aDivision of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada bDivision of Surgery and Interventional Science, University College London, 74 Huntley Street, London, UK.
Curr Opin Urol. 2014 May;24(3):270-9. doi: 10.1097/MOU.0000000000000055.
To summarize the current understanding of the natural history and molecular biology of low-risk prostate cancer, and review the indications for surveillance and focal therapy.
Low-risk prostate cancer, diagnosed in 40-50% of newly diagnosed men in a screened population, represents overdiagnosis in most cases. Gleason pattern 3 cells typically lack the molecular machinery and the genetic abnormalities, which characterize true cancers, with two important caveats. Thirty percent of patients diagnosed with low-risk prostate based on a systematic biopsy cancer harbor higher-grade cancer that is unrepresented on the biopsy. Secondly, a very small minority harbor prehistologic molecular alterations that result in progression to more aggressive disease. Favorable-risk prostate cancer is better viewed as one of multiple risk factors for the presence of higher-grade prostate cancer, and should be managed with close follow-up. Radical intervention should be reserved for clear evidence of more aggressive disease. Focal therapy should be offered to men with higher-risk disease either at baseline, as an alternative to whole gland radiation or surgery or when active surveillance 'fails' (the patient transitions from low risk to higher risk). The two strategies should be seen as complimentary elements of care that can be applied in a risk-stratified manner - taking account of patient preference - from the outset or in sequence
Active surveillance is appropriate for most men with low-risk prostate cancer, and focal therapy may complement active surveillance for those men wishing to continue a tissue-preserving strategy.
总结低危前列腺癌的自然史和分子生物学的现有认识，探讨监测和局灶治疗的适应证。
在筛查人群中，40%-50%的新发前列腺癌患者被诊断为低危前列腺癌，这种诊断在多数情况下属于过度诊断。低危前列腺癌的 Gleason 评分通常缺乏真正癌症所具有的分子机制和遗传异常，但有两个重要的例外。基于系统活检诊断为低危前列腺癌的 30%的患者存在未在活检中表现出的高级别癌症。其次，极少数患者存在导致疾病进展为侵袭性更强的疾病的史前分子改变。有利风险的前列腺癌最好被视为存在高级别前列腺癌的多个危险因素之一，应密切随访。根治性干预应保留用于明确的侵袭性疾病证据。对于具有高危疾病的患者，应提供局灶治疗，作为全腺体放疗或手术的替代方案，或在主动监测“失败”（患者从低危转为高危）时提供。这两种策略应被视为互补的治疗手段，可以根据患者的偏好，从一开始或按顺序以风险分层的方式应用于大多数男性的低危前列腺癌——
