Epstein J I, Walsh P C, Brendler C B
Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
J Urol. 1994 Nov;152(5 Pt 2):1721-9. doi: 10.1016/s0022-5347(17)32370-4.
We review the pathological findings of impalpable prostate cancer detected by transurethral resection (stages T1a and T1b) and needle biopsy (stage T1c). The short-term (4 years) and long-term (8 to 10 years) natural histories of untreated stage T1a prostate cancer are examined, as are options to follow patients expectantly. The findings on radical prostatectomy for stages T1a and T1b disease are reviewed and compared. Of the 64 cases of stage T1a disease 13 (20%) showed substantial tumor, including 7 with more than 1 cc of tumor, 5 with capsular penetration and 1 with a Gleason grade 4 + 5 = 9 tumor. Based on preoperative pathological parameters, one could not predict which cases had minimal versus substantial tumor. In a study from our institution that undertook complete histological examination of 39 radical prostatectomy specimens of stage T1b carcinoma, we found that all prostates contained residual carcinoma, 26% had capsular penetration and 10% had invasion of the seminal vesicles. When comparing morphometrically determined volumes of carcinoma with similar data from 56 patients with stage T2 carcinoma, stage T1b tumors were much more heterogeneous in grade, location and volume than were stage T2 lesions. Unless all 3 variables (grade, volume and location) were known, the final pathological stage of T1b cancers could not be predicted with confidence. Finally, we examined preoperative clinical and pathological parameters in 157 men with clinical stage T1c disease undergoing radical prostatectomy, and correlated these findings with pathological extent of disease in the surgical specimen in an attempt to identify a subset of patients with potentially biologically insignificant tumor who might be followed conservatively. Of the tumors 16% were insignificant (less than 0.2 cc, organ confined and Gleason grade less than 7), 10% were minimal (0.2 to 0.5 cc, organ confined and Gleason grade less than 7), 37% were moderate (more than 0.5 cc or capsular penetration with Gleason sum less than 7) and 37% were advanced (capsular penetration with Gleason sum 7 or more, or positive margins, positive seminal vesicles or positive lymph nodes). These findings are intermediate between those found in clinical stages T1a and T2 disease. The best model predicting insignificant tumor was a prostate specific antigen (PSA) density of less than 0.1 and no adverse pathological finding on needle biopsy or PSA density of 0.1 to 0.15 with less than 3 mm. low to intermediate grade cancer on only 1 needle biopsy core. The positive predictive value of the model was 95% with a negative predictive value of 66%.(ABSTRACT TRUNCATED AT 400 WORDS)
我们回顾了经尿道切除术（T1a和T1b期）及穿刺活检（T1c期）检测到的不可触及前列腺癌的病理结果。研究了未经治疗的T1a期前列腺癌的短期（4年）和长期（8至10年）自然病史，以及对患者进行观察等待的选择。回顾并比较了T1a和T1b期疾病根治性前列腺切除术的结果。在64例T1a期疾病患者中，13例（20%）显示有大量肿瘤，其中7例肿瘤体积超过1立方厘米，5例有包膜侵犯，1例Gleason分级为4 + 5 = 9。根据术前病理参数，无法预测哪些病例的肿瘤为微小肿瘤或大量肿瘤。在我们机构进行的一项研究中，对39例T1b期癌根治性前列腺切除术标本进行了完整的组织学检查，我们发现所有前列腺均有残留癌，26%有包膜侵犯，10%有精囊侵犯。将形态学测定的癌体积与56例T2期癌患者的类似数据进行比较时，T1b期肿瘤在分级、位置和体积方面比T2期病变更具异质性。除非知道所有三个变量（分级、体积和位置），否则无法准确预测T1b期癌的最终病理分期。最后，我们检查了157例临床T1c期疾病行根治性前列腺切除术患者术前的临床和病理参数，并将这些结果与手术标本中疾病的病理范围相关联，试图确定一组可能具有生物学意义不显著肿瘤的患者，这些患者可能适合保守观察。在这些肿瘤中，16%为无意义肿瘤（小于0.2立方厘米，局限于器官内且Gleason分级小于7），10%为微小肿瘤（0.2至0.5立方厘米，局限于器官内且Gleason分级小于7），37%为中度肿瘤（超过0.5立方厘米或有包膜侵犯且Gleason总分小于7），37%为进展期肿瘤（有包膜侵犯且Gleason总分7或更高，或切缘阳性、精囊阳性或淋巴结阳性）。这些结果介于临床T1a期和T2期疾病之间。预测无意义肿瘤的最佳模型是前列腺特异性抗原（PSA）密度小于0.1且穿刺活检无不良病理结果，或PSA密度为0.1至0.15且仅1个穿刺活检核心有小于3毫米的低至中度分级癌。该模型的阳性预测值为95%，阴性预测值为66%。（摘要截取自400字）
