ng/mL) might be less than the need for intermediate‐ or high‐risk patients. The use of hormonal therapy in intermediate‐risk patients (PSA ≥ 20 ng/mL) treated with HDR brachytherapy and pelvic EBRT is appealing, considering the favorable results. High dose rate brachytherapy appears to be an effective treatment for clinically localized and locally extensive prostate cancer, with minimal morbidity.     

8点及12点前列腺穿刺活检诊断前列腺癌的价值比较研究

目的比较8点及12点前列腺穿刺活检诊断前列腺癌的价值,分析前列腺特异性抗原(PSA)、前列腺特异性抗原密度(PSAD)及前列腺体积(PV)对前列腺癌检出率(PCDR)的影响。方法回顾性分析260例因PSA异常增高而接受首次直肠超声引导下前列腺穿刺活检的患者相关资料,其中132例患者接受8点穿刺,128例患者接受12点穿刺。结果依据PSA、PV、PSA与PV及PSAD,患者被进一步分组。8点及12点的总的PCDR没有显著的差异,在PV≥45mL、PSA≥10ng/mL且PV≥45mL及0.15ng/(mL·cm3)≤PSAD≤0.25ng/(mL·cm3)组中,12点的PCDR明显高于8点。结论 8点及12点前列腺穿刺总的PCDR没有显著区别(P0.05),但在PV较大同时PSA较高或者PSAD处于中等大小时(0.15~0.25)ng/(mL·cm3),12点的PCDR明显高于8点(P均0.05)。     

Predictors of androgen independence in metastatic prostate cancer

OBJECTIVE: To assess the factors that influence the onset of androgen independence (AI, which heralds a dismal outcome) in patients with metastatic prostate carcinoma. PATIENTS AND METHODS: The records of 361 consecutive patients with prostate carcinoma diagnosed and treated in the authors' institution from 1 January 1996 to 31 December 1999 were reviewed retrospectively; 92 with metastatic prostate carcinoma were assessed (median age 71.0 years, range 42-93). Patients were included if they developed metastatic disease from prostate cancer at the time of diagnosis. The nadir for prostate specific antigen (PSA) level was defined as the date of the lowest PSA level after hormonal therapy, and AI was defined as the date of the third consecutive PSA increase above the nadir value by any threshold. RESULTS: The median Gleason sum was 8 and the modal Gleason score 4 + 5. The median (range) pretreatment PSA level was 274.0 (1.3-2179) ng/mL. Of the 92 men, 57 (62%) attained a nadir PSA, including 23 with a nadir of < 2 ng/mL; 32 (35%) progressed to AI within 2 years and 27% reached a nadir PSA but did not develop AI. The mean (sd) time from diagnosis to the nadir PSA was 13.7 (11.8) months, while the mean time from diagnosis to progression to AI was 30.3 (15.6) months. Univariate analysis showed that a nadir PSA level after treatment of >/= 1 ng/mL (P = 0.0128) was an early predictor of progression to AI; a nadir PSA level of >/= 2 ng/mL (P = 0.0216) was a predictor of poor overall survival. CONCLUSION: Failure to attain a nadir PSA of < 1 ng/mL after treatment predicts progression to AI and a nadir PSA of > 2 ng/mL predicts poorer overall survival. The development of skeletal events predicts the onset of AI but occurs late in the disease and is unsuitable as an early prognostic marker.     

