前列腺导管腺癌临床病理和诊治特点分析

Diagnosis and management of prostatic ductal adenocarcinoma

目的探讨前列腺导管腺癌的临床病理特征和诊治特点。方法前列腺导管腺癌患者9例。年龄59～106岁，平均76岁。以进行性排尿困难、夜尿频多就诊6例，其中伴无痛性肉眼血尿2例；首发症状为无痛性肉眼血尿2例；常规体检PSA升高行穿刺检查1例。行根治性前列腺切除术1例，根治性前列腺切除术加双侧睾丸切除术加放疗1例，前列腺等离子电切加绿激光汽化术加双侧睾丸切除术5例，前列腺等离子电切加绿激光汽化术1例，双侧睾丸切除加放疗1例。术后8例予氟他胺治疗3～45个月，定期随访。结果9例手术均获成功。肿瘤呈乳头状或菜花状，累及前列腺精阜及中央导管。组织结构主要为导管内乳头和复分支腺结构，被覆不同层次高柱状上皮，核仁大，易见核分裂象。免疫组化检测显示PSA、雄激素受体（AR）、前列腺酸性磷酸酶（PAP）阳性率分别为89％（8／9）、100％（5／5）、100％（5／5）。病理诊断均为前列腺导管腺癌，合并前列腺腺癌5例。Gleason评分6--7分3例，≥8分6例。9例患者平均随访20（3～48）个月。术后生化复发5例，其中伴骨、肺转移1例，死于全身骨转移、多器官功能衰竭3例；无复发3例；1例高龄患者术后6个月仍存活。结论前列腺导管腺癌发病率低，早期缺乏典型症状，确诊主要靠病理检查，预后较差，应按照高危前列腺癌的治疗原则进行治疗并密切随访。

Objective To discuss the pathological and clinical features, diagnosis and treatment of prostatic duct adenocarcinoma. Methods The clinical data of nine cases of prostatic duct adeno carcinoma were retrospectively analyzed, with the average age of 76 （59--106） years. Six cases were presented with dysuresia and/or nocturia, and two of them had the painless gross hematuria. Two pa tients presented painless gross hematuria as the first symptom. One case was detected the elevated serum PSA in a routine healthy examination. Radical prostatectomy （RP） was performed in 1 case; RP and bilateral orchidectomy and external beam radiotherapy （EBRT） were performed in 1 case; 5 cases underwent transurethral resection of the prostate （TURP） combined with photoselective vaporization of the prostate （PVP） by green laser and bilateral orchidectomy; 1 case underwent TURP combined with PVP; 1 case underwent bilateral orchidectomy combined with EBRT. Eight cases took flutamide for 3-45 months. All patients were followed-up according to the scheduled time. Results The operations were successfully performed in all 9 patients. The papillary or cauliflower-like tumors infiltrated colli culus seminalis and prostate duct nearby. The glands were coated with tall pseudostratified columnar cells. The nuclei were large, dark stained with more frequent mitoses. The positive rates of immunolabelling antibody PSA, AR, PAP were found to be 89%（8/9）, 100%（5/5）, 100%（5/5） respectively. The distribution of Gleason score was 6-7（3 cases）, and ≥8（6 cases）, and a coexistingacinar carcinoma component was identified in 5 cases of the group. Nine cases had a mean follow up for 20（3-48） months. Five cases have developed biochemical recurrence, of whom 3 died of bone metas- tasis and multiple organ failure, and 1 developed lung and bone metastasis. Three cases remained alive without recurrence. The remaining 1 case survives during the follow-up survey for 6 months until now, without examinations due to the old age. Conclusions Duct adenocarcinoma of the prostate presents the low incidence and lacks of typical symptoms in the early stage. Diagnosis was confirmed mainly on the basis of pathology. The tumors tend to have a more advanced stage and a very short term survival rate. The treatment options and management are similar to that of high-grade adenocarcinoma of the prostate; meanwhile, close follow-up survey should be performed.