AUA前列腺癌介绍

1、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1,10,472 patients with localized prostate cancer at Cleveland Clinic and Barnes-Jewish Hospital. radical prostatectomy (N=6493) EBRT (N=2260) b

2、rachytherapy (N=1719) 285 OVERALL AND CANCER SPECIFIC URVIVAL FOLLOWING DEFINITIVE THERAPY FOR CLINICALLY LOCALIZED PROSTATE CANCER IN THE PROSTATE-SPECIFIC ANTIGEN ERA,问题1,EBRT and brachytherapy were significantly associated with diminished survival (HR 1.6 95% CI: 1.4-1.9 and 1.7 95% CI: 1.4-2.1,

3、respectively; P 0.001)compared to radical prostatectomy after adjusting for biopsy Gleason score, PSA, age, comorbidity, ethnicity, and clinical stage.,问题1,EBRT and brachytherapy were also associated with a significantly higher rate of androgen-deprivation therapy (P 0.001). Compared to radical pros

4、tatectomy, a trend towards higher cancer-specific mortality was observed for EBRT (adjusted HR 1.6; 95% CI: 1.0-2.6), but not for brachytherapy (adjusted HR 1.1; 95% CI: 0.5, 2.6),问题1,After adjusting for the most relevant disease-specific and patient-specific confounders, radical prostatectomy is as

5、sociated with improved intermediate-term survival compared to EBRT and brachytherapy. Physicians and patients should consider these potential survival differences when choosing among treatment options for localized prostate cancer.,问题2,前列腺癌淋巴结清扫的范围？,问题2,Pelvic lymph node dissection (PLND) during rad

6、ical prostatectomy (RP) provides accurate staging and may be therapeutic, since 10-20% of men with LN metastases (+LN) live 10 years with an undetectable PSA after RP+PLND alone. However, the extent of PLND remains controversial.,1949 LYMPH NODE YIELD USING THE STANDARD LYMPH NODE DISSECTION DURING

7、RADICAL PROSTATECTOMY,问题2,Using a full PLND (external iliac, EI; obturator, O; and hypogastric, H), Studer reported that only 37% of patients with +LN would be identified if PLND was restricted to the EI area above the obturator nerve (the typical limited PLND performed in the US).,问题2,Over a 6 year

8、 period a single surgeon (PTS) submitted the PLN as separate packets during open RP in a consecutive series of 613 patients who received no prior therapy for prostate cancer. A full PLND was performed as described above.,问题2,Thirty-five patients had +LN (8.2%), with a median of 16 (range,2-52) nodes

9、 removed. The median number of +LN per patient was 2 (range, 1-10). Nearly half (49%) of men had only 1 +LN, 31% had 2 and 20% had 2 +LN. The EI, O and H regions had positive nodes in 37%, 60% and 49% of patients (figure).,问题2,Venous thrombo-embolism (VTE) is a source of serious morbidity and mortal

10、ity after radical prostatectomy (RP). Pelvic lymph node dissection (PLND), traditionally a routine part of RP, may be related to the development of VTE.,1951 PELVIC LYMPH NODE DISSECTION IS ASSOCIATED WITH VENOUS THROMBOEMBOLISM RISK DURING LAPAROSCOPIC RADICAL PROSTATECTOMY,问题2,The records of 773 c

11、onsecutive patients who underwent laparoscopic radical prostatectomy (LRP) by a single surgeon from 2001-2009 were reviewed for postoperative VTE. 469 patients (60.7%) underwent LRP+PLND; 304 underwent LRP only (39.3%). VTE occurred in 7/469 LRP+PLND patients (1.5%), and in 0/304 LRP-only patients (

12、0%) (p=0.046). Surgical approach (extra- or trans-peritoneal) and cancer stage were not risk factors for VTE. Only 4/469 (0.9%) men had positive lymph nodes.,问题2,PLND during LRP may increase the risk of VTE without providing an obvious cancer control benefit in most patients with clinically localize

13、d prostate cancer. Our data argue that PLND should be judiciously rather than routinely performed on patients at extremely low risk for LN metastasis.,问题2,Despite the lower incidence of +LN in our series, the distribution of +LN was identical to Studers. The O and H were the only sites of +LN in 31%

