根治性前列腺切除联合扩大盆腔淋巴结清扫术治疗局部高危前列腺癌12年经验总结

Radical prostatectomy plus extended lymph node dissection for locally advanced prostate cancer： 12- year experience of a single centre

目的总结腹腔镜下筋膜外根治性前列腺切除＋扩大盆腔淋巴结清扫术联合内分泌治疗对局部高危前列腺癌的控瘤效果和术后控尿效果。方法回顾性分析2004年1月至2016年6月我院255例行腹腔镜下筋膜外根治性前列腺切除＋扩大盆腔淋巴结清扫术的pT3～4NxM0期前列腺癌患者的临床资料。年龄44—88岁，平均67岁。PSA0．6～454．0ns／ml，中位值21．2ns／ml。根据手术时间分为前期组（2004年1月至2011年12月，160例）和后期组（2012年1月至2016年6月，95例）。前期组和后期组平均年龄分别为（68±7）岁和（66±8）岁，平均体重指数分别为（23±5）kg／m。和（24±4）ks／m^2，中位PSA分别为19．7ns／ml（0．7～454．0ns／m1）和26．7ns／ml（0．6～308．0ns／m1），平均Gleason评分分别为（7．2±1．4）和（7．4±1．6），两组上述指标比较差异均无统计学意义（均P〉0．05）。本组255例患者术后3个月内开始行12～18个月的辅助内分泌治疗。后期组术前检测穿刺标本中塌陷反应蛋白4（collapsinresponsemediatorprotein4，CRMP4）甲基化情况，CRMP4甲基化水平〉15％、直肠或膀胱颈侵犯者术前行3～6个月的新辅助内分泌治疗。比较两组术后切缘阳性率（positive surgical margin，PSM）、无进展生存率（progression—free survival，PFS）、肿瘤特异性生存率（cancer—specificsurvival，CSS）、总体生存率（overallsurvival，os）和术后1年控尿率。结果前期组与后期组平均手术时间分别为（239±65）min和（203±51）min，平均出血量分别为（109±65）ml和（96±44）ml，平均淋巴结清扫数目分别为（19±5）个和（21±7）个，组间比较差异均无统计学意义（均P〉0．05）。总体PSM为19．2％（49／255），前期组和后期组PSM分别为23．1％（37／160）和12．6％（12／95，P=0．04）。255例患者术后均行辅助内分泌治疗，后期组中25例患者术前接受新辅助内分泌治疗。255例均获随访，随访时间10～152个月，中位时间73个月。总体5年PFS、CSS和OS分别为77．7％、94．3％和87．1％。前期组和后期组5年PFS分别为73．8％和86．1％（P=0．03），5年CSS分别为93．1％和98．6％（P=0．07），5年OS分别为85．0％和92．8％（P=0．11）。术后1年总体控尿率为94．1％，前期组和后期组分别为91．9％和97．9％（P=0．09）。结论腹腔镜下筋膜外根治性前列腺切除＋扩大盆腔淋巴结清扫术联合内分泌治疗对局部高危前列腺癌总体控瘤效果和术后控尿效果好，术前评估肿瘤分期能有效改善PFS。

Objective To evaluate the functional and oncologlcal outcomes of patients with locally advanced prostate cancer （PCa） treated by hormone therapy combined with extra-fascial laparoscopie radical prostatectomy （LRP） plus extended lymph node dissection （ePLND）. Methods From January 2004 to June 2016, a total of 255 PCa cases （pT3.4NxM0） who received LRP plus ePLND were enrolled into our study. The mean age of the patients was 67 （ range 44 - 88） years, and median PSA level was 21.2 （ range 0. 6 -454.0） ng/ml. The patients were divided into earlier group （from January 2004 to December 2011, 160 eases） and later group （fl＇om January 2012 to June 2016, 95 cases） according to different treatment periods. The baseline demographics between the two groups were similar. All patients routinely received adjuvant hormone therapy （AHT） postoperatively. The patients in the later group underwent eollapsin response mediator protein 4 （CRMP4） methylation study on the prostatic biopsy preoperatively. Those with a CRMP4 methylation level 〉 15% or rectum/bladder neck invasion, were treated by neoadjuvant hormone therapy （NHT） for 3 -6 months. Positive surgical margin （PSM）, progression-free survival （PFS）, cancer-specific survival （CSS）, overall survival （OS） and postoperative continence rates between the two groups were analyzed and compared. Results The mean operative time of the earlier and later group were （239＋65） min and （203 -＋51） rain, mean blood loss were （109 .＋65） ml and （96-＋44） ml, mean dissected nodes were （19-＋5） and （21 -＋7）, respectively （all P〉0.05）. The total PSM rate was 19.2%, and PSM rates of the two groups were 23.1% and 12.6% （ P = 0.04）. All the 255 cases received AHT and 25 cases in the later group underwent NHT. The median follow-up time was 73 months （range 10 - 152 months）. The total 5-year PFS, CSS and OS rates were 77.7% , 94.3% and 87.1% , respectively, and the rates between groups were 73.8% vs. 86.1% （P=0.03）, 93.1% vs. 98.6% （P=0.07）, and 85.0% vs. 92.8% （P =0.11） , respectively. The 1-year postoperative continence rates were 91.9% vs. 97.9% （ P = 0.09）. Conclusions Hormone therapy combined with LRP plus ePLND represents an ontological and functional effective option in patients with locally advanced PCa, and improved PFS might be acquired by preoperative tumor staging.