Liebross R H, Pollack A, Lankford S P, von Eschenbach A C, Zagars G K
Department of Radiation Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, USA.
Urology. 1998 Oct;52(4):647-52. doi: 10.1016/s0090-4295(98)00273-8.
The strict definition of Stage T1c prostate cancer is that the tumor is not palpable on digital rectal examination (DRE) or seen on imaging studies such as ultrasound. The inclusion of ultrasound imaging was brought about without an understanding of the relationship between ultrasound upstaging and prognosis. We have also noticed that in clinical practice, treatment decisions are made on the basis of the finding of bilateral versus unilateral biopsy positivity. The objectives in this study were to determine the prognostic significance of upstaging by transrectal ultrasound (TRUS) to uT2 or uT3, and unilateral versus bilateral biopsy positivity in patients with Stage T1c cancer as determined by DRE (DRE-Stage T1c patients).
Between 1987 and 1995 there were 643 patients with DRE-Stage T1-T2 prostate cancer treated with external beam radiotherapy; 24 had T1a, 76 had T1b, 183 had T1c, 133 had T2a, 168 had T2b, and 59 had T2c. Of these, 135 DRE-Stage T1c patients underwent ultrasound staging and 122 underwent bilateral prostate biopsies. All had pretreatment prostate-specific antigen values (PSAs) available and no patient received adjuvant androgen ablation. The median pretreatment PSA was 9.1 ng/mL, median radiotherapy dose was 66.0 Gy, and median follow-up was 41 months. Post-treatment failure was defined as disease recurrence and/or two elevations in PSA on consecutive follow-up visits.
The 5-year freedom from failure rate for DRE-Stage T1c patients (71%) was not significantly different from that of DRE-Stage T1b (65%) or DRE-Stage T2a (71%) patients. There was a trend (P = 0.1) toward a worse outcome for DRE-Stage T2b/T2c patients compared with DRE-Stage T1b/T1c/T2a patients. The distribution of DRE-Stage T1c patients by ultrasound staging was 29 with uT1c, 88 with uT2, and 18 with uT3 findings. Twenty percent of patients had bilateral positive biopsy specimens. In univariate and multivariate analyses, the only correlates of patient outcome were pretreatment PSA (P < or = 0.002) and isocenter dose (P = 0.03). TRUS upstaging had no effect on freedom from failure; uT1c patients had about the same risk of relapse or a rising PSA as uT2 or uT3 patients. Patients with bilateral positive prostate biopsy specimens had about the same prognosis as those with unilateral positive biopsy specimens.
For patients with DRE-Stage T1c prostate cancer, the data indicate that ultrasound staging and bilateral biopsy positivity are not predictive of outcome for patients treated with external beam radiotherapy and treatment decisions should not be based on these parameters.
T1c期前列腺癌的严格定义是经直肠指检（DRE）时肿瘤不可触及，或在超声等影像学检查中未见。将超声成像纳入其中时，并未了解超声分期上调与预后之间的关系。我们还注意到，在临床实践中，治疗决策是基于双侧与单侧活检阳性结果做出的。本研究的目的是确定经直肠超声（TRUS）将分期上调至uT2或uT3以及DRE确定为T1c期癌症患者（DRE-T1c期患者）单侧与双侧活检阳性的预后意义。
1987年至1995年间，643例DRE-T1-T2期前列腺癌患者接受了外照射放疗；其中24例为T1a期，76例为T1b期，183例为T1c期，133例为T2a期，168例为T2b期，59例为T2c期。其中，135例DRE-T1c期患者接受了超声分期，122例接受了双侧前列腺活检。所有患者均有治疗前前列腺特异性抗原值（PSA），且无患者接受辅助性雄激素剥夺治疗。治疗前PSA的中位数为9.1 ng/mL，放疗剂量中位数为66.0 Gy，中位随访时间为41个月。治疗后失败定义为疾病复发和/或连续随访中PSA两次升高。
DRE-T1c期患者的5年无失败生存率（71%）与DRE-T1b期（65%）或DRE-T2a期（71%）患者无显著差异。与DRE-T1b/T1c/T2a期患者相比，DRE-T2b/T2c期患者的预后有变差的趋势（P = 0.十）。根据超声分期，DRE-T1c期患者的分布为：uT1c期29例，uT2期88例，uT3期18例。20%的患者双侧活检标本为阳性。在单因素和多因素分析中，患者预后的唯一相关因素是治疗前PSA（P≤0.002）和等中心剂量（P = 0.03）。TRUS分期上调对无失败生存率无影响；uT1c期患者复发或PSA升高的风险与uT2或uT3期患者大致相同。双侧前列腺活检标本阳性的患者与单侧活检标本阳性的患者预后大致相同。
对于DRE-T1c期前列腺癌患者，数据表明超声分期和双侧活检阳性不能预测接受外照射放疗患者的预后，治疗决策不应基于这些参数。
