和前列腺体积对于前列腺癌伴精囊腺转移的评估课件

前列腺体积和术前PSA值水平-预测前列腺癌并精 囊腺转移的两项重要指标 Preoperative Prostate Specific Antigen and Prostate Volume-Two significant predictors of Seminal Vesicle Invasion in Patients with Prostate Cancer University Hospital of Patras, Patras Greece Prague Medical Report / Vol. 112 (2011) No. 4, p. 263271 Background the danger of leaving back cancer material if SV left in place during RP is high. Furthermore, SVI is a bad prognostic factor for survival and most of the patients will present early biochemical relapse and will need an adjuvant treatment protocol (radiotherapy, hormone manipulations). 目前认为，前列腺癌手术中保留精囊腺将增加癌组织残留的 机会，一般前列腺癌出现精囊转移，往往预示不良的预后， 患者术后早期就有可能出现前列腺癌生化复发，并不得不接 受进一步的治疗，如放射治疗，内分泌治疗等。 Background 前列腺癌并发精囊腺转移(SVI) 往往提示不良的预后并降 低生存率。因此，目前标准的前列腺癌根治术都应该包括 完整的切除精囊。 Seminal vesicle invasion (SVI) represents an adverse pathologic and prognostic factor and increases the rates of prostate cancer (PCa) specific mortality. Consequently, the complete removal of seminal vesicles (SV) is included in radical prostatectomy (RP) standard technique Background 但在目前标准的前列腺癌根治术中，膀胱三角区、膀胱颈 部和后尿道分布的神经往往会不可避免的被破坏，因为手 术的本身操作程序就涉及到前列腺、膀胱后壁和精囊的解 剖分离。 During radical prostatectomy, innervation of the trigone, neobladder neck, and posterior urethra may become disrupted, because the surgical procedure involves anatomic dissection around the prostate, posterior aspects of the bladder base, and seminal vesicles. 精囊腺周围紧邻的解剖结构：血管神经束、膀胱三角区的神 经这些解剖特点，决定了不论在手术当中还是术后组织 的纤维化改变，都可能损伤有关控制排尿和性功能的神经和 血供，从而影响术后患者的排尿控制和或性功能。 Background SV are in close anatomical relationship with structures like neurovascular bundle and trigonal nerves and this feature has stimulating research in recent years for the potential benefit of SV sparing RP in continence and erectile function outcomes after surgery. Direct lesion during surgery or postoperative fibrotic changes may harm both the nerve and blood supply. Background (A) Standard retropubic radical prostatectomy： Neural compromise to the trigone and neobladder neck by disrupting the branches of the pelvic nerve. Pr =prostate; Bl= bladder; Sv=seminal vesicle; Ur =ureter; Svp= superior ves. pedicle; Ivp=inferior ves. pedicle; Pp=pelvic plexus. Background (B) Seminal vesicle- sparing radical prostatectomy: The distal end of the seminal vesicle is not dissected, the crossing branches of the pelvic nerve are preserved, and, therefore, the neobladder neck and the trigone remain innervated. Background the continence rate（排尿可控率）： The seminal vesicle-sparing radical prostatectomy group (n=20)： 60% after 6 weeks and 95% after 6 months. The standard prostatectomy group (n=34)： 18% after 6 weeks and 82% after 6 months. The posterior urethral sensory threshold levels（后尿道感觉阈值） ： the seminal vesicle-sparing group the preoperative values the postoperative threshold levels in the standard prostatectomy group. Seminal vesicle-sparing radical prostatectomy: a novel concept to restore early urinary continence. UROLOGY 55 (6), 2000 Seminal vesicle tip- sparing radical prostatectomy may be a surgical option to preserve pelvic innervation（保护骨 盆神经） and maintain urinary continence （保存可 控性排尿）after radical prostatectomy. Background Background They determined the frequency of prostate cancer extension into the distal 1 cm. of seminal vesicles. reported that in 71 consecutive patients underwent RP, no tumor was found in the distal 1 cm of the seminal vesicles （SV）, including 12 with SVI. Radical prostatectomy: is complete resection of the seminal vesicles really necessary? J Urol. 1996 Sep;156(3):1081-3. Background Conclusion: We continue to advocate complete excision of the seminal vesicles during radical prostatectomy. However, if dissection is difficult and a small fragment is left behind, the prognosis is unlikely to be altered. Radical prostatectomy:is complete resection of the seminal vesicles really necessary? 作者还是认为应该继续提倡在前列腺癌根治术中一并切除精囊， 但若出现术中解剖分离困难，导致无法完整切除的时候，其实也太可 能会出现传统认为的将会非常可能出现的那些不良的预后，比如：生 化复发，临床复发，甚至转移等。 