Fernandez Gomez Jesus M, Garcia Rodriguez Jorge
Servicio de Urología. Hospital Universitario Central de Asturias. Universidad de Oviedo. Oviedo. Asturias. España.
Arch Esp Urol. 2014 Jun;67(5):409-18.
To review the pathological criteria used to select patients for active surveillance, the optimization of biopsies and the role of confirmatory biopsy and of the transperineal approach.
A bibliographic revision of the last years about active surveillance in prostate cancer as well as prostate biopsy, optimal rebiopsy protocols and transperineal approach has been carried out.
Misclassification of insignificant disease based on pathological criteria of the first standard biopsy range from 20% to 30% of men. It is likely that many patients who ultimately progress on active surveillance had at the time of diagnosis more advanced disease that was missed by transrectal ultrasound (TRUS) biopsy. This is the main cause of progression on initial follow-up biopsy within 1 year of starting active surveillance. Although the role of immediate prostate rebiopsy after the diagnosis of low-risk prostate cancer and has not been well described, repeat biopsy before the initiation of AS performed shortly after diagnosis (6 months) identifies most patients who harbor high grade or more extensive cancers that may not be appropriate for a surveillance strategy.
PSA, PSAD, and number of cores at initial diagnosis are not helpful in predicting misclassification of AS eligibility. The role of MRI for AS remains unclear and the technique of MRI/US fusion biopsy still lacks consensus on a standardized procedure. Patients considering active surveillance should undergo immediate confirmatory biopsy within 6 months to decrease the risk of substantially underestimating cancer size and grade, even in patients with strict criteria in the initial biopsy and subsequently, to better assess the risk of progression. In this way, most protocols of AS recommend performing volume-based biopsies in the confirmatory procedure. Perhaps, an extensive transperineal template-guided mapping biopsy (TTMB) procedure could more accurately identify those men with occult significant disease. Due to confirmatory biopsy identifies a patient group that is unlikely to progress during the first 5 to 10 years of AS the need of intensive biopsy schedule during follow-up of patients undergoing active surveillance might be reduced.
回顾用于选择主动监测患者的病理标准、活检的优化以及确诊活检和经会阴途径的作用。
对过去几年关于前列腺癌主动监测以及前列腺活检、最佳重复活检方案和经会阴途径进行了文献复习。
根据首次标准活检的病理标准，对无意义疾病的错误分类在20%至30%的男性中存在。很可能许多最终在主动监测中进展的患者在诊断时就有更晚期的疾病，而经直肠超声（TRUS）活检未能检测到。这是在开始主动监测后1年内首次随访活检时疾病进展的主要原因。尽管低风险前列腺癌诊断后立即进行前列腺重复活检的作用尚未得到充分描述，但在诊断后不久（6个月）开始主动监测之前进行重复活检可识别出大多数患有高级别或更广泛癌症的患者，这些患者可能不适合监测策略。
PSA、PSAD和初始诊断时的活检芯数无助于预测主动监测资格的错误分类。MRI在主动监测中的作用仍不明确，MRI/US融合活检技术在标准化程序上仍缺乏共识。考虑主动监测的患者应在6个月内立即进行确诊活检，以降低严重低估癌症大小和分级的风险，即使是初始活检符合严格标准的患者，随后更好地评估进展风险。通过这种方式，大多数主动监测方案建议在确诊程序中进行基于体积的活检。也许，广泛的经会阴模板引导下的图谱活检（TTMB）程序可以更准确地识别那些患有隐匿性重大疾病的男性。由于确诊活检可识别出一组在主动监测的前5至10年不太可能进展的患者，因此可能会减少对接受主动监测患者随访期间密集活检计划的需求。