14、 and 26% of our patients, so a PLND limited to the EI area, above the obturator nerve, would miss more than half of contemporary RP patients with +LN. Whenever PLND is indicated during RP, a full PLND should be performed.,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,Although the majority of local recu

15、rrences of prostate cancer following radical prostatectomy (RP) are associated with positive surgical margins, a subset of patients with negative surgical margins will develop a local recurrence.,1064 PREDICTORS OF LOCAL RECURRENCE OF PROSTATE CANCER FOLLOWING RADICAL PROSTATECTOMY WITH NEGATIVE SUR

16、GICAL MARGINS,问题3,A Total of 8078 patients were identified with negative surgical margins at the time of RP. Median age and BMI at the time of RP were 63 years and 27.5, respectively. Median preoperative PSA was 5.9. Of these patients, a confirmed local recurrence was noted in 335/8078 (4.1%). On mu

17、ltivariable analysis increased Gleason score noted on preoperative biopsy (p = 0.0053) and tumor volume (p = 0.0003) were significantly associated with local recurrence despite negative surgical margins.,问题4,弹性超声成像对前列腺癌检测的结果如何？,问题4,To evaluate whether transrectal sonoelastography (SE) improves visua

18、lization of prostate cancer (PCa) in comparison with transrectal grayscale ultrasound (GSU) in patients with biopsy proven PCa.,134 PREOPERATIVE PROSTATE CANCER ASSESSMENT: COMPARISON OF THE LATEST GENERATION OF TRANSRECTAL SONOELASTOGRAPHY AND MODERN GRAYSCALE ULTRASOUND WITH WHOLE MOUNT SECTIONS A

19、FTER RADICAL PROSTATECTOMY,问题4,Between August 2008 and July 2009 229 patients with biopsy proven PCa underwent preoperative SE with the latest sonoelastographic device (Hitachi, EUB-7500HV).,问题4,The prostate was divided into 6 areas (base,mid, apex for each side, n=1374) and subsequently screened fo

20、r cancer suspicious areas. This was postulated for hypoechoic lesions during GSU and stiffer blue-colored lesions according to SE,respectively.,问题4,Sensitivity and specificity were 51% and 72% for SE and 18% and 90% for GSU. Extracapsular extension was identified with a sensitivity and specificity o

21、f 38% and 96% using SE compared to 15% and 97% using GSU. Imaging of extracapsular extension and locating prostate cancer lesions were significantly better using SE in comparison to GSU (p0.05).,问题4,In comparison with transrectal grayscale ultrasound, sonoelastography of the prostate provides a sign

22、ificant improvement on visualizing prostate cancer. Locating prostate cancer and evaluating extracapsular extension is more precise using latest generation of sonoelastography.,问题5,高危前列腺癌术后的效果如何？,问题5,Controversy exists regarding the optimal treatment for patients with clinical high risk prostate can

23、cer (PCa).Recent retrospective series have shown good cancer control when patients are treated with surgery as part of a multimodality approach, especially when specimen confined at pathological assessment. 2030 HIGH-RISK PROSTATE CANCER PATIENTS WHO HAVE SPECIMEN-CONFINED DISEASE AT PATHOLOGY HAVE

24、EXCEPTIONALLY GOOD OUTCOMES AFTER SURGERY.,问题5,The study included 1584 patients with pre-operative high risk prostate cancer (PSA20 ng/ml or cT3-4 or biopsy Gleason 8-10) treated with RP and pelvic LND at 7 tertiary referral centers between 1987 and 2009.,问题5,Cancer-specific survival（CSS）significant

25、ly better in patients with specimen confined disease compared to those without (10-year CSS 97.4% vs 82.5%, p0.0001). Patients with specimen confined disease were also dramatically less likely to receive adjuvant RT (5.8 vs. 31.4%, p0.0001) and HT (16.2 vs. 64.1%, p0.0001). Outcome of patients with

26、High risk prostate cancer is not invariably poor.,问题6,吸烟与前列腺癌的复发率是否有关系？ Among patients undergoing radical prostatectomy in SEARCH, cigarette smoking was associated with slightly more advanced disease but similar risk for biochemical recurrence（289）.,问题7,前列腺癌根治术后10年，如果没有生化复发，我们是否可以停止PSA的检测？ The majority of biochemical recurrence occurs within 10 years of surgery. Patients who remain free from progression at 10 years postoperatively should be counsel