Background Furthermore, because of the close relationship of SV and bladder base arterial supply, trigonal nerves and proximal neurovascular bundle, sparing techniques may decrease the rates of post surgical impotence and incontinence by avoiding damage in these close neighbour structures. SV sparing RP can be a potential surgical modification, patients selection for such treatment modifications is of great concern： in order not to harbour the oncological outcome. Preoperative clinical and pathological data should be used for clarifying the appropriate candidates that will mostly benefit by SV spare during RP, in terms of functional results, without influencing the oncological parameters (biochemical recurrence, survival). Based on this concept, the aim of our study was to analyze several preoperative factors and evaluate their predictive potential for SVI in patients undergoing RP for clinically localized PCa. （A retrospective analysis Methods: Material and 一项回顾性分析研究） 目的意义 保留精囊的前列腺癌根治术是一种可供选择的新手术，但为了避免此项术 后不良的预后的发生（如肿瘤的生化复发，降低远期生存率）同时又能使 患者术后获得最大的益处（可控性排尿，性功能的恢复），就必须注重病 例的选择，所以必须选择出某些指标（临床/病理），用以术前评估预测局 限性前列腺癌的患者是否伴有精囊腺转移。 PSA and prostate volume should be considered significant predictors for adverse pathology of the seminal vesicles （SV）in patients planned for surgical treatment of prostate cancer. This is of great concern especially in cases that a seminal vesicle sparing technique is planned. 研究提出PSA值和前列腺体积这两项指标，应该 在预测前列腺癌是否并精囊腺转移的方面有重要 价值， 以进一步尝试阐明行保留精囊腺的前列腺癌根治 术的可行性。(SV sparing RP） 目的意义 （A retrospective analysis Methods: Material and 一项回顾性分析研究） （A retrospective analysis Methods: Material and 一项回顾性分析研究） The timeThe time： between January 2005 and November of 2010between January 2005 and November of 2010 The conditionThe condition：underwent a RP（open or laparoscopic extraperitoneal by 4 experienced surgeons. ）with the diagnosis of clinically localized PCa（transrectal ultrasound biopsy 经直肠超声引导下穿刺活检）. The exclusion：1.Any preoperative therapies: 1) in terms of active surveillance, （selection bias ） 2) hormone therapy 3) radiation 4) diagnosed after transurethral resection of the prostate(经尿道前列腺电切术) 2. patients with incomplete records 研究对象 ： 研究参数：预测因子 1. age 2. Preoperative value of PSA ： was measured before any prostate manipulation (digital rectal examination, transrectal ultrasound, biopsy). 3. the value of PSA density 4. % CM：The percentage of cancer found in the biopsy cores material 5. The preoperative 1st and 2nd Gleason pattern and Gleason summary 6. The presence of HGPIN（高级别上皮内瘤变） 7. prostate volume:（Measure The surgical specimen） A formula :D1D2D3/6 D1：标本横断面的最大直径, D2：标本前后面的最大直径, , D3：标本纵向面的最大直径, 结果 *u检验 *卡方检验 SD 均数标准差 IQR 四分位间距; 结果：单变量分析 前列腺体积, 术前PSA水平, PSA密度值， 活检中癌组织的百分 比（% CM）, 活检癌组织的 Gleason评分 和 1st Gleason评分 有统计学显著性意义。 结果：多变量分析 smaller prostate volume and higher preoperative PSA value are significant predictors for SVI 结果：ROC曲线分析 1.曲线越靠近左上角,试验 的准确性就越高。 2.最靠近左上角的ROC曲线 的点是错误最少的最好阈 值，其假阳性和假阴性的 总数最少-最佳的诊断 界限值。 3.在对同一种疾病的两种 或两种以上诊断方法进行 比较时，可将各试验的ROC 曲线绘制到同一坐标中， 以直观地鉴别优劣，最靠 近左上角的ROC曲线所代表 的受试者工作最准确。 4.计算各个试验的ROC曲线 下的面积(AUC)进行比较， 哪一种试验的 AUC最大， 则哪一种试验的诊断价值 最佳。 The optimal cut-off values of PSA and prostate volume for prediction of SVI were 10 ng/ml and 41 ml respectively, obtained by using ROC analysis. Area under the curve for PSA was 0.716 and for prostate volume was 0.609. Conclusion: A multi-institutional study of 6,740 patients reported that by utilizing PSA, grade,stage and patients age, the patients with an increased risk for SVI can be identified (Baccala et al., 2007). In another analysis conducted in a large cohort of 1,283 patients, authors reported that SV involvement is lower than 5% in all patients with a preoperative PSA level 10 ng/ml, except when Gleason score is 7 or when more than 50% of prostate biopsy cores show cancer involvement. Thus, removal of the SV may not be oncologically necessary and might spare complete resection (Zlotta et al., 2004). Other authors suggest that PSA 4 ng/ml, Gleason score 7 and less than 12% of biopsy cores involved with cancer are criteria that can be used preoperatively for vesiculectomy decision during RP, since SV complete removal would not benefit almost 99% of patients (Reis et al., 2010). Conclusion: Several factors have been proposed as potential predictors for SVI. The Partin tables represent one of the most widely used PCa staging tools for adverse pathology features including SVI These nomograms are utilizing preoperative PSA value, biopsy Gleason score and clinical stage and can predict SVI with an accuracy rate of 78%. (Makarov et al., 2007). Recently, another nomogram hasbeen developed using stage, grade and PSA plus the percentage of positive for malignancy cores obtained during transrectal ultrasound prostate bi