Graefen M, Noldus J, Pichlmeier U, Haese A, Hammerer P, Fernandez S, Conrad S, Henke R, Huland E, Huland H
Department of Urology, University Hospital Eppendorf, Hamburg, Germany.
Eur Urol. 1999;36(1):21-30. doi: 10.1159/000019922.
This study was undertaken to distinguish between patients who will and will not benefit from a retropubic radical prostatectomy (RRP) for clinically localized prostatic carcinoma (PCa) on the basis of preoperative and postoperative tumor characteristics.
Data of 318 consecutive patients who underwent RRP for clinically localized PCa were reviewed. Preoperative characteristics used included clinical stage, findings on transrectal ultrasonography, prostate-specific antigen (PSA) values, Gleason grade, number of positive biopsies, number of biopsies containing any Gleason grade 4 and/or 5 cancer, and number of biopsies with predominant (>50% of cancerous tissue) Gleason grade 4 and/or 5 cancer. Postoperative characteristics included pathologic stage, Gleason grade, margin status, cancer volume, and volume of Gleason grade 4 and/or 5 cancer. The impact on biochemical relapse after RRP were calculated by Cox regression and CART (classification and regression tree) analysis to establish low, intermediate, and high risk of recurrence.
Of patients who underwent RRP, 66% showed no evidence of relapse after a follow-up of 42 months. All preoperative and postoperative characteristics showed a significant association with biochemical relapse. Cox regression of preoperative characteristics showed the number of positive biopsies with predominant Gleason grade 4 and/or 5 cancer to be the most accurate predictor of failure (p < 0.0001), followed by the number of positive biopsies and PSA. CART analysis distinguished between four risk groups on the basis of the same characteristics as in the Cox regression. The low-risk group consisted of 232 patients (75.1%) and the high-risk group of 17 patients (5.5%); corresponding Kaplan-Meier curves showed a 2-year PSA-free survival rate of 97% for the low-risk group and 20% for the high-risk group. Cox regression of postoperative characteristics recognized the volume of Gleason grade 4 and/or 5 as the characteristic with the strongest association with biochemical failure. CART analysis distinguished between four risk groups, using the volume of high-grade cancer as the most influential characteristic. The corresponding Kaplan-Meier curves showed for the low-risk group (n = 79; 29.6%) a PSA-free survival rate of 96% after 42 months and for the high-risk group (n = 47; 17.6%) a 21% PSA-free survival rate after 42 months.
For preoperative and postoperative estimation of biochemical recurrence after RRP, a quantitative analysis of high-grade cancer, expressed by the number of preoperative biopsy cores containing high-grade cancer and the volume of cancer, proved to be the best predictor of relapse. CART analysis might be useful in advising patients for their best therapy options. However, defined characteristics of risk groups should be evaluated with new prospective data before they are used routinely.
本研究旨在根据术前和术后肿瘤特征，区分临床局限性前列腺癌（PCa）患者中哪些能从耻骨后根治性前列腺切除术（RRP）中获益，哪些不能。
回顾了318例因临床局限性PCa接受RRP的连续患者的数据。术前特征包括临床分期、经直肠超声检查结果、前列腺特异性抗原（PSA）值、Gleason分级、阳性活检数量、包含任何Gleason 4级和/或5级癌的活检数量，以及主要为（>50%癌组织）Gleason 4级和/或5级癌的活检数量。术后特征包括病理分期、Gleason分级、切缘状态、癌体积以及Gleason 4级和/或5级癌的体积。通过Cox回归和CART（分类与回归树）分析计算RRP后对生化复发的影响，以确定低、中、高复发风险。
接受RRP的患者中，66%在42个月的随访后未显示复发迹象。所有术前和术后特征均与生化复发显著相关。术前特征的Cox回归显示，主要为Gleason 4级和/或5级癌的阳性活检数量是失败的最准确预测指标（p < 0.0001），其次是阳性活检数量和PSA。CART分析基于与Cox回归相同的特征区分出四个风险组。低风险组由232例患者（75.1%）组成，高风险组由17例患者（5.5%）组成；相应的Kaplan-Meier曲线显示，低风险组2年无PSA生存率为97%，高风险组为20%。术后特征的Cox回归发现，Gleason 4级和/或5级癌的体积是与生化失败关联最强的特征。CART分析区分出四个风险组，将高级别癌的体积作为最具影响力的特征。相应的Kaplan-Meier曲线显示，低风险组（n = 79；29.6%）在42个月后的无PSA生存率为96%，高风险组（n = 47；17.6%）在42个月后的无PSA生存率为21%。
对于RRP后生化复发的术前和术后评估，通过术前包含高级别癌的活检核心数量和癌体积来表示的高级别癌定量分析，被证明是复发的最佳预测指标。CART分析可能有助于为患者提供最佳治疗方案建议。然而，在常规使用之前，应使用新的前瞻性数据评估风险组的明确特征。
