McLeod D G, Johnson C F, Klein E, Peabody J O, Coffield S, Soloway M
Walter Reed Army Medical Center, Washington, D.C. 20307, USA.
Urology. 1997 Mar;49(3A Suppl):70-3. doi: 10.1016/s0090-4295(97)00172-6.
Neoadjuvant hormonal therapy reduces positive margins in patients undergoing radical prostatectomy. All patients experience a decrease in serum prostate specific antigen (PSA), but not always to a level that is nondetectable. The results of several prospective, randomized trials indicate that the incidence of positive margins decreases with the use of androgen deprivation prior to radical prostatectomy. It has been suggested that a greater decline in PSA levels would result in fewer positive margins. In a recent US trial of patients with T2bNxMO prostate cancer, we reported that 18% of patients randomized to receive 3 months of leuprolide acetate and flutamide had positive margins, compared to 48% of those who had radical prostatectomy alone (P < 0.001). We correlated the PSA levels prior to and following androgen deprivation and the presence of a positive margin following radical prostatectomy (RP).
One hundred and thirty-seven of 149 patients randomized to receive presurgery androgen deprivation (AD) underwent radical prostatectomy. Of these, 135 had a PSA level obtained both prior to androgen deprivation and prior to surgery. We analyzed the percent positive margins in patients whose PSA values became undetectable and in those whose values remained above 0.1 ng/mL despite androgen deprivation.
Eight of 43 patients (19%) with a nadir PSA < or = 0.1 ng/mL had a positive surgical margin and 16/92 (17%) with a nadir PSA > 0.1 ng/mL had tumor at the margin. There were no statistical differences in these two groups (P = 1.0 by Fisher's Exact Test [two-tailed], and the Pearson correlation was -0.015).
There was no correlation between an undetectable PSA and a PSA > 0.1 ng/mL and the presence of tumor at the margin when 3 months of AD was given prior to RP. It is possible that longer periods of AD prior to RP will reduce PSA to an undetectable level in a higher percent of patients. However, these data suggest that an undetectable level will not result in less positive margins.
新辅助激素治疗可降低接受根治性前列腺切除术患者的切缘阳性率。所有患者血清前列腺特异性抗原（PSA）水平均会下降，但并非总能降至检测不到的水平。几项前瞻性随机试验结果表明，根治性前列腺切除术前行雄激素剥夺治疗可降低切缘阳性率。有人提出，PSA水平下降幅度越大，切缘阳性率越低。在最近一项针对T2bNxM0前列腺癌患者的美国试验中，我们报告称，随机接受3个月醋酸亮丙瑞林和氟他胺治疗的患者中，18%切缘阳性，而单纯接受根治性前列腺切除术的患者中这一比例为48%（P<0.001）。我们对雄激素剥夺治疗前后的PSA水平与根治性前列腺切除术后（RP）切缘阳性情况进行了相关性分析。
149例随机接受术前雄激素剥夺（AD）治疗的患者中有137例接受了根治性前列腺切除术。其中，135例患者在雄激素剥夺治疗前及手术前均检测了PSA水平。我们分析了PSA值降至检测不到的患者以及尽管接受雄激素剥夺治疗但PSA值仍高于0.1 ng/mL的患者的切缘阳性百分比。
最低点PSA≤0.1 ng/mL的43例患者中有8例（19%）手术切缘阳性，最低点PSA>0.1 ng/mL的92例患者中有16例（17%）切缘有肿瘤。两组之间无统计学差异（Fisher精确检验[双侧]P = 1.0，Pearson相关性为-0.015）。
RP术前给予3个月AD治疗时，PSA检测不到与PSA>0.1 ng/mL以及切缘有肿瘤之间无相关性。RP术前给予更长时间的AD治疗有可能使更高比例的患者PSA降至检测不到的水平。然而，这些数据表明，PSA检测不到并不能降低切缘阳性率。
