Epstein J I, Carmichael M J, Partin A W, Walsh P C
Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland 21287.
J Urol. 1994 Jun;151(6):1587-92. doi: 10.1016/s0022-5347(17)35309-0.
It has been suggested that poorly differentiated areas in prostatic carcinoma evolve from more well differentiated cancer with time and increasing tumor volume. However, the association of high grade tumor with increasing tumor volume may merely reflect a growth advantage of the high grade tumor, whereby most high grade tumors would be large by the time they were clinically detected. Prior reports analyzing the relationship of tumor volume and grade suffer from studying fairly advanced tumors in which the relationship of tumor volume and grade at inception of prostate cancer could not be addressed. We evaluated 720 individual tumor foci in 153 radical prostatectomy specimens removed for early prostate cancer detected by screening techniques. Although tumor volume was related to grade, the correlation was weak (r = 0.254). Of 13 peripherally located high grade tumors (Gleason score 8 to 10) 6 (46%) were less than 1 cc. Of 106 peripheral tumors with some Gleason pattern 4 or 5 component 48 (45%) were less than 1 cc. These small high grade tumors were frequently associated with high grade prostatic intraepithelial neoplasia. Small high grade cancers were uncommon within the transition zone, where there exists a greater tendency for large low grade cancers to arise. In this radical prostatectomy series of nonpalpable prostate cancer 9% of the prostates contained tumor foci that were predominantly Gleason pattern 4 or 5 and that measured 1 cc or less. Based on these findings, if some patients with low to intermediate grade cancer are to be followed expectantly, they should undergo widespread sampling of the prostate to enhance the detection of multifocal small high grade disease. The finding of a large proportion of low volume, high grade carcinoma reveals that prostate cancer has the potential to be high grade early in its course and need not arise from low grade carcinoma that has evolved with time and volume.
有人提出，前列腺癌中分化差的区域会随着时间推移和肿瘤体积增大，从分化较好的癌症演变而来。然而，高级别肿瘤与肿瘤体积增加之间的关联可能仅仅反映了高级别肿瘤的生长优势，即大多数高级别肿瘤在临床检测到时已经很大了。先前分析肿瘤体积与分级关系的报告存在局限性，这些报告研究的是相当晚期的肿瘤，无法探讨前列腺癌起始时肿瘤体积与分级的关系。我们评估了153例因筛查技术检测出早期前列腺癌而切除的根治性前列腺切除标本中的720个独立肿瘤病灶。尽管肿瘤体积与分级有关，但相关性较弱（r = 0.254）。在13个位于周边的高级别肿瘤（Gleason评分8至10）中，6个（46%）体积小于1立方厘米。在106个有一些Gleason模式4或5成分的周边肿瘤中，48个（45%）体积小于1立方厘米。这些小的高级别肿瘤常与高级别前列腺上皮内瘤变相关。小的高级别癌症在移行带并不常见，移行带更倾向于发生大的低级别癌症。在这个非触诊性前列腺癌的根治性前列腺切除系列中，9%的前列腺含有主要为Gleason模式4或5且体积为1立方厘米或更小的肿瘤病灶。基于这些发现，如果一些低级别至中级别癌症患者要进行观察等待，他们应该对前列腺进行广泛采样，以提高对多灶性小的高级别疾病的检测。大量低体积、高级别癌的发现表明，前列腺癌在病程早期就有可能是高级别，不一定是由随着时间和体积演变而来的低级别癌发展而来。
