Lellig Ekaterina, Gratzke Christian, Kretschmer Alexander, Stief Christian
Department of Urology, Institution Ludwig Maximilian University of Munich, Munich, Germany,
World J Urol. 2015 Jul;33(7):917-22. doi: 10.1007/s00345-015-1604-6. Epub 2015 Jun 6.
The aim of the current study was to determine in retrospect how many of a group of patients who underwent radical prostatectomy were correctly classified with an insignificant prostate carcinoma by means of preoperative diagnostics. Furthermore, we are aiming at finding preoperative parameters which predict an insignificant prostate carcinoma with higher accuracy. The current inclusion parameters of AS will be verified with regard to their reliability, and we will discuss the possibility of improving their prediction accuracy.
We examined the data of 308 consecutive patients who were diagnosed with a clinically insignificant prostate carcinoma and therefore would be suited for AS, but opted for a radical prostatectomy. According to the literature(1), the following inclusion criteria were chosen for our evaluation: a proven prostate carcinoma, detected by either ultrasonically guided transrectal core needle biopsy (cT1c) with at least six obtained samples and with a maximum of two positive samples on one side and a less than a 50 % tumor rate per sample, or a 5 % or lower tumor rate found in the tissue obtained by transurethral prostate resection (cT1a). The PSA value in all cases was below 10 ng/ml and the Gleason Score ≤6. The probability of a preoperative "undergrading" or "understaging" was determined as a function of preoperative parameters like Gleason Score, PSA value, the number of collected samples and positive samples obtained by core needle biopsy, prostate volume, and PSA density. Based on the available preoperative data, we developed and tested several regression models for the identification of independent factors for upgrading and upstaging.
Within the examined patient population, 232 of 308 patients (75 %) were, according to their final prostate histology, diagnosed with a stage ≥pT2b prostate carcinoma. Eight percentage of the patients who had undergone surgery had a stage ≥pT3a carcinoma, and 118 of 308 (38 %) had a Gleason Score of 6 or higher. Positive lymph nodes and an infiltration of the seminal vesicle each occurred in 1 % of the cases. Histopathologic positive margins of resection existed in 33 of 308 patients (11 %). Independent factors for upgrading and upstaging a prostate volume of <50 ml and a preoperative Gleason Score of ≤6 were identified.
The presented results show that the current inclusion criteria for AS are insufficient. For many patients, the beginning of the necessary therapy is delayed. According to our data, the prostate volume, the preoperative Gleason Score, and the number of positive samples obtained by transrectal core needle biopsy have the highest predictive power with regard to aggressiveness and expansion of the tumor. Despite the consideration of all these preoperative parameters, the differentiation of the prostate carcinomas was underrated in a third of all cases. The expansion of the tumor within the prostate was underrated even in three fourths of the cases.
本研究的目的是回顾性确定一组接受根治性前列腺切除术的患者中，有多少患者通过术前诊断被正确分类为低危前列腺癌。此外，我们旨在寻找能更准确预测低危前列腺癌的术前参数。将验证当前主动监测（AS）的纳入参数的可靠性，并讨论提高其预测准确性的可能性。
我们检查了308例连续患者的数据，这些患者被诊断为临床低危前列腺癌，因此适合进行主动监测，但选择了根治性前列腺切除术。根据文献（1），我们选择了以下纳入标准进行评估：经超声引导经直肠穿刺活检确诊为前列腺癌（cT1c），至少获取6个样本，一侧最多2个阳性样本，且每个样本的肿瘤率低于50%；或经尿道前列腺切除术获取的组织中肿瘤率为5%或更低（cT1a）。所有病例的前列腺特异性抗原（PSA）值均低于10 ng/ml，Gleason评分≤6。根据术前参数如Gleason评分、PSA值、穿刺活检获取的样本数量和阳性样本数量、前列腺体积以及PSA密度，确定术前“分级过低”或“分期过低”的概率。基于可用的术前数据，我们开发并测试了多个回归模型，以识别升级和分期增加的独立因素。
在检查的患者群体中，根据最终的前列腺组织学检查，308例患者中有232例（75%）被诊断为前列腺癌分期≥pT2b。接受手术的患者中有8%患有分期≥pT3a的癌症，308例中有118例（38%）的Gleason评分为6或更高。阳性淋巴结和精囊浸润在各病例中均占1%。308例患者中有33例（11%）存在组织病理学切缘阳性。确定了升级和分期增加的独立因素为前列腺体积<50 ml和术前Gleason评分≤6。
所呈现的结果表明，当前主动监测的纳入标准不足。对于许多患者来说，必要治疗的开始被延迟。根据我们的数据，前列腺体积、术前Gleason评分以及经直肠穿刺活检获取的阳性样本数量对肿瘤的侵袭性和扩散具有最高的预测能力。尽管考虑了所有这些术前参数，但在所有病例中有三分之一对前列腺癌的分化评估过低。即使在四分之三的病例中，对肿瘤在前列腺内的扩散评估也过低。
