初诊无远处转移的穿刺病理Gleason评分10分前列腺癌的临床特点

Clinical Characteristics of Gleason Score 10 Prostate Cancer on Core Biopsy without Distant Metastases at Initial Diagnosis

目的分析初诊无远处转移的穿刺病理Gleason评分为10分前列腺癌的临床特点并探讨外放疗联合内分泌治疗的疗效。方法 2003年1月至2014年3月北京协和医院收治初诊无远处转移的Gleason评分10分前列腺癌患者9例。所有患者均接受全盆腔外放疗联合长期内分泌治疗。全盆腔外放疗的照射剂量为50.0 Gy,前列腺、双侧精囊腺及区域阳性淋巴结加量至76.2~78.0 Gy。内分泌治疗采用最大限度雄激素阻断：口服抗雄激素药物加每月注射一次黄体生成素释放激素类似物。分析患者临床特点及联合治疗效果,并运用Kaplan-Meier法绘制生存曲线。结果患者中位随访时间为4.8年（26~75个月）。治疗前中位血清前列腺特异性抗原（prostate specific antigen,PSA）为11.2μg/L,其中6例低于20μg/L,3例高于70μg/L。中位穿刺活检针数阳性率为90.9%。TNM分期：3例T2c,4例T3a,2例T3b;6例N0,3例N1;9例M0。随访期间,6例患者出现生化复发,其中5例进一步发展为转移性前列腺癌;4例患者死亡,其中3例死于前列腺癌。5年无生化复发率、无远处转移率、肿瘤特异性生存率及总体生存率分别为28.6%、57.1%、66.7%和57.1%。5例出现1~2级早期放疗胃肠道不良反应,6例出现1~2级早期泌尿系统不良反应,无晚期胃肠道及泌尿系统不良反应。无骨折、心血管意外等严重内分泌治疗并发症。结论初诊无远处转移的穿刺病理Gleason评分10分前列腺癌常伴穿刺阳性范围大、肿瘤分期偏晚等高危因素,患者通常预后不良,放疗联合内分泌治疗等及时和积极的综合治疗方案往往是必需的。

Objective To analyze the clinical characteristics of patients with Gleason score 10 prostate cancer on core biopsy and without distant metastases when first diagnosed , and to evaluate the effectiveness of ex-ternal radiotherapy combined with hormone therapy in these patients .Methods From January 2003 to March 2014 , 9 patients were identified as Gleason score 10 prostate cancer without distant metastases when first diag-nosed at Peking Union Medical College Hospital .All the patients were treated by whole pelvic external radiothera-py and long-term hormone therapy .The whole pelvic radiation dose was 50.0 Gy, the boost dose for the whole prostate, bilateral seminal vesicles , and regional positive lymph nodes ranged from 76.2 to 78.0 Gy.The hor-mone therapy used maximal androgen blockade , i.e.oral anti-androgen drugs plus monthly injection of luteini-zing hormone-releasing hormone analogs .We assessed the clinical characteristics of the patients and the treat-ment outcomes of the combination therapy .Survival curves were calculated using the Kaplan-Meier method. Results The median follow-up was 4.8 years （ 26 -75 months ） .The median pre-treatment serum prostate specific antigen （ PSA） level was 11.2 μg/L.The pre-treatment PSA levels were lower than 20 μg/L in 6 pa-tients, and higher than 70 μg/L in 3 patients.The median percentage of positive biopsy cores was 90.9 %. In TNM staging, 3, 4, and 2 cases were classified as T2c, T3a, and T3b, respectively;6 and 3 cases were clas-sified as N0 and N1 , respectively;and all the 9 cases were classified as M0 .Six patients developed biochemical failure, 5 of which progressed into distant metastasis .Four patients died during the follow-up period, 3 of which died of prostate cancer .The 5-year biochemical failure-free survival （ BFFS ） , distant metastasis-free survival （ DMFS ） , cancer-specific survival （ CSS ） , and overall survival （ OS ） were 28.6%, 57.1%, 66.7%, and 57.1%, respectively .Five patients experienced grade 1-2 acute gastrointestinal （ GI） toxicity and 6 patients developed grade 1-2 acute genitourinary （GU） toxicity due to radiotherapy.No late GI or GU toxicity was reported.No bone fracture, cardiovascular event, or other severe hormone therapy-related compli-cations was detected .Conclusions Gleason score 10 prostate cancer without distant metastases when first di-agnosed may be often combined with high risk factors such as high percentage of positive biopsy cores , and ad-vanced tumor stage .Timely and active comprehensive treatments including external radiotherapy and hormone therapy are usually necessary because these patients generally have unfavorable prognosis .