D'Amico A V, Whittington R, Malkowicz S B, Schultz D, Schnall M, Tomaszewski J E, Wein A
Joint Center for Radiation Therapy, Harvard Medical School, Boston, Massachusetts 02747, USA.
Cancer J Sci Am. 1996 Nov-Dec;2(6):343-50.
This study was performed to determine the clinical factors that can optimize preoperative staging for clinically localized intermediate-risk prostate cancer patients.
Logistic and Cox regression multivariable analyses were performed on 480 prostate cancer patients whose disease was confined to the prostate to evaluate the ability of clinical stage, prostate-specific antigen (PSA), biopsy Gleason sum, percent positive biopsies, and endorectal coil magnetic resonance imaging (MRI) results to predict pathologic established extracapsular extension, seminal vesicle invasion, and time to postoperative PSA failure in patients with clinically localized prostate cancer. Intermediate risk was defined as PSA 4-10 ng/mL and Gleason sum 5-7; PSA 10-20 ng/mL and Gleason sum < or = 7.
Intermediate-risk patients with at least 50%, 67%, 83%, or 100% positive biopsies have disease pathologically confined to the prostate at least 45% of the time; however, if an endorectal coil MRI is positive for either capsular penetration or seminal vesicle invasion, no more than 29% of patients have pathologically determined organ-confined disease. No intermediate-risk patient with both a positive MRI and at least 50% positive biopsies had pathologically determined organ-confined disease. Intermediate-risk patients with less than 50% positive biopsies had pathologically determined organ-confined disease in at least 77% of the cases.
Intermediate-risk patients with an endorectal coil MRI showing extracapsular extension or seminal vesticle invasion are at high risk for early postoperative PSA failure. The concomitant presence of at least 50% positive biopsies increases this risk to unity. Therefore, these patients are not good candidates for surgery alone because of their high risk of extraprostatic disease and should be considered for entry onto phase III trials examining the effect of adding androgen-deprivation therapy to definitive local therapy (external-beam radiation therapy or surgery) on overall survival. The subgroup of intermediate-risk patients likely to benefit from an endorectal coil MRI are those patients with PSA > 10-20 ng/mL; biopsy Gleason score < or = 7, and at least 50% positive biopsies representing approximately 7.5% of the total patient population.
本研究旨在确定可优化临床局限性中危前列腺癌患者术前分期的临床因素。
对480例疾病局限于前列腺的前列腺癌患者进行逻辑回归和Cox回归多变量分析，以评估临床分期、前列腺特异性抗原（PSA）、活检Gleason评分总和、阳性活检百分比及直肠内线圈磁共振成像（MRI）结果预测临床局限性前列腺癌患者病理确定的包膜外侵犯、精囊侵犯及术后PSA失败时间的能力。中危定义为PSA 4 - 10 ng/mL且Gleason评分总和为5 - 7；PSA 10 - 20 ng/mL且Gleason评分总和≤7。
活检阳性率至少为50%、67%、83%或100%的中危患者，其疾病病理局限于前列腺的时间至少为45%；然而，如果直肠内线圈MRI显示包膜穿透或精囊侵犯阳性，则不超过29%的患者病理确定为器官局限性疾病。MRI阳性且活检阳性率至少为50%的中危患者，无一例病理确定为器官局限性疾病。活检阳性率低于50%的中危患者，至少77%的病例病理确定为器官局限性疾病。
直肠内线圈MRI显示包膜外侵犯或精囊侵犯的中危患者术后早期PSA失败风险高。活检阳性率至少为50%会使此风险升至100%。因此，这些患者单独手术并非理想选择，因其前列腺外疾病风险高，应考虑纳入III期试验，研究在确定性局部治疗（外照射放疗或手术）基础上加用雄激素剥夺治疗对总生存的影响。可能从直肠内线圈MRI中获益的中危患者亚组为PSA>10 - 20 ng/mL、活检Gleason评分≤7且活检阳性率至少为50%的患者，约占总患者人群的7.5%。
