Stone Nelson N, Stock Richard G, White Ida, Unger Pam
Department of Urology, Mount Sinai School of Medicine, New York, NY, USA.
J Urol. 2007 May;177(5):1759-63; duscussion 1763-4. doi: 10.1016/j.juro.2007.01.069.
We describe biopsy results in patients with prostate cancer treated with brachytherapy.
A total of 1,562 men with localized prostate cancer were treated with permanent prostate brachytherapy, of whom 508 agreed to ultrasound guided biopsies 2 years after the completion of all therapy. Median followup was 6.7 years (range 2 to 14.6) and median prostate specific antigen was 7.4 ng/ml (range 0.3 to 300). Disease was categorized as Gleason score less than 7 in 74.8% of patients, stage T2a or less in 64.2%, low risk in 43.1%, intermediate risk in 24.2% and high risk in 32.7%. Of the 508 men 315 (62%) received (125)I, 110 (21.7%) received (103)Pd and 83 (16.3%) received (103)Pd and external beam radiotherapy. A total of 237 men (46.7%) received a short course of hormonal therapy (3 to 9 months). Subsequent biopsies were performed after 2 years if initial biopsy was positive or prostate specific antigen increased. Post-implantation dosimetry results were grouped into low, normal and high dose. Associations were tested by chi-square analysis. Survival functions were calculated with Kaplan-Meier analysis and Cox regression.
A total of 643 biopsies were performed in 508 men between 2 and 11 years after implantation. Of the 508 men 39 (7.7%) had a final positive biopsy. Positive biopsy was associated with high prostate specific antigen (p=0.035), stage (p=0.003), risk (p=0.024), no hormonal therapy (p=0.002) and low dose (p<0.0001). On multivariate analysis only dose and hormonal therapy were significant (p<0.0001 and p=0.004, respectively). Of the patients 80% were free of PSA failure at 10 years if final biopsy was negative compared to 27.3% with a positive biopsy (p<0.0001). Death from prostate cancer was associated with a positive biopsy (OR 18.5, 95% CI 2.3-143, p<0.0001). Of the 52 men with a positive biopsy at year 2, 23 (44.2%) had negative results on subsequent biopsy, while 10 of the 456 (2.2%) with negative 2-year biopsies showed positive results. Positive biopsy occurred in the prostate only in 31 of 39 men (79.5%), in the prostate and seminal vesicles in 3 (7.7%), and in the seminal vesicles only in 5 (12.8%).
Patients undergoing prostate brachytherapy must receive an adequate radiation dose to eradicate local disease. Hormonal therapy may benefit local control in patients with intermediate to high risk disease. Extraprostatic biopsies should be performed in patients with local failure who are considering salvage therapy to rule out seminal vesicle involvement.
我们描述接受近距离放射治疗的前列腺癌患者的活检结果。
共有1562例局限性前列腺癌男性接受了永久性前列腺近距离放射治疗，其中508例在所有治疗结束2年后同意接受超声引导下活检。中位随访时间为6.7年（范围2至14.6年），中位前列腺特异性抗原为7.4 ng/ml（范围0.3至300）。74.8%的患者疾病分类为Gleason评分小于7，64.2%为T2a期或更低，43.1%为低风险，24.2%为中风险，32.7%为高风险。508例男性中，315例（62%）接受了碘-125，110例（21.7%）接受了钯-103，83例（16.3%）接受了钯-103和外照射放疗。共有237例男性（46.7%）接受了短期激素治疗（3至9个月）。如果初始活检为阳性或前列腺特异性抗原升高，则在2年后进行后续活检。植入后剂量测定结果分为低、正常和高剂量。通过卡方分析检验相关性。用Kaplan-Meier分析和Cox回归计算生存函数。
在植入后2至11年期间，对508例男性共进行了643次活检。508例男性中，39例（7.7%）最终活检为阳性。活检阳性与高前列腺特异性抗原（p = 0.035）、分期（p = 0.003）、风险（p = 0.024）、未接受激素治疗（p = 0.002）和低剂量（p < 0.0001）相关。多因素分析显示，只有剂量和激素治疗具有显著性（分别为p < 0.0001和p = 0.004）。如果最终活检为阴性，80%的患者在10年时无前列腺特异性抗原失败，而活检阳性的患者为27.3%（p < 0.0001）。前列腺癌死亡与活检阳性相关（比值比18.5，95%可信区间2.3 - 143，p < 0.0001）。在第2年活检阳性的52例男性中，23例（44.2%）在后续活检中结果为阴性，而456例2年活检阴性的男性中有10例（2.2%）结果为阳性。39例活检阳性的男性中，仅前列腺阳性的有31例（79.5%），前列腺和精囊阳性的有3例（7.7%），仅精囊阳性的有5例（12.8%）。
接受前列腺近距离放射治疗的患者必须接受足够的放射剂量以根除局部疾病。激素治疗可能有利于中高风险疾病患者的局部控制。对于考虑挽救性治疗的局部失败患者，应进行前列腺外活检以排除精囊受累。
