前列腺癌根治术切缘阳性的诊断和治疗

随着近年我国前列腺癌诊治水平的不断提高，传统的开放和腹腔镜下前列腺癌根治术已广泛运用于临床实践，成为目前治疗局限性前列腺癌的主要方式。切缘阳性是前列腺癌根治术最常遇到的问题之一，一旦发生便意味着前列腺肿瘤很可能未被完全清除，患者出现生化复发，临床进展的可能性增加，直接影响患者的生存预后。但在国内切缘阳性的问题尚未引起足够重视。因此，如何正确诊断和评价切缘阳性，降低切缘阳性的发生率，提高前列腺癌根治术的治疗效果，是我们泌尿外科医生亟需正视的问题。     

前列腺癌根治切除术后阳性手术切缘的预测

前列腺癌根治术后出现阳性手术切缘（ｐｏｓｉｔｉｖｅｓｕｒｇｉｃａｌ ｍａｒｇｉｎｓ ＰＳＭ） 的机会相对较多，而ＰＳＭ患者多预后不良。认识ＰＳＭ 的影响因素，可预防前列腺切除术后ＰＳＭ 的发生。本文对ＰＳＭ的影响因素作一简要综述。     

前列腺癌根治切除术后阳性手术切缘的预测

前列腺癌根治术后出血阳性手术切缘的机会相对较多，而ＰＳＭ患者多预后不良。认识ＰＳＭ的影响因素，可预防前列腺切除术后ＰＳＭ的发生。本文对ＰＳＭ的影响因素作一简要综述。     

根治性前列腺切除术切缘阳性对前列腺癌患者预后的影响

作者回顾分析了1983-2000年由2位医生完成的1389例前列腺癌根治手术。临床分期为T1 579例，T2 734例，T3 76例。共有179例肿瘤切缘阳性（PSM），其中37例接受了辅助治疗（AT），放疗29例，内分泌治疗8例。考虑AT对治疗结果的影响，采用5种均衡危险因素的统计学方法：①排除AT，②包含但忽略AT，⑧开始AT时剔除，④开始AT时忽略，⑤AT作为一个时间依赖性变量。结果：方法1，3，4和5均证实PSM是预测肿瘤复发的有效指标，     

前列腺癌根治术后切缘阳性相关危险因素及处理方案的研究进展

切缘阳性是前列腺癌根治术后的常见问题,长期以来术后切缘阳性率是判断手术质量及患者预后、制定术后辅助治疗方案的重要指标之一.切缘阳性是预后不良的重要预测因素.切缘阳性意味着前列腺癌组织很可能未被完整切除,患者出现生化复发乃至临床进展的可能性大大增加.影响切缘阳性的相关危险因素有很多,包括肿瘤体积大小、肿瘤分期、病理分级、...     

腹腔镜下前列腺癌根治术后切缘阳性的危险因素分析

目的 探讨腹腔镜下前列腺癌根治术后切缘阳性的相关危险因素.方法 回顾性分析2014年9月至2019年12月在苏州大学附属第一医院泌尿外科行腹腔镜下前列腺癌根治术的499例患者资料,其中术后切缘阳性79例,切缘阴性420例.采用单因素分析患者年龄、术前PSA(≤20 ng/ml vs>20 ng/ml)、前列腺体积、穿刺...     

