Progress in diagnosis and treatment of positive surgical margins after radical prostatectomy
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摘要: 前列腺癌根治术是治疗局限性及局部进展期前列腺癌最有效的方法之一，术后切缘阳性是经常发生的问题，有可能导致根治术后的生化复发甚至临床进展，但在国内切缘阳性的问题尚未引起足够的重视。本文旨在总结前列腺癌根治术后切缘阳性患者的最新诊疗进展，为预防和治疗此类患者提供思路。Abstract: Radical prostatectomy is one of the most effective methods for the treatment of localized and locally advanced prostate cancer. Positive surgical margins are a frequent problem, which may lead to postoperative biochemical recurrence and even clinical progression. However, the problem of positive surgical margins in China has not attracted enough attention. This article aims to summarize the latest progress in diagnosis and treatment of patients with positive surgical margins after radical prostatectomy, and provide ideas for the prevention and treatment of such patients.
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Key words:
- prostate cancer /
- radical prostatectomy /
- positive surgical margins
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表 1 前列腺癌根治术后切缘阳性率及意义的临床研究
第一作者 年份 纳入患者/例 阳性切缘/例(%) 中位随访时间/月 研究结果 Dev HS[12] 2015 4001 486(12.1) 58.0 阳性切缘vs阴性切缘生化复发率：37% vs 10% Sachdeva A[13] 2017 592 181(30.6) 52.8 阳性切缘vs阴性切缘生化复发率：40.7% vs 15.1% Jo JK[14] 2017 815 270(33.1) 37.0 阳性切缘vs阴性切缘生化复发率：40.4% vs 7.9% Chalfin HJ[18] 2012 4461 462(10.4) 120.0 阳性切缘vs阴性切缘前列腺癌20年特异性生存率：75% vs 93% Mauermann J[19] 2013 1712 591(34.5) 74.9 (单灶16.4%，多灶18.1%)单灶性阳性切缘vs多灶性阳性切缘vs阴性切缘生化复发率：22.1% vs 31.0% vs 10.9% Pfitzenmaier J[20] 2008 406 70(17.2) 62.4 阳性切缘vs阴性切缘生化复发率：64.3% vs 20.5%；阳性切缘vs阴性切缘局部复发率：18.6% vs 2.7%；阳性切缘vs阴性切缘远处转移率：15.7% vs 1.5% Lake AM[22] 2010 2465 443(18.0) NA (单灶14.0%，多灶4.0%)局部阳性切缘vs广泛阳性切缘vs阴性切缘10年无病生存率：76% vs 53% vs 90% Koskas Y[24] 2019 1275 189(14.8) 101.0 (单灶9.0%，多灶5.8%)单灶性阳性切缘vs多灶性阳性切缘5年无生化复发生存率：86.8% vs 49.4%，8年时：85.1%和44.8% 注：NA：未获得；单灶：单灶阳性切缘，单个病灶且长度≤3 mm；多灶：多灶阳性切缘，多个病灶或长度 > 3 mm。 
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表 2 前列腺癌根治术后切缘阳性辅助治疗的临床研究
第一作者 年份 纳入患者类型及例数 分组情况 中位随访时间/月 研究结果 Hackman G[27] 2019 切缘阳性：250例 辅助EBRT组：126例观察组：124例 辅助放疗组：111.6观察组：103.2 辅助放疗组vs观察组10年无生化复发生存率：82% vs 61% Thompson IM[28] 2009 病理高危前列腺癌(包括切缘阳性)：425例 辅助EBRT组：214例观察组：211例 辅助放疗组：152.4观察组：150.0 辅助放疗组vs观察组无转移生存率：43.5% vs 54.0% Bolla M[29] 2012 病理高危前列腺癌(包括切缘阳性)：1005例 辅助EBRT组：502例观察组：503例 辅助放疗组：127.2观察组：127.2 辅助放疗组vs观察组10年无生化复发生存率：60.6% vs 41.1% Choi KH[33] 2018 切缘阳性：223例 辅助EBRT组：55例间歇性ADT组：50例持续性ADT组：86例观察组：32例 NA 辅助EBRT组vs间歇性ADT组vs持续性ADT组vs观察组生化复发率：7.3% vs 6.0% vs 4.7% vs 15.6% 注：NA：未获得；EBRT：外放射治疗；ADT：雄激素剥脱治疗。
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表 3 前列腺癌根治术后切缘阳性预防的临床研究
第一作者 年份 纳入患者/例 分组 研究结果 Tewari AK[43] 2010 1874 同步尿道离断组：209例常规组：1665例 同步尿道离断组vs常规组尖部切缘阳性率：4.4% vs 1.4% Komori H[45] 2022 814 不保留神经组：544例保留单侧神经组：152例保留双侧神经组：118例 不保留神经组vs保留单侧神经组vs保留双侧神经组切缘阳性率：20.1% vs 23.0% vs 29.7% Schlomm T[47] 2012 5134 NeuroSAFE组：2567例非NeuroSAFE组：2567例 NeuroSAFE组vs非NeuroSAFE组切缘阳性率：15.2% vs 21.7% McClintock TR[54] 2019 386 027 新辅助ADT组：377 843例单纯手术组：8184例 新辅助ADT组vs单纯手术组切缘阳性率：21.62% vs 24.68% 注：NeuroSAFE：神经血管结构-相邻冷冻切片检查；ADT：雄激素剥脱治疗。
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