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北京大学学报（医学版） ›› 2020, Vol. 52 ›› Issue (4): 625-631. doi: 10.19723/j.issn.1671-167X.2020.04.005

• 论著 • 上一篇    下一篇

穿刺活检单针阳性的前列腺癌手术策略选择及经验总结

郝一昌,颜野,张帆,邱敏,周朗,刘可,卢剑,肖春雷,黄毅,刘承(),马潞林()   

  1. 北京大学第三医院泌尿外科,北京 100191
  • 收稿日期:2020-04-13 出版日期:2020-08-18 发布日期:2020-08-06
  • 通讯作者: 刘承,马潞林 E-mail:chengliu@bjmu.edu.cn;malulin@medmail.com.cn

Surgical strategy selection and experience summary of prostate cancer with positive single needle biopsy

Yi-chang HAO,Ye YAN,Fan ZHANG,Min QIU,Lang ZHOU,Ke LIU,Jian LU,Chun-lei XIAO,Yi HUANG,Cheng LIU(),Lu-lin MA()   

  1. Department of Urology, Peking University Third Hospital, Beijing 100191, China
  • Received:2020-04-13 Online:2020-08-18 Published:2020-08-06
  • Contact: Cheng LIU,Lu-lin MA E-mail:chengliu@bjmu.edu.cn;malulin@medmail.com.cn

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摘要：

目的: 分析穿刺活检单针阳性的前列腺癌患者行前列腺癌根治性切除术后的临床病理特征,以协助选择手术策略。方法: 回顾性分析2010年1月至2018年12月北京大学第三医院泌尿外科收治的经直肠前列腺系统穿刺活检单针阳性并且接受前列腺癌根治术的患者共计53例,患者年龄(69.7±6.9)岁(54~81岁)。穿刺前前列腺特异抗原(prostate specific antigen,PSA)为(9.70±5.24) μg/L(1.69~25.69 μg/L),前列腺体积为(50.70±28.39) mL(12.41~171.92 mL),穿刺Gleason评分6分、7分和≥8分者分别为39例(73.6%)、11例(20.8%)和3例(5.7%),临床分期T1期、T2期和T3期者分别为6例(11.3%)、44例(83.0%)和3例(5.7%)。按年龄、术前PSA水平、穿刺Gleason评分、单针肿瘤占穿刺组织百分比和临床分期等因素进行分组,比较各组患者的临床病理特征差异。结果: 术后Gleason评分6分、7分和≥8分者分别为 20例(37.7%)、21例(39.6%)和10例(18.9%),另有2例(3.8%)为pT0;病理分期T0期、T2a期、T2b期、T2c期和T3期者分别为2例(3.8%)、9例(17.0%)、2例(3.8%)、29例(54.7%)和11例(20.8%);11例(20.8%)手术切缘阳性,10例前列腺包膜外侵犯(18.9%),1例(1.9%)精囊侵犯。术后肿瘤呈多灶状分布42例(79.2%),双侧分布37例(69.8%)。与术前穿刺Gleason评分比较,术后Gleason评分下降3例(5.7%), 不变28例(52.8%),升级20例(37.7%),其中有2例(3.8%)为pT0;与临床分期比较,术后病理分期下降2例(3.8%),不变10例(18.9%),升级41例(77.4%)。根据术后病理分为微灶癌组(n=8)和非微灶癌组(n=45), 经比较,两组单针肿瘤占穿刺组织百分比(≤5%)差异有统计学意义(P=0.014),而年龄、前列腺体积、术前前列腺特异抗原密度(prostate special antigen density,PSAD)和术前穿刺Gleason评分差异无统计学意义(P>0.05);通过穿刺活检判断癌灶位于尖部的方法,假阴性率41.4%(12/29),假阳性率 50.0%(12/24)。实际清扫淋巴结和保留性神经的病例,与根据术后病理再次判断方案选择时存在统计学差异(P<0.05)。结论: 单针肿瘤占穿刺组织百分比≤5%是前列腺微灶癌的预测因素。37.7%病例发生病理分级升级和77.4%病例发生病理分期升级,选择手术方案(如性神经保护、淋巴结清扫、尖部的处理等)时,需要综合分析肿瘤危险度分层、列线图预测因素、多参数磁共振成像以及术中情况等多因素。

关键词: 前列腺肿瘤, 活组织检查, 针吸, 病理学, 临床

Abstract:

