Dinh Kathryn T, Muralidhar Vinayak, Mahal Brandon A, Chen Yu-Wei, Nezolosky Michelle D, Beard Clair J, Choueiri Toni K, Martin Neil E, Orio Peter F, Sweeney Christopher J, Trinh Quoc-Dien, Nguyen Paul L
Harvard Medical School, Boston, MA.
Harvard T.H. Chan School of Public Health, Boston, MA.
Urology. 2016 Jan;87:125-32. doi: 10.1016/j.urology.2015.08.026. Epub 2015 Sep 21.
To identify contemporary, clinically low-risk patients with ≥50% cores positive and compare the risk of upgrading at prostatectomy with other low- or intermediate-risk patients.
We studied 14,902 patients with prostate cancer in the Surveillance, Epidemiology, and End Results database in 2010-2011 treated with prostatectomy. Patients were categorized by National Comprehensive Cancer Network clinical risk groups, separating low-risk patients by percent positive biopsy cores (PBC). We measured incidence of pathologic high-risk disease, defined as pT3a-T4 or Gleason 8-10, and multivariable logistic regression was used to determine if patients with clinical low-risk disease and ≥50% PBC were similar to other low- or intermediate-risk patients. This analysis was repeated with favorable and unfavorable intermediate risk.
At prostatectomy, 9.2% of clinically low-risk patients with <50% PBC, 18.6% of clinically low-risk patients with ≥50% PBC, and 27.6% of clinically intermediate-risk patients had occult, high-risk disease (P <.001). On multivariable logistic regression, low-risk patients with ≥50% PBC were more likely than low-risk patients with <50% PBC to have pathologic high-risk disease (adjusted odds ratio [AOR] 2.28, 95% confidence interval 1.90-2.73, P <.001), had similar risk to favorable intermediate patients overall (AOR 1.09, 0.91-1.31, P = .33), and had higher risk than favorable intermediate patients aged over 60 years (AOR 1.28, 1.00-1.64, P = .04). Low-risk patients with ≥50% PBC had a mean tumor size similar to unfavorable intermediate-risk patients (21.3 vs 21.0 mm, P = .82).
Nearly 1 in 5 clinically low-risk prostate cancer patients with ≥50% PBC harbor occult pT3a-T4 or Gleason 8-10, suggesting that national guidelines should not classify low-risk patients with ≥50% cores positive as "low risk," and patients should be made aware of this excess risk if considering active surveillance.
识别当代临床低风险且穿刺阳性核心灶≥50%的患者，并比较其前列腺切除术后病理升级风险与其他低风险或中风险患者的差异。
我们研究了2010 - 2011年监测、流行病学及最终结果数据库中14902例接受前列腺切除术的前列腺癌患者。患者按照美国国立综合癌症网络临床风险组进行分类，根据穿刺阳性活检核心灶百分比（PBC）对低风险患者进行细分。我们测量了病理高危疾病的发生率，定义为pT3a - T4或 Gleason 8 - 10，并采用多变量逻辑回归分析来确定临床低风险疾病且PBC≥50%的患者是否与其他低风险或中风险患者相似。对有利和不利中风险患者重复进行了该分析。
在前列腺切除术中，穿刺阳性活检核心灶<50%的临床低风险患者中9.2%、穿刺阳性活检核心灶≥50%的临床低风险患者中18.6%以及临床中风险患者中27.6%存在隐匿性高危疾病（P <.001）。多变量逻辑回归分析显示，穿刺阳性活检核心灶≥50%的低风险患者比穿刺阳性活检核心灶<50%的低风险患者更易发生病理高危疾病（校正比值比[AOR] 2.28，95%置信区间1.90 - 2.73，P <.001），总体上与有利中风险患者风险相似（AOR 1.09，0.91 - 1.31，P = 0.33），且比60岁以上的有利中风险患者风险更高（AOR 1.28，1.00 - 1.64，P = 0.04）。穿刺阳性活检核心灶≥50%的低风险患者的平均肿瘤大小与不利中风险患者相似（21.3对21.0mm，P = 0.82）。
近五分之一穿刺阳性活检核心灶≥50%的临床低风险前列腺癌患者存在隐匿性pT3a - T4或Gleason 8 - 10，这表明国家指南不应将穿刺阳性核心灶≥50%的低风险患者归类为“低风险”，且患者若考虑主动监测应知晓这种额外风险。
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