Michigan State University College of Human Medicine, Grand Rapids, MI.
Department of Urology, Michigan Medicine, Ann Arbor, MI.
Urol Oncol. 2022 Aug;40(8):380.e1-380.e9. doi: 10.1016/j.urolonc.2022.05.029. Epub 2022 Jun 29.
High-risk (HR) prostate cancer (CaP) patients are at greatest risk for occult metastases and disease progression. Radical prostatectomy (RP) provides benefit, but remains of unknown oncologic value compared with other options. We investigated outcomes of RP for HR, very-high-risk (VHR), or metastatic CaP.
Included are 1,635 patients undergoing RP between January 2012 and December 2018 (prior to widespread availability of CaP-specific PET imaging). VHR CaP was defined as having ≥2HR features, >4cores of biopsy Gleason ≥4+4, or primary Gleason pattern 5. Metastatic CaP was defined by radiographic evidence of N1 and/or M1 CaP and grouped as cN1M and cN0M1. Pre-treatment, perioperative, and early oncologic data were compared. Patient/tumor characteristics were compared according to risk groups using Chi-squared and Wilcoxon rank-sum tests. Kaplan-Meier analysis of cancer progression and multivariable analyses were performed.
Length of stay >2days and readmission following RP was 10.8% and 5.5% for patients with HR or higher CaP. Median time to progression was 3.9 months (IQR:1.6-13.9), and 2-year progression-free probability was 67% for HR, 53% for VHR, 51% for cN1M, and 58% for cN0M1. In multivariable analysis, VHR (hazard ratio:1.70; P < 0.0001) and cN1M (1.96, P < 0.0001) were highly significant predictors of progression, while cN0M1 was not (P = 0.54), compared with non-metastatic HR CaP. Limitations include selection biases and imprecision of imaging methodologies.
Most patients with HR or higher CaP remain progression-free 2 years after RP, with acceptable perioperative outcomes. Progression-free survival was similar in cN1 and VHR patients, better with non-metastatic HR CaP, and between these for cN0M1 patients indicating the imprecise clinical staging occurring with conventional imaging modalities alone.
高危（HR）前列腺癌（CaP）患者最有可能发生隐匿性转移和疾病进展。根治性前列腺切除术（RP）有一定益处，但与其他选择相比，其肿瘤学价值尚不清楚。我们研究了 RP 治疗 HR、超高危（VHR）或转移性 CaP 的结果。
纳入了 2012 年 1 月至 2018 年 12 月间接受 RP 的 1635 例患者（在 CaP 特异性 PET 成像广泛应用之前）。VHR CaP 的定义为具有≥2 个 HR 特征、≥4 个活检 Gleason 评分≥4+4 或原发性 Gleason 模式 5。转移性 CaP 的定义为影像学检查有 N1 和/或 M1 CaP 证据，并分为 cN1M 和 cN0M1。比较术前、围手术期和早期肿瘤学数据。根据风险组使用卡方检验和 Wilcoxon 秩和检验比较患者/肿瘤特征。采用 Kaplan-Meier 分析癌症进展情况，并进行多变量分析。
HR 或更高 CaP 患者 RP 后住院时间>2 天和再入院的比例分别为 10.8%和 5.5%。中位无进展时间为 3.9 个月（IQR：1.6-13.9），2 年无进展生存率为 HR 67%、VHR 53%、cN1M 51%和 cN0M1 58%。多变量分析显示，VHR（风险比：1.70；P<0.0001）和 cN1M（1.96，P<0.0001）是进展的高度显著预测因素，而 cN0M1 则不是（P=0.54），与非转移性 HR CaP 相比。局限性包括选择偏倚和成像方法的不精确性。
大多数 HR 或更高 CaP 患者在 RP 后 2 年内仍无进展，围手术期结果可接受。无进展生存率在 cN1 和 VHR 患者中相似，非转移性 HR CaP 更好，而 cN0M1 患者介于两者之间，表明单独使用常规成像方法进行临床分期不精确。
