Sherertz Tracy, Wallner Kent, Merrick Gregory, Cavanagh William, Butler Wayne, Reed Daniel, True Lawrence
Department of Radiation Oncology, Puget Sound Health Care System, Department of Veterans Affairs, Seattle, Washington 98108, USA.
Cancer J. 2004 Sep-Oct;10(5):301-6. doi: 10.1097/00130404-200409000-00007.
There is little clinical information specifically regarding the clinical significance of Gleason pattern 5 in prostate biopsies. Accordingly, we have analyzed the effect of pattern 5 cancer on the prognosis of prostate cancer treated with Pd-103 brachytherapy.
Intermediate-risk patients with a Gleason score of 7 or higher and/or a prostate-specific antigen level of 10-20 ng/mL and whose biopsy slides were available for review were treated on a randomized trial. The regimens consisted of implantation with Pd 103 (90 vs 115 Gy [National Institute of Standards and Technology; NIST-1999]), combined with 44 Gy versus 20 Gy of supplemental beam radiation, respectively. Beam radiation was delivered with a four-field arrangement, designed to cover the prostate and seminal vesicles with a 2-cm margin (reduced to 1.0 cm posteriorly). Isotope implantation was per formed by standard techniques, using a modified peripheral loading pattern. All prostate biopsy specimens were reviewed for Gleason score by one investigator (L. T.). Along with assignment of a Gleason score based on established criteria, the presence of any pattern 5 cancer was separately noted and photographed for future review. Freedom from biochemical failure was defined as a serum prostate-specific antigen level < or = 0.5 ng/mL at last follow-up. Four of the 156 patients had insufficient PSA follow-up for inclusion, leaving 152 patients for cancer control analysis.
Overall actuarial biochemical freedom from failure was 86% at 3 years, with 20 patients having experienced biochemical failure. Patients with or without Gleason pattern 5 cancer in their biopsy specimen had similar overall biochemical control. There was no obvious trend toward poorer overall biochemical cancer control in patients with pattern 5 cancer, regardless of whether the pretreatment prostate-specific antigen was less than or greater than 10 ng/mL. Of the 17 patients with biochemical failure, clinically evident bone metastases has developed in five. Three of these five patients who had a positive bone scan had pattern 5 cancer in their biopsy.
Although the presence of pattern 5 disease may be a risk factor for early systemic failure, we are encouraged that high-dose, brachytherapy-based treatment seems to provide a high likelihood of biochemical cancer control, even in patients with the highest-grade cancer.
关于前列腺活检中Gleason 5级的临床意义，几乎没有具体的临床信息。因此，我们分析了5级癌对接受钯-103近距离放射治疗的前列腺癌预后的影响。
对Gleason评分7分及以上和/或前列腺特异性抗原水平为10 - 20 ng/mL的中危患者且其活检切片可供复查的患者进行随机试验治疗。治疗方案包括植入钯103（90 Gy与115 Gy [美国国家标准与技术研究院；NIST - 1999]），分别联合44 Gy与20 Gy的补充束放射治疗。束放射采用四野布局，设计为在前列腺和精囊周围留出2 cm的边界（后方减至1.0 cm）。同位素植入采用标准技术，采用改良的周边加载模式。所有前列腺活检标本由一名研究者（L.T.）复查Gleason评分。除了根据既定标准指定Gleason评分外，还单独记录并拍摄任何5级癌的存在情况以供未来复查。无生化失败定义为最后一次随访时血清前列腺特异性抗原水平≤0.5 ng/mL。156例患者中有4例因前列腺特异性抗原随访不足而未纳入，剩余152例患者进行癌症控制分析。
3年时总体精算无生化失败率为86%，有20例患者发生生化失败。活检标本中有或无Gleason 5级癌的患者总体生化控制情况相似。无论治疗前前列腺特异性抗原是小于还是大于10 ng/mL，5级癌患者的总体生化癌症控制均无明显的较差趋势。在17例发生生化失败的患者中，有5例出现了临床明显的骨转移。这5例骨扫描阳性的患者中有3例活检中有5级癌。
虽然5级病变的存在可能是早期全身失败的一个危险因素，但我们感到鼓舞的是，即使是最高分级癌症的患者，基于高剂量近距离放射治疗似乎也有很高的生化癌症控制可能性。
