Epstein J I, Pizov G, Walsh P C
Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland 21205.
Cancer. 1993 Jun 1;71(11):3582-93. doi: 10.1002/1097-0142(19930601)71:11<3582::aid-cncr2820711120>3.0.co;2-y.
This study was performed to evaluate the effect of positive margins, Gleason grade, and capsular penetration on progression after radical prostatectomy.
The authors followed 507 men with totally embedded retropubic prostatectomy specimens performed for clinical Stages A and B prostate cancer for a mean of 3.9 years.
Fifty-nine percent of the specimens had negative margins, 37% had focally positive margins, and 4% had extensive positive margins. Although some positive margins were the result of extensive and/or high-grade tumor, in many cases, the tumors only focally reached the capsular margin such that positive margins resulted from an inability to remove additional soft tissue surrounding the prostate. Gleason sum 7 tumors had a significantly higher progression rate compared with Gleason sum 5 or 6 ones, although historically Gleason sum 5-7 lesions had been considered together as intermediate-grade tumors. In a multivariate analysis, positive margins and Gleason sum strongly correlated with progression, whereas capsular penetration did not. Only approximately 50% of patients with positive margins experienced disease progression during 5 years of follow-up. The most common single sites of positive margins were distal (22%), posterior (17%), and posterolateral (14%); 22% of positive margins were extensive. Only four patients (0.8% of the total) had positive margins only in the region of the spared neurovascular bundle and experienced progression.
The most likely explanation for the discrepancy between margins and progression is that some of these margins represented artifactually positive margins caused by the unique problems with handling and assessing radical prostatectomy specimens. Radical prostatectomy provided excellent local control, with only 8% of patients exhibiting local recurrence. Sixty-one percent of men with progression had an elevated serum prostate-specific antigen level as their only manifestation of progression. The significance of isolated elevated serum prostate-specific antigen levels is uncertain, and long-term morbidity and mortality will depend on whether these patients have local disease or occult distant metastases.
本研究旨在评估根治性前列腺切除术后切缘阳性、Gleason分级及包膜侵犯对疾病进展的影响。
作者对507例行耻骨后前列腺切除术且标本完全包埋的男性患者进行了随访，这些患者因临床A期和B期前列腺癌接受手术，平均随访3.9年。
59%的标本切缘阴性，37%切缘局灶阳性，4%切缘广泛阳性。尽管部分切缘阳性是由广泛和/或高级别肿瘤导致，但在许多病例中，肿瘤仅局灶性累及包膜边缘，致使切缘阳性是由于无法切除前列腺周围更多软组织所致。Gleason评分为7分的肿瘤进展率显著高于Gleason评分为5分或6分的肿瘤，尽管从历史上看，Gleason评分为5 - 7分的病变一直被视为中级肿瘤。在多变量分析中，切缘阳性和Gleason评分与疾病进展密切相关，而包膜侵犯则不然。在5年随访期间，仅约50%切缘阳性的患者出现疾病进展。切缘阳性最常见的单一部位为远端（22%）、后部（17%）和后外侧（14%）；22%的切缘阳性为广泛阳性。仅4例患者（占总数的0.8%）仅在保留神经血管束区域切缘阳性并出现进展。
切缘与疾病进展之间差异的最可能解释是，其中一些切缘代表了因处理和评估根治性前列腺切除标本的独特问题而导致的人为切缘阳性。根治性前列腺切除术提供了出色的局部控制，仅8%的患者出现局部复发。61%疾病进展的男性患者血清前列腺特异性抗原水平升高是其疾病进展的唯一表现。孤立性血清前列腺特异性抗原水平升高的意义尚不确定，长期发病率和死亡率将取决于这些患者是否存在局部疾病或隐匿性远处转移。
