von Eschenbach A C
Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston 77030, USA.
Cancer. 1996 Jul 15;78(2):326-9. doi: 10.1002/(SICI)1097-0142(19960715)78:2<326::AID-CNCR21>3.0.CO;2-X.
The clinician has long been challenged by the diversity in clinical expression of carcinoma of the prostate. On one end of the spectrum is a disease that is phenotypically malignant but biologically not virulent. It is the prostate carcinoma that males die with rather than of. On the other end of the spectrum, there is a carcinoma of the prostate that is relentless and virulent, and has been resistant to our intervention efforts. Although all males are known to be at risk for the occurrence of carcinoma of the prostate, there is no means at present to predict the type and behavior of the disease they will experience. This is the conundrum faced upon recognition of premalignant and early microscopic disease.
This paper presents a conceptual framework of the evaluation of disease behavior along one of three distinctive pathways. In this trilogy of expression of carcinoma of the prostate, there are the indolent (Type I), the slowly progressive (Type II), and the virulent and systemic (Type III). These general patterns of behavior may be an expression of the tumor cell ("seed") and the factors that were its genesis, or the effect of the environment ("soil") in which the tumor cell finds itself. The more likely fact is that it is the product of both ("seed and soil").
Our goal is to identify tumors for which no therapy is warranted at their outset by molecular and biologic methods; age group in whom curative local therapy is feasible; and the carcinomas that require effective systemic therapy.
The three general patterns of clinical expression provide a framework in which to identify the genetic, molecular, and cellular determinant of the biologic behavior of carcinoma of the prostate. Being able to correlate such parameters with likely behavior patterns would help us choose appropriate therapy.
长期以来，临床医生一直面临前列腺癌临床表型多样性的挑战。在这个范围的一端是一种表型上为恶性但生物学上无侵袭性的疾病。这是一种男性与之共存而非死于其的前列腺癌。在这个范围的另一端，有一种前列腺癌具有侵袭性且难以控制，并且对我们的干预措施具有抗性。虽然已知所有男性都有患前列腺癌的风险，但目前尚无办法预测他们将会患何种类型及具有何种行为的前列腺癌。这就是在识别癌前病变和早期微小病变时所面临的难题。
本文提出了一个沿着三种不同途径之一评估疾病行为的概念框架。在前列腺癌的这种三部曲式表现中，存在惰性（I型）、缓慢进展型（II型）和侵袭性及全身性（III型）。这些一般行为模式可能是肿瘤细胞（“种子”）及其起源因素的一种表现，或者是肿瘤细胞所处环境（“土壤”）的影响。更有可能的事实是，它是两者（“种子和土壤”）共同作用的产物。
我们的目标是通过分子和生物学方法识别出一开始就无需治疗的肿瘤；确定可行治愈性局部治疗的年龄组；以及确定需要有效全身治疗的前列腺癌。
这三种临床表达的一般模式提供了一个框架，用于识别前列腺癌生物学行为的遗传、分子和细胞决定因素。能够将这些参数与可能的行为模式相关联将有助于我们选择合适的治疗方法。
