Ramirez-Backhaus M, Iborra I, Gomez-Ferrer A, Rubio-Briones J
Servicio de Urología. Instituto Valenciano de Oncología. Valencia. España.
Arch Esp Urol. 2014 Jun;67(5):431-9.
The difficulty in predicting indolent prostate cancer leads to the use of different inclusion criteria in an active surveillance (AS) program. This chapter presents the pathology findings of radical prostatectomy (RP) in patients whose disease meet criteria for AS, as well as of those who are operated during AS.
Two independent Medline searches were conducted, both of them with a double objective: pathological findingsin radical prostatectomy specimens of patients who could have been included in AS and pathological features of patients operated after an AS period. The following terms were used for the research: "prostaticneoplasm", "radical prostatectomy" and "active surveillance": "radical prostatectomy", "after", "following" and "active surveillance". Pathological findings in radical prostatectomy specimens, down staging and downgrading rates were recorded. Active surveillance length and reason for surgery was included when it was available.
Depending on different AS inclusion criteria, clinical downgrading rate (pathological Gleason > 6) varied between 12.1 and 61% and clinical downstaging between 0-26%. Pathological Gleason score =8 was reported in 0-7.8% and there were anecdotal findings of seminal vesicle invasion or positive nodes. Overall, unfavorable pathology (Gleason ≥ 7 or stage ≥ pT3)was detected in 13.1-42.4%, based on different definitions. The criteria at John Hopkins were the strictest and had the lowest clinical downgrading and downstaging. On the other hand, the Memorial Sloan Kettering Cancer Center(MSKCC) criteria had the highest risk of unfavorable pathology but had the highest recruitment capacity. Indolent tumor was observed in 70-82.2% according to the current definition. The average duration in AS prior to surgery was 15-37 months. pT3 stage was seen in 7.7-36.7%, Gleason score 3+4 in 18.6-42.9%, Gleason score 4+3 in 1.4-31.8%, Gleason score >7 in 0-10.3%, positive margins in 3-40.9%. Seminal vesicle invasion rate was extremely low (0-2.9%) as well as positive nodes (0-4.5%).
Although there is a low risk of clinical downstaging and downgrading between patients who have being included in AS, it remains feasible. The probability of predicting an indolent tumor depends greatly on the quality of the prostate biopsy and/or the confirmatory biopsy. On the other hand, most patients who progress in an AS program can have a high probability of cure. We are still in the early stages of AS management in order to be able to predict the biological behavior and the cure rate of radical prostatectomy in patients after a long AS period.
预测惰性前列腺癌存在困难，这导致在主动监测（AS）计划中使用不同的纳入标准。本章介绍了疾病符合AS标准的患者以及在AS期间接受手术的患者的根治性前列腺切除术（RP）的病理结果。
进行了两项独立的医学文献检索，均有双重目标：可能纳入AS的患者根治性前列腺切除标本的病理结果以及AS期后接受手术的患者的病理特征。检索使用了以下术语：“前列腺肿瘤”“根治性前列腺切除术”和“主动监测”；“根治性前列腺切除术”“之后”“随访”和“主动监测”。记录根治性前列腺切除标本的病理结果、降期和降级率。如有可用信息，纳入主动监测时长和手术原因。
根据不同的AS纳入标准，临床降级率（病理Gleason评分>6）在12.1%至61%之间变化，临床降期在0至26%之间。病理Gleason评分为8的报告为0至7.8%，有精囊侵犯或阳性淋巴结的个别病例报告。总体而言，根据不同定义，13.1%至42.4%的患者检测到不良病理（Gleason≥7或分期≥pT3）。约翰霍普金斯医院的标准最严格，临床降级和降期最低。另一方面，纪念斯隆凯特琳癌症中心（MSKCC）的标准不良病理风险最高，但招募能力最强。根据当前定义，70%至82.2%的患者观察到惰性肿瘤。手术前AS的平均时长为15至37个月。pT3期见于7.7%至36.7%的患者，Gleason评分为3 + 4的见于18.6%至42.9%的患者，Gleason评分为4 + 3的见于1.4%至31.8%的患者，Gleason评分>7的见于0至10.3%的患者，切缘阳性见于3%至40.9%的患者。精囊侵犯率极低（0至2.9%），阳性淋巴结率也极低（0至4.5%）。
尽管纳入AS的患者临床降期和降级风险较低，但仍可行。预测惰性肿瘤的可能性很大程度上取决于前列腺活检和/或确认性活检的质量。另一方面，大多数在AS计划中病情进展的患者有较高的治愈可能性。我们仍处于AS管理的早期阶段，以便能够预测长期AS期后患者根治性前列腺切除术的生物学行为和治愈率。