腹腔镜下前列腺癌根治术后切缘阳性的相关因素分析

目的 探讨腹腔镜下前列腺癌根治术后切缘阳性的相关因素. 方法 2004年2月至2007年9月,采用腹膜外途径行腹腔镜下前列腺癌根治术33例.患者年龄57～78岁,平均70岁.术前均经病理证实前列腺癌诊断.Gleason评分3+3者14例(43%)、3+4者11例(33%)、4+3者6例(18%)、4+4者2例(6%),临床分期T1a～T1b 4例(12%)、T1c14例(43%)、T2a～T2b 5例(15%)、T2c 10例(30%).多因素回归分析比较根治术后标本切缘阳性与阴性组临床及生物学参数指标. 结果 腹腔镜下完成前列腺癌根治术31例,中转开放手术2例.术后病理报告切缘阳性9例(27%)、阴性24例(73%).切缘阳性组与阴性组患者术前临床分期T2c分别为6例(67%)和4例(17%)(P=0.010),术后Gleason评分＞7分者分别为3例(33%)和0例(P=0.015),术前PSA＞20ng/ml分别为4例(44%)和5例(21%)(P=0.178),直肠指诊可触及结节或局部质硬者分别为4例(44%)和9例(38%)(P=0.509).多因素回归分析结果显示:临床分期T2c与切缘阳性呈独立正相关关系(OR=24.69),T2c患者术后切缘阳性率明显增高.术前Gleason评分＞7分者切缘阳性率增高,PSA＞20 ng/ml者切缘阳性率有增高趋势,但二者需结合临床分期等指标综合判断对术后切缘阳性的影响.直肠指诊触及结节或质硬者切缘阳性率略增高,可作为参考指标. 结论 影响腹腔镜下前列腺癌根治术后切缘阳性的因素为临床分期、术前病理Gleason评分、总PSA和直肠指诊.临床分期可以作为预测术后切缘阳性的独立相关因素,≥T2c期的患者术后切缘阳性率明显增加.Gleason评分＞7分、PSA＞20 ng/ml作为重要参考指标,应结合临床分期综合分析;直肠指诊有结节或质硬可作为参考指标.     

腹腔镜和开放前列腺癌根治术后配对比较切缘阳性情况

目的 通过配对比较腹腔镜和开放性前列腺癌根治术两种不同手术方式,明确术后切缘阳性的影响因素。方法 回顾性分析我院2012年12月至2014年7月行前列腺癌根治术230例患者,其中行开放手术136例,腹腔镜94例,术后通过前列腺整体组织大切片的方式由我院泌尿病理医师阅片评估术后切缘阳性情况及部位。结果 通过倾向指数评分配对比较腹腔镜和开放手术效果,其中腹腔镜94例占40.9%。根据患者年龄、PSA水平和穿刺Gleason评分进行配对,最终选取腔镜和开放手术患者各94例进行分析。两组人群的年龄、PSA水平、穿刺Gleason评分和病理T分期均无显著差异。年龄、PSA、穿刺Gleason综合、T分期和手术方式5个变量进行多因素分析,可发现仅有术后病理T分期可作为切缘阳性的独立预后因素。无论是总体切缘阳性率还是不同部位的切缘阳性率,腹腔镜手术和开放手术相比均没有显著差异(P>0.05)。结论 两组人群的手术切缘阳性率没有显著性差异,提示腹腔镜手术提供了不劣于开放手术的肿瘤切除的完整性。     

手术切缘阳性是否和前列腺癌特异性死亡率密切相关?

<正>前列腺癌根治术后切缘阳性意味着肿瘤很可能没有被完全清除,患者的5年生化复发率可达50%~60%,并且基本上最终均会出现临床复发。手术切缘通常是评价手术质量高低的标准之一,临床上切缘阳性患者需要进一步接受辅助放疗,然而,到底手术切缘阳性和患者前列腺癌特异性死亡率之间存在何种关系目前仍不清楚。《欧洲泌尿学》杂志(STEPHENSON AJ,EGGENER SE,HERNANDEZ     

Robotic-assisted laparoscopic and radical retropubic prostatectomy generate similar positive margin rates in low and intermediate risk patients

ObjectiveRobotic-assisted laparoscopic prostatectomy (RALP) is being increasingly utilized. To assess the efficacy of the operation, we compared apical and overall margin status for RALP with radical retropubic prostatectomy (RRP) in a group of contemporary patients.Patients and methodsWe retrospectively reviewed 98 consecutive RRPs and then 94 RALPs from a single institution. Groups were analyzed and matched with regard to preoperative prostate-specific antigen (PSA), cancer grade, pathologic stage, and tumor volume. Surgical margins were quantitated.ResultsClinicopathologic parameters were compared and additional high risk patients were observed in the RRP vs. RALP group. To risk-adjust these patient groups, those meeting preoperative high risk criteria were excluded from further positive margin analysis. Postoperatively, the average tumor volume was 13% in both groups. Pathologic stage pT3 was similar between RRP (14%) and RALP (11%). A positive surgical margin (PSM) was found in 12 cases (14%) after RRP and 11 cases (13%) after RALP including apical margins. Positive margins at the apex, non-apex, and both were statistically similar between groups.ConclusionsIn this study, no differences were seen between robotic prostatectomy with regard to apical or overall margin status compared with open prostatectomy in lower risk patients. This suggests that despite improved visualization, RALP generates a similar margin status as RRP.     