PSA elevation during prostate cryosurgery and subsequent decline

PURPOSE: To determine the immediate effect of prostate cryosurgery on PSA and the subsequent decline. METHODS AND MATERIALS: PSA level was measured in 14 patients who underwent cryosurgery for prostate cancer. Blood samples were taken immediately before and after cryosurgery and 1, 2, 4, 6 weeks and 3 months postoperatively. A confidence interval for the elevation from baseline to maximal PSA was calculated. PSA decline was assessed in patients with a nadir PSA < or =0.5 ng/mL. Patients with a postoperative nadir PSA >0.5 ng/mL were considered to harbor viable cancer and were excluded from the decline analysis. The observed PSA levels during the postoperative period were compared with the expected levels that were calculated according to the maximal PSA level and a serum half-life of 2.5 days. Student t-test was used to compare expected and observed PSA levels. RESULTS: PSA increased from an average of 9.23 ng/mL preoperatively to a maximum average of 155 ng/mL (maximal PSA ranges: 18.9-490.5 ng/mL). The 95% CI for the increase in PSA from baseline level was 63.4 to 224.14. PSA nadir < or =0.5 ng/mL was achieved in 10 patients. The observed PSA decline course was slower than expected according to its half-life. Average observed and expected PSA levels at 2,4 and 6 weeks after cryosurgery were 10.4 versus 3.57 ng/mL (P = 0.005), 0.65 versus 0.07 (P = 0.007) and 0.09 versus 0.001 (P = 0.03), respectively. CONCLUSION: PSA levels increase steeply following cryosurgery, and decline slower than expected according to the serum half-life.     

Failing to achieve a nadir prostate-specific antigen after combined androgen blockade: Predictive factors

Objectives:   To determine the optimal cut-off of a nadir prostate-specific antigen (PSA) for prediction of progression within 24 months after combined androgen blockade (CAB) and to analyze predictive factors of failing to achieve the nadir PSA.
Methods:   We retrospectively reviewed the medical records of 343 patients with prostate cancer treated with CAB from 2000 to 2005. We determined the nadir PSA level that predicts progression to hormone refractory prostate cancer (HRPC) at 24 months after CAB. Predictive factors for failing to achieve a determined nadir PSA were analyzed.
Results:   Mean age was 74.0 years. Mean follow up was 42.1 month. Seventy-seven patients experienced progression to HRPC. A nadir PSA of 1.0 ng/mL predicts progression to HRPC at 24 months. Predictive factors for failing to achieve a nadir PSA of 1.0 ng/mL or less include pretreatment PSA, percentage positive biopsy core, Gleason score, serum hemoglobin, stage, and extent of bone metastasis in univariate analysis. Pretreatment PSA (>50 ng/mL) and serum hemoglobin (<12 g/dL) were significant factors to predict failing to achieve a nadir PSA of 1.0 ng/mL or less in logistic regression analysis.
Conclusions:   A nadir PSA of 1.0 ng/mL can predict progression to HRPC after CAB. Pretreatment PSA and serum hemoglobin are significant predictors of failing to achieve a nadir PSA of 1.0 ng/mL or less.     

老年男性静脉麻醉下经直肠超声引导无痛前列腺穿刺疼痛控制与并发症分析

目的：探讨前列腺特异抗原增高（PSA〉4/μg/L）老年男性静脉麻醉下经直肠超声引导无痛前列腺穿刺疼痛控制与并发症发生情况.方法：选取96例PSA增高老年男性患者（69±7岁）进行静脉麻醉下直肠超声引导无痛前列腺12针系统穿刺（静脉麻醉组）,并选取同期进行前列腺周围神经阻滞麻醉下直肠超声引导前列腺12针系统穿刺的51例PSA增高老年男性患者（67±6岁）为对照组.记录穿刺后30 min视觉模拟疼痛评分（VAS）、穿刺时间、麻醉不良事件和并发症发生情况.结果：静脉麻醉组90例（94%）为无疼痛（VAS=0）,6例（6%）为轻度疼痛 对照组21例（41%）为轻度疼痛,30例（59%）为中度疼痛.静脉麻醉组平均VAS评分和穿刺时间分别为（0.1±0.3）分和（5.1±1.3）min,显著低于对照组（3.85±1.2）分和（11.35±3.9）min.静脉麻醉组无一例发生麻醉不良事件.静脉麻醉组术后肉眼血尿、大便带血、发热和尿潴留的发生率分别为55%、15%、5%和3%,与对照组的差异无统计学意义（57%、18%、6%和4%）.结论：对于PSA增高老年男性患者,静脉麻醉直肠超声引导无痛前列腺穿刺具有无痛安全准确的优点.