Bonin S R, Hanlon A L, Lee W R, Movsas B, al-Saleem T I, Hanks G E
Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA.
Cancer. 1997 Jan 1;79(1):75-80. doi: 10.1002/(sici)1097-0142(19970101)79:1<75::aid-cncr11>3.0.co;2-3.
The detection of perineural invasion (PNI) in the diagnostic transrectal biopsy of the prostate is associated with a 93% frequency of extracapsular disease extension in patients treated by prostatectomy for adenocarcinoma of the prostate. Extracapsular extension is associated with an inferior outcome compared with that of patients who have organ-confined disease. This study examined the association of PNI and treatment failure in a consecutive series of patients treated with three-dimensional conformal radiation therapy (3DCRT) alone.
The authors report actuarial biochemical no evidence of disease (bNED) survival rates for 484 consecutive patients with clinically localized prostate carcinoma diagnosed by transrectal needle biopsy who completed 3DCRT alone between May 1989 and December 1994. The median follow-up time was 28 months (range, 2-75 months), and the median dose to the center of the prostate was 7368 centigray (cGy) (range, 6316-8074 cGy). Patients were subdivided into 2 groups according to pretreatment prostate specific antigen (PSA) levels (< 20 ng/mL vs. > or = 20 ng/mL). Pathology records were reviewed for the presence or absence of PNI. bNED failure was defined as a PSA level > or = 1.5 ng/mL and rising on 2 consecutive occasions. bNED survival rates were calculated using Kaplan-Meier methodology and comparisons of survival curves were accomplished using the log rank test.
The 3-year bNED survival for all 484 patients was 77%. The presence of PNI predicted decreased bNED survival in all patients. This detrimental effect, however, was confined to patients with pretreatment PSA values < 20 ng/mL. The bNED survival rates for patients with pretreatment PSA < 20 ng/mL demonstrated a highly significant decrease if PNI was present versus when it was absent (65% vs. 88% at 3 years, 39% vs. 65% at 5 years; P = 0.0009 for overall curve comparison). For patients with pretreatment PSA < 20 ng/mL, multivariate analysis of prognostic variables demonstrated a significant association between bNED survival and PNI (P = 0.002), palpation stage (P = 0.02), and pretreatment PSA (P = 0.006). Gleason score, age, and dose were not independent predictors of bNED survival in this group of patients.
To the authors' knowledge, this is the first report demonstrating that PNI detected on diagnostic transrectal biopsy is a significant predictor of decreased bNED survival in patients treated with radiotherapy. The subgroup of patients affected are those with pretreatment PSA < 20 ng/mL. This result suggests that such patients may benefit from more aggressive treatment, particularly the use of larger planning target volumes or adjuvant therapies.
在前列腺癌诊断性经直肠活检中检测到神经周围浸润（PNI），在接受前列腺腺癌前列腺切除术的患者中，其与93%的包膜外疾病扩展频率相关。与局限性疾病患者相比，包膜外扩展与较差的预后相关。本研究在一系列仅接受三维适形放疗（3DCRT）治疗的连续患者中，研究了PNI与治疗失败的相关性。
作者报告了1989年5月至1994年12月期间，484例经直肠穿刺活检诊断为临床局限性前列腺癌且仅完成3DCRT的连续患者的精算无生化疾病证据（bNED）生存率。中位随访时间为28个月（范围2 - 75个月），前列腺中心的中位剂量为7368厘戈瑞（cGy）（范围6316 - 8074 cGy）。根据治疗前前列腺特异性抗原（PSA）水平（< 20 ng/mL与≥20 ng/mL）将患者分为两组。回顾病理记录以确定是否存在PNI。bNED失败定义为PSA水平≥1.5 ng/mL且连续两次上升。使用Kaplan-Meier方法计算bNED生存率，并使用对数秩检验比较生存曲线。
484例患者的3年bNED生存率为77%。PNI的存在预示着所有患者的bNED生存率降低。然而，这种有害影响仅限于治疗前PSA值< 20 ng/mL的患者。治疗前PSA < 20 ng/mL的患者，存在PNI时与不存在PNI时相比，bNED生存率显著降低（3年时为65%对88%，5年时为39%对65%；总体曲线比较P = 0.0009）。对于治疗前PSA < 20 ng/mL的患者，对预后变量的多因素分析表明bNED生存率与PNI（P = 0.002）、触诊分期（P = 0.02）和治疗前PSA（P = 0.006）之间存在显著关联。在该组患者中，Gleason评分、年龄和剂量不是bNED生存率的独立预测因素。
据作者所知，这是第一份表明在诊断性经直肠活检中检测到的PNI是放疗患者bNED生存率降低的重要预测因素的报告。受影响的患者亚组是治疗前PSA < 20 ng/mL的患者。这一结果表明，这类患者可能从更积极的治疗中获益，特别是使用更大的计划靶体积或辅助治疗。