Prognostic significance of a positive surgical margin in pathologically organ‐confined prostate cancer

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To identify risk factors of a positive surgical margin (PSM) and the significance of a PSM after radical prostatectomy (RP) on biochemical recurrence (BCR) in exclusively pathologically confirmed organ‐confined (OC) prostate cancer, as despite an excellent prognosis after RP, some patients with pathologically confirmed OC disease have BCR, and the prognostic significance of a PSM in these men remains unclear.

PATIENTS AND METHODS

We assessed 932 men with pathologically OC disease who were treated with RP by nine different surgeons between 1992 and 2004. The prognostic significance of clinical and pathological variables, including tumour volume (TV) and percentage of high‐grade TV (%HGTV) were assessed. Logistic and Cox regression models were fitted to identify risk factors of a PSM and BCR. BCR was defined as a prostate‐specific antigen (PSA) level of 0.1 ng/mL and increasing after an undetectable PSA level.

RESULTS

The total PSM rate was 12.9% (120 men); the mean TV (P < 0.001), but not %HGTV (P= 0.2) was significantly higher in patients with PSM. TV, nerve‐sparing RP technique and surgical volume were independent risk factors for a PSM (P= 0.03). After a median follow‐up of 35 months the overall BCR rate was 8.8% (82 men). Patients with a PSM had significantly higher BCR rates (21.7% vs 6.9%; P < 0.001). In univariable analysis, a high %HGTV (70.4%) was the most informative risk factor of BCR, followed by RP Gleason score (65.8%) and PSM (65.7%). Removal of PSM from a multivariable Cox model decreased the accuracy by 12.1% (P < 0.001).

CONCLUSIONS

Our findings show that in OC prostate cancer, the risk of a PSM depends on TV, surgical technique and surgical volume. PSM is a significant risk factor for BCR. However, only 20% men with OC disease and a PSM develop BCR; conversely, 80% of men are cured despite a PSM. Therefore, adjuvant therapy must be considered, with caution to avoid unnecessary overtreatment.     

Creation and internal validation of a biopsy avoidance prediction tool to aid in the choice of diagnostic approach in patients with prostate cancer suspicion

Introduction

To reduce unnecessary prostate biopsies while using novel tests judiciously, we created a tool to predict the probability of clinically significant prostate cancer (CSPC) vs. low-risk prostate cancer or negative biopsy (i.e., when intervention is likely not needed) among men undergoing initial or repeat biopsy.

腹膜外途径腹腔镜下根治性前列腺切除术切缘阳性的影响因素

目的探讨经腹膜外途径腹腔镜下根治性前列腺切除术后切缘阳性的影响因素。方法回顾性分析我院2010年1月至2018年12月99例行腹膜外途径腹腔镜下根治性前列腺切除术患者的临床资料。年龄51~79岁,平均(65.37±6.07)岁;前列腺特异抗原(PSA)2.80~79.50ng/mL,平均(16.84±12.28)ng/mL。分析术后病理切缘阳性的特征。按年龄、体质指数、术前PSA水平、穿刺针数阳性百分率、穿刺至手术时间、穿刺病理Gleason评分、临床T分期、前列腺癌危险分度、术后病理Gleason评分、术后T分期、腹盆腔手术史等进行分组,分析各组切缘阳性率的差异。采用χ^2检验进行单因素分析,有统计学差异的变量进入多因素Logistic回归分析,评价临床及病理相关资料与切缘阳性的关系。结果本组99例患者均在腹腔镜下顺利完成,无1例中转开放,手术时间平均(199.66±66.01)min,术中出血量平均(152.02±140.28)mL。术后病理证实均为前列腺癌,术后病理切缘阳性26例(26.3%)。将各危险因素分组后进行单因素分析,结果显示不同穿刺针数阳性百分率(P=0.047)、穿刺病理Gleason评分(P=0.023)、术后病理Gleason评分(P=0.007)、术后T分期(P=0.004)与切缘阳性存在相关性(P<0.05),而年龄(P=0.134)、体质指数(P=0.838)、术前PSA水平(P=0.299)、穿刺至手术时间(P=1.000)、临床T分期(P=0.821)、前列腺癌危险分度(P=0.903)、腹盆腔手术史(P=0.607)与切缘阳性均无相关性(P>0.05)。将单因素分析差异有统计学意义的指标及术前PSA、临床分期进行多因素分析,结果显示仅术后T分期(P=0.011)是切缘阳性的独立危险因素。结论穿刺针数阳性百分率、穿刺病理Gleason评分、术后病理Gleason评分、术后T分期与切缘阳性存在相关性,其中穿刺针数阳性百分率、穿刺病理Gleason评分及术后T分期越高,切缘阳性率越高。术后T分期是经腹膜外途径腹腔镜下根治性前列腺切除术后切缘阳性的独立危险因素。     

