Gandaglia Giorgio, Ploussard Guillaume, Isbarn Hendrik, Suardi Nazareno, De Visschere Peter J L, Futterer Jurgen J, Ghadjar Pirus, Massard Christophe, Ost Piet, Sooriakumaran Prasanna, Surcel Christian I, van der Bergh Roderick C N, Montorsi Francesco, Ficarra Vincenzo, Giannarini Gianluca, Briganti Alberto
Unit of Urology/Division of Oncology; URI; IRCCS Ospedale San Raffaele, Milan, Italy.
Department of Urology, Saint-Louis Hospital, Paris, France.
Urol Oncol. 2015 Apr;33(4):164.e1-9. doi: 10.1016/j.urolonc.2014.12.011. Epub 2015 Jan 22.
The risk of unfavorable prostate cancer in active surveillance (AS) candidates is nonnegligible. However, what represents an adverse pathologic outcome in this setting is unknown. We aimed at assessing the optimal definition of misclassification and its effect on recurrence in AS candidates treated with radical prostatectomy (RP).
Overall, 1,710 patients eligible for AS according to Prostate Cancer Research International: Active Surveillance criteria treated with RP between 2000 and 2013 at 3 centers were evaluated. Patients were stratified according to pathology results at RP: organ-confined disease and pathologic Gleason score ≤ 6 (group 1); organ-confined disease and Gleason score 3+4 (group 2); and non-organ-confined disease, Gleason score ≥ 4+3, and nodal invasion (group 3). Biochemical recurrence (BCR) was defined as 2 consecutive prostate-specific antigen (PSA) ≥ 0.2 ng/ml. Kaplan-Meier curves assessed time to BCR. Multivariable Cox regression analyses tested the association between pathologic features and BCR. Multivariable logistic regression analyses identified the predictors of adverse pathologic characteristics.
Overall, 926 (54.2%), 653 (33.0%), and 220 (12.9%) patients were categorized in groups 1, 2, and 3, respectively. Median follow-up was 32.2 months. The 5-year BCR-free survival rate was 94.2%. Patients in group 3 had lower BCR-free survival rates compared with those in group 1 (79.1% vs. 97.0%, P<0.001). No differences were observed between patients included in group 1 vs. group 2 (97.0% vs. 94.7%, P = 0.1). These results were confirmed at multivariable analyses and after stratification according to margin status. Older age and PSA density ≥ 10 ng/ml/ml were associated with higher risk of unfavorable pathologic characteristics (i.e., inclusion in group 3; all P<0.001).
Among patients eligible for AS treated with RP, only men with Gleason score ≥ 4+3 or non-organ-confined disease at final pathology were at increased risk of BCR. These individuals represent the real misclassified AS patients, who can be predicted based on older age and higher PSA density.
主动监测（AS）候选者中发生不良前列腺癌的风险不可忽视。然而，在这种情况下代表不良病理结果的因素尚不清楚。我们旨在评估误分类的最佳定义及其对接受根治性前列腺切除术（RP）的AS候选者复发的影响。
总体上，对2000年至2013年间在3个中心接受RP治疗的1710例根据国际前列腺癌研究组织：主动监测标准符合AS条件的患者进行了评估。根据RP时的病理结果对患者进行分层：器官局限性疾病且病理Gleason评分≤6（第1组）；器官局限性疾病且Gleason评分为3+4（第2组）；以及非器官局限性疾病、Gleason评分≥4+3和淋巴结转移（第3组）。生化复发（BCR）定义为连续2次前列腺特异性抗原（PSA）≥0.2 ng/ml。采用Kaplan-Meier曲线评估至BCR的时间。多变量Cox回归分析检验病理特征与BCR之间的关联。多变量逻辑回归分析确定不良病理特征的预测因素。
总体上，分别有926例（54.2%）、653例（33.0%）和220例（12.9%）患者被归入第1组、第2组和第3组。中位随访时间为32.2个月。5年无BCR生存率为94.2%。第3组患者的无BCR生存率低于第1组患者（79.1%对97.0%，P<0.001）。第1组和第2组患者之间未观察到差异（97.0%对94.7%，P = 0.1）。这些结果在多变量分析以及根据切缘状态分层后得到证实。年龄较大和PSA密度≥10 ng/ml/ml与不良病理特征的风险较高相关（即归入第3组；所有P<0.001）。
在接受RP治疗的符合AS条件的患者中，只有最终病理Gleason评分≥4+3或存在非器官局限性疾病的男性BCR风险增加。这些个体代表真正被误分类的AS患者，可根据年龄较大和PSA密度较高进行预测。
