Center for Urologic Oncology, Glickman Urological & Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195-0001, USA.
Nat Rev Urol. 2011 Jun 14;8(7):385-92. doi: 10.1038/nrurol.2011.80.
Approximately 15-25% of men who undergo radical prostatectomy for localized prostate cancer will experience a PSA-defined biochemical recurrence (BCR) of their cancer--men with poorly differentiated cancer, non-organ-confined disease, and positive surgical margins are at the highest risk. Accumulating evidence indicates that postoperative radiation therapy to the prostate bed favorably influences the course of disease in men with pathological features of poor prognosis. Three phase III randomized trials of adjuvant radiotherapy versus observation have reported improved freedom from BCR, and one study has reported improved metastasis-free survival and overall survival. Similar evidence from randomized trials for salvage radiotherapy is lacking; however, several observational studies have reported durable responses to salvage radiotherapy and reduced cancer-specific mortality in a substantial proportion of high-risk patients, provided that it is administered at the earliest evidence of BCR. The appeal of salvage radiotherapy is that a substantial proportion of patients with non-organ-confined cancer or positive surgical margins are cured after radical prostatectomy alone, thereby limiting the adverse effects of postoperative radiotherapy--which include urinary and bowel dysfunction, sexual dysfunction and secondary pelvic malignancies--to only those whose cancer was not cured by surgery. In the absence of data from randomized trials demonstrating the superiority of adjuvant radiotherapy over a surveillance strategy (with planned salvage radiotherapy at the earliest evidence of BCR), we advocate shared decision making between physicians and patients, based on the relative advantages and disadvantages of each approach.
约 15-25%接受根治性前列腺切除术治疗局限性前列腺癌的男性将经历 PSA 定义的生化复发 (BCR)——分化不良的癌症、非器官受限疾病和阳性手术切缘的男性风险最高。越来越多的证据表明，前列腺床术后放疗有利于改善预后不良的男性的疾病进程。三项辅助放疗与观察的 III 期随机试验报告了无 BCR 的改善，一项研究报告了无转移生存和总生存的改善。缺乏关于挽救性放疗的随机试验的类似证据；然而，几项观察性研究报告了挽救性放疗的持久反应，并降低了相当一部分高危患者的癌症特异性死亡率，前提是在 BCR 最早出现时给予放疗。挽救性放疗的吸引力在于，相当一部分非器官受限癌症或阳性手术切缘的患者在单独接受根治性前列腺切除术后被治愈，从而将术后放疗的不良反应——包括尿失禁和肠功能障碍、性功能障碍和继发性骨盆恶性肿瘤——仅限于那些手术未治愈的癌症患者。在没有随机试验数据表明辅助放疗优于监测策略（在 BCR 最早出现时计划进行挽救性放疗）的情况下，我们提倡医生和患者之间基于每种方法的相对优缺点进行共同决策。
