Shinohara K, Rhee B, Presti J C, Carroll P R
Department of Urology, University of California School of Medicine and the Program in Urologic Oncology, UCSF/Mt. Zion Cancer Center, San Francisco 94143-0738, USA.
J Urol. 1997 Dec;158(6):2206-9; discussion 2209-10. doi: 10.1016/s0022-5347(01)68198-9.
We determined the rate of biochemical and biopsy failure in relation to the prostate specific antigen (PSA) nadir, the effect of neoadjuvant androgen blockade and the pattern of residual tumor after cryosurgical ablation of prostate cancer.
From July 1993 to April 1996, 134 patients underwent 147 cryosurgical ablation procedures. Of those patients, 110 had adequate followup and did not receive post-treatment androgen deprivation. Followup included PSA determination at 3, 6 and 12 months, and every 6 months thereafter. Biopsies were performed at 6 months or with biochemical failure defined as PSA nadir 0.5 ng./ml. or greater or subsequent biochemical failure (PSA increase 0.2 ng./ml. or greater). Biochemical and biopsy failures were correlated with PSA nadir values following cryosurgery (less than 0.1 ng./ml., 0.1 to 0.4 and or greater 0.5). A total of 68 patients had careful ultrasound guided mapping biopsy preoperatively and postoperatively to define the sites of disease. The likelihood of residual disease was correlated with the initial site(s) of the cancer in an attempt to identify if areas of the prostate and/or seminal vesicles were more likely to be sites of treatment failure.
At a mean followup of 17.6 months biochemical failure (subsequent rise in PSA 0.2 ng./ml. or greater) was lowest in those who achieved PSA nadirs less than 0.1 ng./ml. (21%) but it was noted in 48% of patients with nadirs between 0.1 and 0.4 ng./ml. Those patients with PSA nadirs 0.5 or greater had either immediate local failure (46%), subsequent local or biochemical failures (43%) or extremely high PSA nadirs (greater than 30 ng./ml.) necessitating hormonal therapy (11%). Biopsy failure was lowest in those with nadirs less than 0.1 ng./ml. (7%) and those with nadirs 0.1 to 0.4 ng./ml. (22%). In contrast, 60% of the patients with nadir values 0.5 ng./ml. or greater had biopsy failure. Biochemical and biopsy failure tended to occur within the first 18 months after treatment. Neoadjuvant androgen blockade appeared to reduce subsequent biochemical failure in patients with stages T1 and T2 cancers (11% versus 50% in those without androgen deprivation) but not in those with T3 and T4 cancers. Recurrence was more common in cancers at the apex (9.5%) and seminal vesicles (44%), in contrast to those located in the mid gland (4%) and base (0%).
A PSA nadir of 0.4 ng./ml. or less should be achieved following cryotherapy. Higher values are associated with a significant risk of continued PSA elevation and a high likelihood of residual disease detected on prostatic biopsy. Local failure tends to occur at the apex and seminal vesicles. Neoadjuvant androgen blockade reduces the risk of biochemical failure in patients with stages T1 and T2 cancers.
我们确定了与前列腺特异性抗原（PSA）最低点相关的生化及活检失败率、新辅助雄激素阻断的效果以及前列腺癌冷冻消融术后残留肿瘤的模式。
1993年7月至1996年4月，134例患者接受了147次冷冻消融手术。其中110例患者有充分的随访且未接受治疗后的雄激素剥夺。随访包括在3、6和12个月时测定PSA，此后每6个月测定一次。在6个月时或当生化失败定义为PSA最低点为0.5 ng/ml或更高或随后出现生化失败（PSA升高0.2 ng/ml或更高）时进行活检。将生化及活检失败与冷冻术后的PSA最低点值（小于0.1 ng/ml、0.1至0.4 ng/ml以及0.5 ng/ml或更高）进行关联分析。共有68例患者在术前和术后接受了仔细的超声引导下定位活检以确定疾病部位。将残留疾病的可能性与癌症的初始部位进行关联分析，以试图确定前列腺和/或精囊的哪些区域更可能是治疗失败的部位。
平均随访17.6个月时，PSA最低点小于0.1 ng/ml的患者生化失败（随后PSA升高0.2 ng/ml或更高）率最低（21%），但在PSA最低点在0.1至0.4 ng/ml之间的患者中为48%。PSA最低点为0.5 ng/ml或更高的患者要么立即出现局部失败（46%），要么随后出现局部或生化失败（43%），要么PSA最低点极高（大于30 ng/ml）而需要激素治疗（11%）。活检失败率在PSA最低点小于0.1 ng/ml的患者中最低（7%），在PSA最低点为0.1至0.4 ng/ml的患者中为22%。相比之下，PSA最低点值为0.5 ng/ml或更高的患者中有60%出现活检失败。生化及活检失败往往发生在治疗后的前18个月内。新辅助雄激素阻断似乎可降低T1和T2期癌症患者随后的生化失败率（11%，而未接受雄激素剥夺的患者为50%），但对T3和T4期癌症患者无效。复发在前列腺尖部（9.5%）和精囊（44%）的癌症中比在前列腺中叶（4%）和底部（0%）的癌症中更常见。
冷冻治疗后PSA最低点应达到0.4 ng/ml或更低。更高的值与PSA持续升高的显著风险以及前列腺活检中检测到残留疾病的高可能性相关。局部失败往往发生在前列腺尖部和精囊。新辅助雄激素阻断可降低T1和T2期癌症患者生化失败的风险。
