AUA前列腺癌介绍

2010年美国泌尿外科年会前列腺癌相关进展北京大学第三医院泌尿外科刘磊马潞林关于前列腺癌的文献数量多，分类细临床随访数量多，资料翔实涉及的领域比较广泛问题1前列腺癌根治术（RP）、前列腺癌外放射治疗（EBRT）、前列腺癌近距离照射治疗（brachytherapy）这三种方法治疗效果的比较？问题110,472patientswithlocalizedprostatecanceratClevelandClinicandBarnes-JewishHospital.radicalprostatectomy(N=6493)EBRT(N=2260)brachytherapy(N=1719)285OVERALLANDCANCERSPECIFICURVIVALFOLLOWINGDEFINITIVETHERAPYFORCLINICALLYLOCALIZEDPROSTATECANCERINTHEPROSTATE-SPECIFICANTIGENERA问题1EBRTandbrachytherapyweresignificantlyassociatedwithdiminishedsurvival(HR1.6[95%CI:1.4-1.9]and1.7[95%CI:1.4-2.1],respectively;P0.001)comparedtoradicalprostatectomyafteradjustingforbiopsyGleasonscore,PSA,age,comorbidity,ethnicity,andclinicalstage.问题1EBRTandbrachytherapywerealsoassociatedwithasignificantlyhigherrateofandrogen-deprivationtherapy(P0.001).Comparedtoradicalprostatectomy,atrendtowardshighercancer-specificmortalitywasobservedforEBRT(adjustedHR1.6;95%CI:1.0-2.6),butnotforbrachytherapy(adjustedHR1.1;95%CI:0.5,2.6)问题1Afteradjustingforthemostrelevantdisease-specificandpatient-specificconfounders,radicalprostatectomyisassociatedwithimprovedintermediate-termsurvivalcomparedtoEBRTandbrachytherapy.Physiciansandpatientsshouldconsiderthesepotentialsurvivaldifferenceswhenchoosingamongtreatmentoptionsforlocalizedprostatecancer.问题2前列腺癌淋巴结清扫的范围？问题2Pelviclymphnodedissection(PLND)duringradicalprostatectomy(RP)providesaccuratestagingandmaybetherapeutic,since10-20%ofmenwithLNmetastases(+LN)live10yearswithanundetectablePSAafterRP+PLNDalone.However,theextentofPLNDremainscontroversial.1949LYMPHNODEYIELDUSINGTHESTANDARDLYMPHNODEDISSECTIONDURINGRADICALPROSTATECTOMY问题2UsingafullPLND(externaliliac,EI;obturator,O;andhypogastric,H),Studerreportedthatonly37%ofpatientswith+LNwouldbeidentifiedifPLNDwasrestrictedtotheEIareaabovetheobturatornerve(thetypicallimitedPLNDperformedintheUS).问题2Overa6yearperiodasinglesurgeon(PTS)submittedthePLNasseparatepacketsduringopenRPinaconsecutiveseriesof613patientswhoreceivednopriortherapyforprostatecancer.AfullPLNDwasperformedasdescribedabove.问题2Thirty-fivepatientshad+LN(8.2%),withamedianof16(range,2-52)nodesremoved.Themediannumberof+LNperpatientwas2(range,1-10).Nearlyhalf(49%)ofmenhadonly1+LN,31%had2and20%had2+LN.TheEI,OandHregionshadpositivenodesin37%,60%and49%ofpatients(figure).问题2Venousthrombo-embolism(VTE)isasourceofseriousmorbidityandmortalityafterradicalprostatectomy(RP).Pelviclymphnodedissection(PLND),traditionallyaroutinepartofRP,mayberelatedtothedevelopmentofVTE.1951PELVICLYMPHNODEDISSECTIONISASSOCIATEDWITHVENOUSTHROMBOEMBOLISMRISKDURINGLAPAROSCOPICRADICALPROSTATECTOMY问题2Therecordsof773consecutivepatientswhounderwentlaparoscopicradicalprostatectomy(LRP)byasinglesurgeonfrom2001-2009werereviewedforpostoperativeVTE.469patients(60.7%)underwentLRP+PLND;304underwentLRPonly(39.3%).VTEoccurredin7/469LRP+PLNDpatients(1.5%),andin0/304LRP-onlypatients(0%)(p=0.046).Surgicalapproach(extra-ortrans-peritoneal)andcancerstagewerenotriskfactorsforVTE.Only4/469(0.9%)menhadpositivelymphnodes.问题2PLNDduringLRPmayincreasetheriskofVTEwithoutprovidinganobviouscancercontrolbenefitinmostpatientswithclinicallylocalizedprostatecancer.OurdataarguethatPLNDshouldbejudiciouslyratherthanroutinelyperformedonpatientsatextremelylowriskforLNmetastasis.问题2Despitethelowerincidenceof+LNinourseries,thedistributionof+LNwasidenticaltoStuder’s.TheOandHweretheonlysitesof+LNin31%and26%ofourpatients,soaPLNDlimitedtotheEIarea,abovetheobturatornerve,wouldmissmorethanhalfofcontemporaryRPpatientswith+LN.WheneverPLNDisindicatedduringRP,afullPLNDshouldbeperformed.问题3前列腺癌根治术后切缘阴性的患者肿瘤复发的几率有多大，危险因素有哪些？问题3Althoughthemajorityoflocalrecurrencesofprostatecancerfollowingradicalprostatectomy(RP)areassociatedwithpositivesurgicalmargins,asubsetofpatientswithnegativesurgicalmarginswilldevelopalocalrecurrence.1064PREDICTORSOFLOCALRECURRENCEOFPROSTATECANCERFOLLOWINGRADICALPROSTATECTOMYWITHNEGATIVESURGICALMARGINS问题3ATotalof8078patientswereidentifiedwithnegativesurgicalmarginsatthetimeofRP.MedianageandBMIatthetimeofRPwere63yearsand27.5,respectively.MedianpreoperativePSAwas5.9.Ofthesepatients,aconfirmedlocalrecurrencewasnotedin335/8078(4.1%).OnmultivariableanalysisincreasedGleasonscorenotedonpreoperativebiopsy(p=0.0053)andtumorvolume(p=0.0003)weresignificantlyassociatedwithlocalrecurrencedespitenegativesurgicalmargins.问题4弹性超声成像对前列腺癌检测的结果如何？问题4Toevaluatewhethertransrectalsonoelastography(SE)improvesvisualizationofprostatecancer(PCa)incomparisonwithtransrectalgrayscaleultrasound(GSU)inpatientswithbiopsyprovenPCa.134PREOPERATIVEPROSTATECANCERASSESSMENT:COMPARISONOFTHELATESTGENERATIONOFTRANSRECTALSONOELASTOGRAPHYANDMODERNGRAYSCALEULTRASOUNDWITHWHOLEMOUNTSECTIONSAFTERRADICALPROSTATECTOMY问题4BetweenAugust2008andJuly2009229patientswithbiopsyprovenPCaunderwentpreoperativeSEwiththelatestsonoelastographicdevice(Hitachi,EUB-7500HV).问题4Theprostatewasdividedinto6areas(base,mid,apexforeachside,n=1374)andsubsequentlyscreenedforcancersuspiciousareas.ThiswaspostulatedforhypoechoiclesionsduringGSUandstifferblue-color