Predictive factors associated with Gleason score upgrading after radical prostatectomy
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摘要: Gleason评分作为一种被广泛使用的前列腺癌分级系统，其准确评分是制定前列腺癌治疗方案的重要步骤。尽管目前穿刺活检技术在不断进步，但前列腺根治性切除术后的Gleason评分升级仍然很常见。Gleason评分升级使临床医生术前低估了肿瘤的危险度，可能导致治疗不足，影响预后。本文回顾了近6年的相关文献，并对前列腺根治性切除术后的Gleason评分升级相关预测因素的研究进展进行综述，旨在帮助临床医生在前列腺癌的诊疗过程中做出精确的病情评估和有利于改善患者预后的治疗决策。Abstract: Gleason score is a widely used grading system for prostate cancer. Its precise determination is one of the most important initial steps in the management of prostate cancer. Despite current advances in puncture biopsy techniques, Gleason score upgrading after radical prostatectomy remains common. Gleason score upgrading causes clinicians to underestimate the risk of the tumor preoperatively, which might lead to inadequate treatments and a poorer prognosis. In this article, we review the relevant literature in the last six years and summarize the research progress in the predictive factors related to Gleason score upgrading after radical prostatectomy, aiming to help clinicians to make accurate assessment of the disease and treatment decisions conducive to the improvement of patient's prognosis during the management of prostate cancer.
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Key words:
- prostate cancer /
- Gleason score /
- predictive factors
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表 1 Gleason评分升级相关预测因素总结
预测因素 相关文献数 影响方式及可能机制 年龄 9 年龄增加使睾丸激素水平下降，性腺功能低下，使肿瘤更具侵袭性。 PSA及其相关衍生指标(PSAD、PHI) 8 PSA是由前列腺上皮细胞及尿道周围组织分泌的一种蛋白酶，正常情况下不会入血，PCa病变后会导致血-上皮屏障破坏，使PSA直接入血，因此PSA浓度与肿瘤恶性程度正相关。 PV 3 PV较小和睾酮和双氢睾酮水平较低有关，较低的睾酮和双氢睾酮会影响前列腺生长因子分泌，使细胞所处的微环境利于肿瘤细胞的生长。 穿刺相关因素 10 病理错误和抽样错误会导致前列腺根治标本和穿刺标本的病理评分不匹配；前列腺肿瘤具有多灶性，前列腺阳性针数的位置和数量不太可能反映整个PCa疾病的严重程度和恶性程度；穿刺到手术有一定的间隔时间，在此期间肿瘤固有的侵袭性也可能导致病理升级。 影像学因素 6 影像学检查对PCa病变的检出效果很大程度上取决于肿瘤的大小和肿瘤的分级，较大和较高级的肿瘤在影像学上可能表现为更明显的信号，导致评分更高。 生物标志物 2 肿瘤抑制基因DNA甲基化的变化导致抑制基因下调，从而促进PCa的侵袭和转移。 BMI 4 肥胖男性PCa细胞增殖更快；过量脂肪能分泌各种促炎细胞因子促进肿瘤生长；肥胖男性具有高水平胰岛素和胰岛素样生长因子1，两者能抑制细胞凋亡，促进癌变。 其他 5 PNI的存在与抑制癌细胞凋亡有关，从而促进癌细胞增殖；血清睾酮低，前列腺生长因子分泌有限，细胞所处的微环境利于肿瘤细胞的生长；肿瘤微环境中的炎症反应有助于癌细胞的增殖和存活。 注：前列腺健康指数(prostate health index，PHI)；体重指数(body mass index，BMI)；神经浸润(perineural invasion，PNI)。 
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