Objective: To analyze the clinicopathological characteristics of prostate cancer patients undertaking radical prostatectomy with single positive core biopsy, and to optimize the rational choice of therapeutic strategy. Methods: In the study, 53 patients with single positive core prostate biopsy and treated by radical prostatectomy from January 2010 to December 2018, were analyzed retrospectively. The mean age was (69.7±6.9) years (54-81 years), the mean prostate specific antigen (PSA) level was (9.70±5.24) μg/L (1.69-25.69 μg/L), and the mean prostate volume was (50.70±28.39) mL (12.41-171.92 mL). Thirty-nine out of 54 (73.6%) patients presented Gleason score with 6, 11 patients (20.8%) had Gleason score of 7 and 3 patients (5.7%) showed Gleason score ≥8. For clinical stages, 6 out of the 53 patients (11.3%) had prostate cancer in cT1,44 cases (83.0%) had prostate cancer in cT2,and 3 cases (5.7%) in cT3.The patients were divided into subgroups according to age, preoperative PSA level, Gleason score, percentage of tumor in single needle tissue and clinical stage, and the differences of their clinicopathological characteristics were compared. Results: Postoperative Gleason score of 6, 7 and ≥8 were found in 20 cases (37.7%), 21 cases (39.6%) and 10 cases (18.9%) respectively, another 2 cases (3.8%) were pT0 prostate cancer; pathological stages of T0, T2a, T2b, T2c and T3 were found in 2 cases (3.8%), 9 cases (17.0%), 2 cases (3.8%), 29 cases (54.7%) and 11 cases (20.8%) respectively; 11 cases (20.8%) had positive surgical margin, 10 cases (18.9%) had extracapsular invasion of prostate, and 1 case (1.9%) showed seminal vesicle invasion. Forty-two cases (79.2%) had multifocal lesions and 37 cases (69.8%) presented bilateral lesion. Compared with the biopsy Gleason score, the postoperative Gleason score was downgrated in 3 cases (5.7%), unchanged in 28 cases (52.8%), and upgraded in 20 cases (37.7%), of which 2 cases (3.8%) were pT0. Compared with the clinical stage, the postoperative pathological stage decreased in 2 cases (3.8%), unchanged in 10 cases (18.9%), and upgraded in 41 cases (77.4%). According to the postoperative pathology, the patients were divided into two groups: microfocus cancer group (n=8) and non-microfocus cancer group (n=45). The difference between the two groups in the percentage of tumor in the single-needle tissue ≤5% was statistically significant (P=0.014). Other parameter diffe-rences including age, prostate volume, and preoperative prostate special antigen density (PSAD) and Gleason scores were not statistically significant (P>0.05). The method to determine the location of cancer at the apex of prostate according to biopsy results showed 41.4% (12/29) false negative rate and 50.0% (12/24) false positive rate. There was statistically significant difference between the actual cases of lymph node dissection and reserved nerve and the cases of scheme selection in theory according to the postoperative pathology (P<0.05). Conclusion: The proportion of single needle cancer tissue less than or equal to 5% is a predictor of prostate microfocal cancer. 37.7% cases had pathological upgrading and 77.4% cases had pathological staging upgrading. When choosing the operation scheme, such as sexual nerve reserved, lymph node dissection and apex operation skill, it is necessary to comprehensively analyze multiple factors, such as tumor risk classification, prediction factors of nomogram, multi-parameter MRI and intraoperative situation and so on.

Key words: Prostatic neoplasms, Biopsy, needle, Pathology, clinical

中图分类号: 

  • R737.25

表1

患者一般临床资料"

Items n (%)
Age
<70 years old 25 (47.2)
≥70 years old 28 (52.8)
Preoperative PSA level
≤4 μg/L 4 (7.5)
4-10 μg/L 30 (56.6)
≥10 μg/L 19 (35.8)
Prostate volume
≤30 mL 10 (18.9)
30-50 mL 21 (39.6)
≥50 mL 22 (41.5)
Proportion cancer tissue
≤5% 18 (34.0)
>5% 35 (66.0)
Biopsy Gleason score
6, 3+4=7 48 (90.6)
4+3=7, 8, 9 5 (9.4)
Pathologic stage
T0 2 (3.8)
T2a 9 (17.0)
T2b 2 (3.8)
T2c 29 (54.7)
T3 11 (20.8)
Surgical margin
Negative 42 (79.2)
Positive 11 (20.8)
Microfocality (<3 mm)
Negative 45 (84.9)
Positive 8 (15.1)
Mutifocality
Negative 11 (20.8)
Positive 42 (79.2)
Bilaterality
Negative 16 (30.2)
Positive 37 (69.8)

表2

术前临床资料与术后病理分期升级的相关性分析"

Items Non-upgraded
(n=12)		 Upgraded
(n=41)		 P
Agea 0.823
<70 years old 6 (24.0) 19 (76.0)
≥70 years old 6 (21.4) 22 (78.6)
Prostate volumeb >0.999
<30 mL 2 (20.0) 8 (80.0)
≥30 mL 10 (23.3) 33 (76.7)
Preoperative PSADa 0.302
<0.15 7 (29.2) 17 (70.8)
≥0.15 5 (17.2) 24 (82.8)
Proportion cancer tissueb 0.298
≤5% 6 (33.3) 12 (66.7)
>5% 6 (17.1) 29 (82.9)
Biopsy Gleason scoreb >0.999
6, 3+4=7 12 (24.0) 38 (76.0)
4+3=7, 8, 9 0 3 (100.0)

表3

微灶癌与非微灶癌组术前临床资料对比"

Items Non-microfocality
(n=45)		 Microfocality
(n=8)		 P
Age 0.708
<70 years old 22 (88.0) 3 (12.0)
≥70 years old 23 (82.1) 5 (17.9)
Prostate volume 0.636
<30 mL 8 (80.0) 2 (20.0)
≥30 mL 37 (86.0) 6 (14.0)
Preoperative PSAD >0.999
<0.15 20 (83.3) 4 (16.7)
≥0.15 25 (86.2) 4 (13.8)
Proportion cancer tissue 0.014
≤5% 12 (66.7) 6 (33.3)
>5% 33 (94.3) 2 (5.7)
Biopsy Gleason score >0.999
6, 3+4=7 42 (84.0) 8 (16.0)
4+3=7, 8, 9 3 (100.0) 0

表4

术前穿刺活检与术后病理判断前列腺尖部阳性的差异"

Items Postoperative pathological results P
Negative Positive
Preoperative biopsy >0.999
Negative 17 (58.6) 12 (41.4)
Positive 12 (50.0) 12 (50.0)

表5

术后病理判断是否应行淋巴结清扫术与实际情况的差异"

Items Intraoperative lymphadenectomy Pa
Negative Positive
Briganti nomogram 0.029
Negative 14(60.9%) 9(39.1%)
Positive 22(73.3%) 8(26.7%)
Tumor risk classification <0.001
Negative 6(75.0%) 2(25.0%)
Positive 30(66.7%) 15(33.3%)
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ISSN 1671-167X
CN 11-4691/R
主管单位：中华人民共和国教育部
主办单位：北京大学
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