Ohori M, Goad J R, Wheeler T M, Eastham J A, Thompson T C, Scardino P T
Matsunaga-Conte Prostate Cancer Research Center, Scott Department of Urology, Baylor College of Medicine, Houston, Texas.
J Urol. 1994 Nov;152(5 Pt 2):1843-9. doi: 10.1016/s0022-5347(17)32398-4.
A favorable outcome after radical prostatectomy for early stage prostate cancer has sometimes been attributed to the relatively benign natural history of the disease rather than the beneficial effects of treatment. Poorly differentiated tumors, however, are recognized as inherently aggressive and progress rapidly when managed conservatively. We determined the actuarial rate of treatment failure after radical prostatectomy for clinically localized (stages T1 to T3) poorly differentiated cancer, using as an end point an increase in the serum level of prostate specific antigen (PSA) to assess whether treatment altered the rapid progression expected of these cancers. Of 500 patients treated with radical prostatectomy, regardless of grade, the actuarial nonprogression rate was 76 +/- 5% at 5 years and 73 +/- 6% at 10 years. Poorly differentiated cancer, defined as Gleason score 7 or greater in the radical prostatectomy specimen, was present in 268 patients (54%) who had a nonprogression rate at 5 years of 55 +/- 12% compared to 92 +/- 4% for the 232 patients with a well or moderately differentiated (Gleason score less than 7) cancer (p < 0.00005). The extent of the cancer (confined or not confined) was strongly associated with progression (p < 0.00005). Only 76 of the 268 poorly differentiated tumors (28%) were confined to the prostate and the prognosis was excellent. At 5 years 85 +/- 18% of the patients had no evidence of progression, compared to 46 +/- 12% with poorly differentiated cancer extending outside the gland (p < 0.0001). In a multivariate analysis neither the grade nor volume of the tumor influenced the rate of progression when the cancer was confined to the prostate. Impalpable tumors detected by an elevated PSA level were as likely to be poorly differentiated as palpable disease (56% versus 63%) but were significantly more likely to be confined to the prostate (44% versus 24%, p < 0.01). Poorly differentiated cancers usually extend outside of the prostate by the time they are detected, and they progress rapidly. PSA increases the detection of impalpable high grade cancer confined to the gland. When these tumors are detected while still confined, most can be controlled by radical prostatectomy.
早期前列腺癌根治性前列腺切除术后的良好预后有时被归因于该疾病相对良性的自然病程，而非治疗的有益效果。然而，低分化肿瘤被认为具有内在侵袭性，保守治疗时进展迅速。我们确定了临床局限性（T1至T3期）低分化癌根治性前列腺切除术后的精算治疗失败率，以前列腺特异性抗原（PSA）血清水平升高作为终点，评估治疗是否改变了这些癌症预期的快速进展。在500例行根治性前列腺切除术的患者中，无论分级如何，5年时的精算无进展率为76±5%，10年时为73±6%。根治性前列腺切除标本中Gleason评分7分或更高定义为低分化癌，268例患者（54%）存在低分化癌，其5年无进展率为55±12%，而232例高分化或中分化（Gleason评分小于7分）癌患者的5年无进展率为92±4%（p<0.00005）。癌症范围（局限或未局限）与进展密切相关（p<0.00005）。268例低分化肿瘤中仅76例（28%）局限于前列腺，预后良好。5年时，85±18%的患者无进展证据，而低分化癌侵犯前列腺外的患者为46±12%（p<0.0001）。在多变量分析中，当癌症局限于前列腺时，肿瘤分级和体积均不影响进展率。通过PSA水平升高检测到的不可触及肿瘤与可触及病变一样，低分化的可能性较大（56%对63%），但局限于前列腺的可能性显著更高（44%对24%，p<0.01）。低分化癌在被检测到时通常已侵犯前列腺外，且进展迅速。PSA增加了对局限于腺体内不可触及的高级别癌的检测。当这些肿瘤仍局限时被检测到，大多数可通过根治性前列腺切除术得到控制。
