耻骨后根治性前列腺切除治疗淋巴结转移前列腺癌的疗效分析

Radical retropubic prostatectomy for prostate cancer with pelvic lymph node metastasis

目的:探讨耻骨后根治性前列腺切除结合辅助内分泌治疗或局部外放疗治疗20例前列腺癌伴盆腔淋巴结转移的安全性和疗效。方法:术前对20例前列腺癌患者均行双侧足背淋巴管造影,对其中11例盆腔可疑淋巴结穿刺抽吸淋巴液,进行实时定量PCR(RT-PCR)检测淋巴液PSA mRNA和前列腺特异膜抗原(PSMA)mRNA的表达。20例均行耻骨后根治性前列腺切除和扩大盆腔淋巴结清扫,对其中3例切端阳性者待尿失禁控制后给予外放疗。结果:11例经RT-PCR检测淋巴结液PSA mRNA和PSMA mRNA阳性表达中均经病理证实为前列腺癌淋巴结转移。术中失血量中位数575 ml,术中输血5例。手术切缘阳性3例,漏尿和淋巴漏各2例,无尿失禁、血管损伤和直肠损伤病例。经中位数42个月随访,术后6~48个月生化复发12例,复发时间中位数12个月。术后12个月和48个月分别死亡2例。结论:术前淋巴管造影后穿刺抽吸淋巴结液,用RT-PCR方法检测淋巴液PSA mRNA和PSMA mRNA表达有助于术前确定前列腺癌盆腔淋巴结转移。采用耻骨后根治性前列腺切除和扩大淋巴结清扫结合辅助内分泌治疗,对切端阳性者给予局部外放射治疗是治疗前列腺癌伴盆腔淋巴结转移患者安全、有效的方法。但对Gleason 10分的盆腔淋巴结转移前列腺癌采用根治性前列腺切除应慎重。

Objective： To investigate the safety and effectiveness of radical retropubic prostatectomy （RRP） with adjuvant an- drogen deprivation or external radiotherapy in the treatment of prostate cancer （PCa） with pelvic lymph node metastasis （PLNM）. Methods ： Twenty PCa patients underwent bilateral pedal lymphangiography （PLG） preoperatively, and 11 of＂ them received lymph node aspiration for examination of the mRNA expressions of prostate-specific antigen （PSA） and prostate-specific membrane antigen （PSMA） in the lymph fluid by real-time RT-PCR. All the patients were treated by RRP with extended dissection of pelvic lymph nodes, and 3 of them by external radiotherapy in addition after recovery from urinary incontinence because of positive surgical margins, followed by adjuvant androgen deprivation therapy. Results ： Real-time RT-PCR showed positive mRNA expressions of PSA and PSM A in the lymph fluid of the 11 patients, all pathologically confirmed with PLNM. The median intraoperative blood loss was 575 ml, with blood transfusion for 5 cases. Positive surgical margin was found in 3 cases, lymphorrhagia in 2 mad urinary leakage in another 2 each. There were no such severe complications as vascular injury and rectum perforation. The patients were followed up for 6 - 48 （ mean 42） months, during which, biochemical recurrence was observed in 12 cases at a median of 12 months postoperatively and 2 patients died at 12 and 48 months respectively. Conclusion ： Bilateral PLG and lymph node aspiration for examination of the mRNA expressions of PSA and PSMA in the lymph fluid help to confirm PLNM preoperatively. Radical retropubic prostatectomy with adjuvant androgen dep- rivation or external radiotherapy is safe and effective for the treatment of PCa with PLNM, but it should be chosen cautiously for those with Gleason 5 ＋ 5.