前列腺特异性抗原水平≤4 和>4ng/ml 与活检 Gleason 评分 9-10 级前列腺癌患者前列腺癌特异性死亡率的关系。
Prostate-specific antigen levels of ≤4 and >4 ng/mL and risk of prostate cancer-specific mortality in men with biopsy Gleason score 9 to 10 prostate cancer.
机构信息
Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, Massachusetts.
Department of Statistics, University of Connecticut, Mansfield, Connecticut.
出版信息
Cancer. 2021 Jul 1;127(13):2222-2228. doi: 10.1002/cncr.33503. Epub 2021 Jun 8.
BACKGROUND
Defining workup beyond usual clinical practice that may improve treatment outcomes in men with a prostate-specific antigen (PSA) level of ≤4 ng/mL (vs >4 ng/mL) and Gleason score (GS) 9 to 10 prostate cancer (PC) remains to be determined.
METHODS
Between February 25, 1992, and February 25, 2016, 17,632 men with clinical T1-4 PC with a biopsy GS of 6 to 10 underwent radical prostatectomy at a single academic center. Multivariable Fine and Gray regressions were used to evaluate the risk of prostate cancer-specific mortality (PCSM) with an interaction model evaluating the prognostic significance of PSA ≤ 4 ng/mL versus PSA > 4 ng/mL among men with PC with a biopsy GS of 9 to 10 versus ≤8, with adjustments made for the time-dependent use of adjuvant and/or salvage radiation therapy and androgen deprivation therapy (ADT) in addition to known PC prognostic factors.
RESULTS
There was a significant interaction in men with a biopsy GS of 9 to 10 versus ≤8 and a PSA level of ≤4 ng/mL versus >4 ng/mL (adjusted hazard ratio [AHR], 2.87; 95% confidence interval [CI], 1.02-8.08; P = .046). Specifically, among men with a biopsy GS of 9 to 10 and a PSA level of ≤4 ng/mL versus >4 ng/mL, there was a significantly higher rate of PCSM (AHR, 2.59; 95% CI, 1.19-5.67; P = .017); however, there was no significant difference in the risk of PCSM in men with a biopsy GS ≤ 8 and a PSA level of ≤4 ng/mL versus >4 ng/mL (AHR, 0.90; 95% CI, 0.46-1.78; P = .771). Moreover, the time-dependent use of postoperative ADT was also associated with an increased risk of PCSM (AHR, 10.76; 95% CI, 6.88-16.81; P < .0001).
CONCLUSIONS
Some men with PSA ≤ 4 ng/mL and a biopsy GS of 9 to 10 may have pathologic or genetic variants that make them less amenable to a cure with current standards of care. Additional workup assessing for small cell, neuroendocrine, and genetic variants should be considered.
背景
确定超出常规临床实践的检查项目，这些项目可能会改善前列腺特异性抗原（PSA）水平≤4ng/ml（vs＞4ng/ml）和 Gleason 评分（GS）9-10 的前列腺癌（PC）患者的治疗效果，但仍有待确定。
方法
1992 年 2 月 25 日至 2016 年 2 月 25 日，在一家学术中心，对 17632 名经活检证实 GS 为 6-10 分的临床 T1-4PC 患者进行了根治性前列腺切除术。采用多变量 Fine 和 Gray 回归来评估前列腺癌特异性死亡率（PCSM）的风险，采用交互模型评估 PSA≤4ng/ml 与 PSA＞4ng/ml 在 GS 为 9-10 分与≤8 分的 PC 患者中的预后意义，调整了辅助和/或挽救性放疗以及雄激素剥夺治疗（ADT）的时间依赖性使用，以及已知的 PC 预后因素。
结果
在 GS 为 9-10 分与≤8 分和 PSA 水平≤4ng/ml 与＞4ng/ml 的患者中，存在显著的交互作用（调整后的危险比[AHR]，2.87；95%置信区间[CI]，1.02-8.08；P=0.046）。具体来说，在 GS 为 9-10 分且 PSA 水平≤4ng/ml 与＞4ng/ml 的患者中，PCSM 的发生率明显更高（AHR，2.59；95%CI，1.19-5.67；P=0.017）；然而，在 GS≤8 分且 PSA 水平≤4ng/ml 与＞4ng/ml 的患者中，PCSM 的风险无显著差异（AHR，0.90；95%CI，0.46-1.78；P=0.771）。此外，术后 ADT 的时间依赖性使用也与 PCSM 风险增加相关（AHR，10.76；95%CI，6.88-16.81；P＜0.0001）。
结论
一些 PSA≤4ng/ml 且 GS 为 9-10 的患者可能存在使他们更难通过当前治疗标准治愈的病理或遗传变异。应考虑进行额外的检查，以评估小细胞、神经内分泌和遗传变异。
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