Altwein J E
Department of Urology, Hospital Barmherzige Brüder, Munich-Nymphenburg, Germany.
Urol Int. 1998;60 Suppl 2:2-10; discussion 35. doi: 10.1159/000056545.
Locally advanced prostate cancer patients comprise those with iatrogenic capsular injury, extracapsular extension resulting in positive surgical margins following radical prostatectomy, and tumors with lymph node metastases, thus representing stage T3,N0,M0 or T1-4,N1-2,M0 disease. Parameters can be combined, as shown below, in a nomogram to predict advanced prostate cancer: if, for example, stage T2c is coupled with a PSA of 16 ng/ml and a high Gleason grade, the patient will have an approximately 70% likelihood of having extracapsular extension; then again, if the Gleason score is known from biopsies and a PSA of 10-20 ng/ml is given, then a stage T2c prostate cancer patient with a Gleason of 7 will have a 39% probability of having positive lymph nodes. The following therapeutic considerations may be used to enhance the chance of eradicating advanced disease through radical prostatectomy: (1) Neoadjuvant hormonal therapy helps downsize the tumor and may eventually reduce the number of positive margins by almost 50%. However, it is a moot point if this will lead to a prolonged survival period. (2) Technical refinements on radical prostatectomy may be achieved through the principle of wide extension excision, a modification of current apical dissection procedures, which involves the use of panoramic magnifying loupes, and an examination of resection margins during surgery using repetitive frozen sections. (3) If positive (not simply 'equivocal' as defined by Epstein) margins are found, radical prostatectomy alone is not curative. Among the various options available is postoperative irradiation with or without adjuvant hormonal therapy. The latter should probably be reserved for patients with extracapsular extension, a high Gleason score or positive lymph nodes. Hormonal therapy may be used continuously or intermittently. The value of adjuvant treatment is currently being tested in phase-III trials. (4) Hormonal therapy may be commenced at the time of biochemical or clinical progression, although it is not clear whether this modality is inferior to adjuvant forms of treatment. Technical expertise in radical prostatectomy accumulated at major institutions can be used to the advantage of patients with locally advanced prostate cancer. In this regard, results of ongoing phase-III trials testing various options including this procedure are eagerly awaited.
局部晚期前列腺癌患者包括那些存在医源性包膜损伤、根治性前列腺切除术后因包膜外侵犯导致手术切缘阳性以及伴有淋巴结转移的肿瘤患者，因此代表T3、N0、M0期或T1 - 4、N1 - 2、M0期疾病。参数可以如下组合在一个列线图中以预测晚期前列腺癌：例如，如果T2c期与16 ng/ml的前列腺特异抗原（PSA）以及高格里森分级相关联，那么患者出现包膜外侵犯的可能性约为70%；再者，如果活检已知格里森评分且给出的PSA为10 - 20 ng/ml，那么一名格里森评分为7的T2c期前列腺癌患者出现淋巴结阳性的概率为39%。以下治疗考量可用于通过根治性前列腺切除术提高根除晚期疾病的几率：（1）新辅助激素治疗有助于缩小肿瘤体积，最终可能使阳性切缘数量减少近50%。然而，这是否会导致生存期延长尚无定论。（2）根治性前列腺切除术的技术改进可通过广泛扩大切除原则实现，这是对当前尖部解剖手术的一种改良，包括使用全景放大 loupes 以及在手术期间使用重复冰冻切片检查切除切缘。（3）如果发现切缘阳性（并非如爱泼斯坦所定义的仅仅“可疑”），单纯根治性前列腺切除术无法治愈。可用的各种选择中包括术后放疗，可联合或不联合辅助激素治疗。后者可能应保留给有包膜外侵犯、高格里森评分或淋巴结阳性的患者。激素治疗可连续或间歇使用。辅助治疗的价值目前正在III期试验中进行测试。（4）激素治疗可在生化或临床进展时开始，尽管尚不清楚这种治疗方式是否劣于辅助治疗形式。主要机构积累的根治性前列腺切除术技术专长可用于局部晚期前列腺癌患者的优势。在这方面，人们急切期待正在进行的测试包括该手术在内的各种选择的III期试验结果。