Prediction of indolent prostate cancer: validation and updating of a prognostic nomogram

PURPOSE: Screening with serum prostate specific antigen testing leads to the detection of many prostate cancers early in their natural history. Statistical models have been proposed to predict indolent cancer. We validated and updated model predictions for a screening setting. MATERIALS AND METHODS: We selected 247 patients with clinical stage T1C or T2A from the European Randomized Study on Screening for Prostate Cancer who were treated with radical prostatectomy. We validated a nomogram that had previously been developed in a clinical setting. Predictive characteristics were serum prostate specific antigen, ultrasound prostate volume, clinical stage, prostate biopsy Gleason grade, and total length of cancer and noncancer tissue in biopsy cores. Indolent cancer was defined as pathologically organ confined cancer 0.5 cc or less in volume without poorly differentiated elements. Logistic regression was used to update the previous model and examine the contribution of other potential predictors. RESULTS: Overall 121 of 247 patients (49%) had indolent cancer, while the average predicted probability was around 20% (p <0.001). Effects of individual variables were similar to those found before and discriminative ability was adequate (AUC 0.76). An updated model was constructed, which merely recalibrated the nomogram and did not apply additional predictors. CONCLUSIONS: Prostate cancers identified in a screening setting have a substantially higher likelihood of being indolent than those predicted by a previously proposed nomogram. However, an updated model can support patients and clinicians when the various treatment options for prostate cancer are considered.     

PAP和PSA与前列腺癌诊治的关系

目的 :探讨前列腺酸性磷酸酶 (PAP)、前列腺特异抗原 (PSA)与前列腺癌的诊断、临床分期、预后判断的关系。方法 :用放射免疫测定法 (RIA)检测经病理检查证实的前列腺癌 5 2例 ,同时以 PAP、PSA辅助诊断。结果 :PSA阳性率明显高于直肠指检、B超和 PAP(P <0 .0 5 )。PAP和 PSA升高与前列腺癌的分期、肿瘤细胞分化程度具有相关性。结论 :PAP和 PSA对前列腺癌的诊断、临床分期、预后判断有较大应用价值     

Clinical effect of a positive surgical margin without extraprostatic extension after robot-assisted radical prostatectomy

ObjectivesThe aim of this study was to investigate the effect of positive surgical margin (PSM) without extraprostatic extension after robot-assisted radical prostatectomy (RARP).Materials and methodsWe retrospectively reviewed 837 patients who underwent RARP for clinically localized prostate cancer without neoadjuvant endocrine therapy. The pT2+category lesions were defined according to World Health Organization classification. The actuarial probabilities of biochemical recurrence-free survival (BCR-FS) were determined using Kaplan-Meier analysis. Univariate and multivariate Cox proportional hazards regression analyses were also used to identify independent predictors for BCR.ResultsOf the 837 patients, 102 (12.2%) experienced BCR during the follow-up period. The BCR-FS rate was significantly higher in patients with pT2+category tumors than in those with pT3a category tumors, and significantly lower in patients with pT2+category tumors than that in those with pT2 category tumors without PSM. The BCR-FS rate of patients with pT2+category tumors was significantly higher than that with pT3a category tumors with PSM but not significantly different from that with pT3a category tumors without PSM. In a multivariate analysis, the pathological T category considering pT2+category was one of independent predictive factors for BCR.ConclusionsThis study support the hypothesis that the pT2+category disease is associated with a significantly increased risk of BCR in patients with organ-confined prostate cancer after RARP. As PSM can be avoided in some cases, urologists should continually seek to improve their operative skills and to reduce the rate of PSM, especially in patients with organ-confined prostate cancer.     

