Department of Urology, NYU Langone Health, New York, NY.
Department of Urology, NYU Langone Health, New York, NY.
Urol Oncol. 2020 Aug;38(8):671-677. doi: 10.1016/j.urolonc.2020.04.017. Epub 2020 May 31.
Historically, the primary objection to partial gland ablation (PGA) for management of prostate cancer (CaP) has been disease multifocality and inability to localize significant disease. Improved disease localization and risk stratification with multiparametric magnetic resonance imaging and targeted biopsy, along with its minimal adverse impact on quality of life has enabled PGA to gain acceptance. Today, the primary barrier for adopting PGA is its unknown oncological outcomes. Objectives of this review are to provide a rationale for PGA for managing intermediate-risk (IR) CaP; review oncological outcomes following PGA for IR disease; and assess whether there is adequate data to justify PGA for management of IR CaP. There is no consensus how to assess or define oncological outcomes following PGA. We propose the following definitions for oncological outcomes: Oncological control (detection of any cancer following biopsy), oncological failure (detection of Gleason grade group >1 on follow-up biopsy), and oncological treatment failure (any disease that precipitate salvage treatment). There are only 3 reports in the literature where inclusion criteria specified pretreatment targeted biopsy and reflex prostate biopsy within 1 year of PGA in cohorts of men where >50% had Gleason grade group >1 disease. These studies reported that prostate-specific antigen is not a reliable surrogate and multiparametric magnetic resonance imaging is reliable when prevalence of in-field CaP is high. "Freedom from failure" is used to assess longer-term oncologic outcomes, and is defined by freedom from CaP mortality, androgen deprivation therapy, or whole-gland treatment. Rationale for PGA in selected cases of IR CaP is compelling and early oncological studies are reassuring. If patient selection is done judiciously, oncologic outcomes are disclosed, and follow-up plan is rigorously implemented, it is unlikely rates of metastasis or CaP mortality with be adversely impacted and many men will avoid or defer adverse effects of whole-gland treatment.
从历史上看，前列腺癌（CaP）局部腺体消融术（PGA）治疗的主要反对意见是疾病的多灶性和无法定位重要疾病。多参数磁共振成像和靶向活检改善了疾病定位和风险分层，同时对生活质量的影响最小，使 PGA 得以被接受。如今，采用 PGA 的主要障碍是其未知的肿瘤学结果。本综述的目的是为管理中危（IR）CaP 的 PGA 提供一个理由；回顾 IR 疾病 PGA 后的肿瘤学结果；并评估是否有足够的数据支持 PGA 来管理 IR CaP。如何评估或定义 PGA 后的肿瘤学结果尚无共识。我们提出了以下肿瘤学结果的定义：肿瘤学控制（活检后检测到任何癌症）、肿瘤学失败（随访活检中检测到 Gleason 分级组>1）和肿瘤学治疗失败（任何引发挽救性治疗的疾病）。文献中只有 3 篇报道符合纳入标准，即预处理靶向活检和 PGA 后 1 年内的反射性前列腺活检，这些研究队列中超过 50%的患者有 Gleason 分级组>1 疾病。这些研究报告前列腺特异性抗原不是可靠的替代物，当局灶性 CaP 的患病率较高时，多参数磁共振成像是可靠的。“无失败”用于评估较长时间的肿瘤学结果，其定义为无 CaP 死亡率、雄激素剥夺治疗或全腺体治疗。在选择的 IR CaP 病例中 PGA 的理由是令人信服的，早期的肿瘤学研究令人安心。如果谨慎选择患者，披露肿瘤学结果，并严格执行随访计划，转移或 CaP 死亡率的发生率不太可能受到不利影响，许多男性将避免或推迟全腺体治疗的不良反应。
