Cancer Research Program, Garvan Institute of Medical Research, NSW, Australia.
BJU Int. 2012 Jun;109(12):1794-800. doi: 10.1111/j.1464-410X.2011.10572.x. Epub 2011 Oct 12.
Study Type - Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Only 30-35% of patients with positive surgical margins after radical prostatectomy develop recurrent disease. Adjuvant radiotherapy reduces the rate of biochemical relapse or metastasis and improves overall survival after radical prostatectomy. Various pathological factors, such as location and extent of positive margins, have been proposed as possible prognostic factors in men with margin-positive prostate cancer, however, the recent International Society of Urological Pathology consensus meeting in Boston noted that there is limited data on the significance of Gleason grade of the carcinoma at a positive margin. The present study shows that the presence of high grade prostate cancer, i.e. Gleason pattern 4 or 5, at a positive surgical margin is an independent predictor of biochemical recurrence after radical prostatectomy. Moreover, patients with lower grade carcinoma at the margin have a similar prognosis to men with negative margins. Hence, assessment of Gleason grade at the site of positive margin may aid optimal selection of patients for adjuvant radiotherapy.
• To establish predictors of biochemical recurrence by analysing the pathological characteristics of positive surgical margins (PSMs), including Gleason grade of the carcinoma at the involved margin.
• Clinicopathological and outcome data on 940 patients who underwent radical prostatectomy (RP) between 1997 and 2003 were collected. • Of these, 285 (30.3%) patients with PSMs were identified for pathological review, including assessment of location of margin, linear extent, number of PSMs, plane of margin and Gleason grade (3 vs 4 or 5) at the margin.
• At a median follow-up of 82 months, the biochemical recurrence rate of the PSM cohort was 29%. • On univariate analysis, the presence of Gleason grade 4 or 5 at the margin (34.4% of cases) was significantly associated with biochemical recurrence (hazard ratio [HR] 2.80, 95% confidence interval [CI]= 1.82-4.32, P < 0.001) compared with the presence of Gleason grade 3. • Linear extent of margin involvement was also associated with recurrence (P= 0.009). • Single vs multiple margin involvement, location, and plane of the involved margin were not significant predictors of recurrence. • On multivariate analysis, Gleason grade 4 or 5 at the margin remained an independent predictor of recurrence (HR 2.14, 95% CI = 1.29-4.03, P= 0.003).
• The Gleason grade at the site of a PSM identifies patients at increased risk of biochemical recurrence and should aid stratification of patients for adjuvant radiation therapy.
研究类型-预后（病例系列）证据水平 4 已知的是什么？研究增加了什么？仅 30-35%接受根治性前列腺切除术的患者在术后出现阳性切缘后会出现疾病复发。辅助放疗可降低生化复发或转移的发生率，并改善根治性前列腺切除术后的总生存率。各种病理因素，如阳性切缘的位置和范围，已被提出作为阳性切缘前列腺癌患者的可能预后因素，但最近在波士顿举行的国际泌尿病理学会共识会议指出，关于阳性切缘处癌的 Gleason 分级的意义数据有限。本研究表明，阳性切缘处存在高级别前列腺癌，即 Gleason 模式 4 或 5，是根治性前列腺切除术后生化复发的独立预测因子。此外，切缘处有较低级别癌的患者与切缘阴性的患者具有相似的预后。因此，评估阳性切缘处的 Gleason 分级可能有助于为辅助放疗选择最佳患者。
通过分析阳性手术切缘（PSM）的病理特征，包括受累切缘处的癌的 Gleason 分级，确定生化复发的预测因子。
收集了 1997 年至 2003 年间接受根治性前列腺切除术（RP）的 940 例患者的临床病理和结局数据。其中，对 285 例（30.3%）有 PSM 的患者进行了病理复查，包括切缘部位、线性范围、PSM 数量、切缘平面和 Gleason 分级（3 级与 4 级或 5 级）的评估。
在中位随访 82 个月时，PSM 组的生化复发率为 29%。单因素分析显示，切缘处存在 Gleason 分级 4 或 5（占病例的 34.4%）与生化复发显著相关（风险比[HR]2.80，95%置信区间[CI]=1.82-4.32，P<0.001），而 Gleason 分级 3 级则无此关联。切缘受累的线性范围也与复发相关（P=0.009）。单处 vs 多处切缘受累、切缘位置和切缘平面不是复发的显著预测因素。多因素分析显示，Gleason 分级 4 或 5 在切缘处仍是复发的独立预测因子（HR 2.14，95%CI=1.29-4.03，P=0.003）。
PSM 处的 Gleason 分级可识别出生化复发风险增加的患者，有助于对辅助放疗患者进行分层。
