Miyamoto Hiroshi, Hernandez David J, Epstein Jonathan I
Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.
Hum Pathol. 2009 Dec;40(12):1693-8. doi: 10.1016/j.humpath.2009.05.001. Epub 2009 Aug 14.
Prior studies of radical prostatectomies have reported a small percentage of men with biochemical progression after radical prostatectomy showing organ-confined, Gleason Score 6. One might predict that this should virtually never occur. We identified 2551 (1983-2005) radical prostatectomies coded by the urologists at our institution as pathologically organ-confined, Gleason score 6 cancer with more than 1 year of follow-up. We re-examined histopathogically the serially sectioned and completely embedded radical prostatectomy specimens of 38 men who developed biochemical recurrence defined as a single prostate-specific antigen level of 0.2 ng/mL or greater. In 27 (71%) of 38 of cases, pathology re-review showed higher grade or stage than coded by the urologists. These included 10 cases of organ-confined with Gleason pattern 4 as either the primary or secondary pattern; 9 cases of organ-confined, Gleason score 6 with tertiary pattern 4 (in 4 cases, tertiary pattern 4 was described in the initial pathology report); 5 cases of Gleason score 7 plus extraprostatic extension; 1 case of Gleason score 6 with focal extraprostatic extension; and 2 cases with positive margins due to intraprostatic incision (listed in the initial pathology report). The remaining 11 cases were true organ-confined, Gleason score 6 tumors, but none of the patients developed systemic disease. Most prior reports of organ-confined, Gleason score 6 with progression are undergraded (upgrading with revision of Gleason system), understaged (difficulty recognizing focal extraprostatic extension), or suffer from situations with ambiguous staging (intraprostatic incision) or grading (tertiary pattern 4 or 2 + 4 = 6). Even for the rare true organ-confined, Gleason score 6 (no pattern 4) tumor with supposed biochemical progression, some may be false-positive progression based on low post-radical prostatectomy prostate-specific antigen levels and minute tumors that seem highly improbable to progress. With accurate pathologic evaluation, men with organ-confined, Gleason score 6 (no pattern 4) prostate cancer can be told that their risk of progression is very rare (0.4%).
先前关于根治性前列腺切除术的研究报告称，一小部分在根治性前列腺切除术后出现生化进展的男性患者，其肿瘤表现为器官局限性、 Gleason评分6分。有人可能会预测这种情况几乎不会发生。我们确定了2551例（1983 - 2005年）由我们机构的泌尿科医生编码为病理器官局限性、Gleason评分6分的癌症且随访时间超过1年的根治性前列腺切除术病例。我们对38例出现生化复发（定义为前列腺特异性抗原水平单次达到0.2 ng/mL或更高）的患者的根治性前列腺切除标本进行了组织病理学重新检查，这些标本是连续切片并完全包埋的。在38例病例中的27例（71%）中，病理复查显示分级或分期高于泌尿科医生编码的结果。其中包括10例器官局限性病例，其主要或次要模式为Gleason模式4；9例器官局限性、Gleason评分6分且三级模式为4的病例（在4例中，三级模式4在初始病理报告中有描述）；5例Gleason评分7分并伴有前列腺外侵犯的病例；1例Gleason评分6分并伴有局灶性前列腺外侵犯的病例；以及2例因前列腺内切开导致切缘阳性的病例（在初始病理报告中有列出）。其余11例为真正的器官局限性、Gleason评分6分的肿瘤，但这些患者均未发生全身疾病。大多数先前关于器官局限性、Gleason评分6分且有进展的报告存在分级过低（随着Gleason系统修订而升级）、分期过低（难以识别局灶性前列腺外侵犯），或存在分期不明确（前列腺内切开）或分级不明确（三级模式4或2 + 4 = 6） 的情况。即使对于罕见的真正器官局限性、Gleason评分6分（无模式4）且假定有生化进展的肿瘤，有些可能是基于根治性前列腺切除术后较低的前列腺特异性抗原水平和似乎极不可能进展的微小肿瘤而出现的假阳性进展。通过准确的病理评估，可以告知器官局限性、Gleason评分6分（无模式4）前列腺癌患者，其进展风险非常低（0.4%）。