Influence of pathological factors on oncological outcomes after robot-assisted radical prostatectomy for localized prostate cancer: Results of a prospective study

PurposeTo assess the prognostic significance of lymphovascular invasion (LVI), maximum tumor diameter (MTD), high-grade prostatic intraepithelial neoplasia, perineural invasion, and length of positive surgical margins after robot-assisted radical prostatectomy (RARP).MethodsA single-institution prospective analysis of all patients who underwent RARP for localized prostate cancer was performed between January 2005 and June 2013. The primary end point was biochemical recurrence-free survival (BRFS). BRFS was estimated using the Kaplan-Meier method and compared to that from the log-rank test. Cox׳s proportional hazards regression univariate and multivariate analyses were performed to define the prognostic factors.ResultsOverall, 742 men were included. After a median follow-up of 31.4 months, biochemical recurrence occurred in 80 patients (10.8%). BRFS was 93%, 87%, and 80.7% at 1, 3, and 5 years, respectively. Progression to local recurrence occurred in 49 patients (6.6%). During the follow-up period, 3 patients experienced progression to metastatic disease and were treated with hormonotherapy. No patient died of disease during the study period. In multivariate analyses, Gleason score was the strongest predictor of BRFS (hazard ratio [HR] = 3.4; P<0.001). There were 3 other predictive factors of BRFS were LVI (HR = 7.64; P = 0.005), MTD (HR = 4.04; P =0.009), and margin length≥3 mm (HR = 1.25; P = 0.04).ConclusionIn the era of serum prostate-specific antigen testing maturity in conjunction with a single approach to extirpation of the prostate gland by RARP, LVI, MTD, and positive surgical margins≥3 mm are prognostic factors associated with BRFS after RARP. Consideration could be given to incorporate them in the pathology report of the radical prostatectomy specimens and they could assist physicians in clinical decision making.     

Rates of margin positive resection with breast conservation for invasive breast cancer using the NCDB

BackgroundPrevious studies suggest the rate of positive surgical margin (PSM) after lumpectomy for breast cancer is approximately 20 %. The risk of PSM at time of resection is often a source of fear for patients, driving some to elect to undergo mastectomy. This study describes rates and predictors of positive margins for invasive breast cancers in the National Cancer Database (NCDB).Materials and methodsFrom 2004 to 2013, patients with non-metastatic invasive breast cancers who underwent breast conservation surgery were identified from the NCDB. Patients’ demographic, clinical, and facility of treatment characteristics were collected and compared. Per SSO-ASTRO-ASCO criteria, margin negative is defined as no gross or microscopic disease (i.e. no tumor on ink). Bivariate tests and multivariate logistic regression were conducted to identify independent predictors of patients with PSM at the time of resection.ResultsA total of 707,798 patients were identified with non-metastatic invasive breast tumors who underwent lumpectomy. Rate of PSM across the entire cohort was 5.02 %. Over time, the rate of PSM decreased significantly from 6.54 % in 2004 to 3.91 % in 2013 (p < 0.001). Pure lobular histology predicted for the highest rate of PSM compared with IDC (8.63 vs 4.55 %; p < 0.001). In adjusted analysis, high grade, non-ductal histology and HER2 amplification were significantly associated with PSM with breast conservation while estrogen and progesterone status were not.ConclusionThis study demonstrates a 5 % risk of PSM at time of breast conservation surgery using a large, modern national database. Patients with invasive lobular and mixed histology have a nearly two-fold risk of PSM compared to invasive ductal cancers. These results provide important data points to help appropriately counsel patients regarding the risk of PSM.