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前列腺癌(prostate cancer,PCa)是男性常见的恶性肿瘤之一,其发病率位居恶性肿瘤的第六位、病死率位居第九位,且发病率逐年上升[1]。PCa起病隐匿,临床上常难以与前列腺增生等相鉴别。多参数磁共振成像(multi-parametric magnetic resonance imaging,mpMRI)是PCa最重要的影像学检查方法,有助于提高肿瘤的检出率,明确肿瘤诊断及临床分期[2]。根治性切除术是局部早期PCa患者首选的治疗方案[3-4],但部分PCa患者术后易出现生化复发(biochemical recurrence,BCR),进而导致预后不良。BCR是指患者行PCa根治性切除术后,连续2次血清前列腺特异性抗原(prostate specific antigen, PSA)水平≥0.2 ng/ml[5]。明确PCa患者术后BCR的危险因素具有重要的临床指导意义,且一直是研究的热点。既往有研究结果表明,术后Gleason评分>7、病理包膜侵犯、切缘阳性及术前PSA水平>10 ng/ml均为BCR的高危因素[6-7]。本研究探讨了mpMRI特征和临床因素与PCa术后BCR的相关性,旨在对BCR风险进行评估。
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通过X-tile 3.6.1软件进行数据分析,最后确定连续变量的最佳临界值分别为年龄64岁、BMI 21.2 kg/m2、术前PSA水平17.2 ng/ml、术前PSAD水平2.0 ng/(ml·cm3)、前列腺体积24.9 cm3和肿瘤最大径18.0 mm。
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152例PCa患者中,BCR组患者41例、非BCR患者111例。所有患者的随访时间为13(7~61)个月。41例患者出现BCR,BCR发生率为27%(41/152)。BCR组与非BCR组患者的mpMRI征象和临床信息见表1。
因素 BCR组(n=41) 非BCR组(n=111) χ2值 P值 年龄(岁) 3.008 0.083 ≤64 13 21 >64 28 90 BMI(kg/m2) 10.681 0.001 ≤21.2 9 6 >21.2 32 105 术前PSA水平(ng/ml) 13.562 <0.001 ≤17.2 6 57 >17.2 35 54 术前PSAD水平[ng(ml·cm3)] 7.410 0.006 ≤2.0 29 101 >2.0 12 10 穿刺Gleason评分 8.105 0.004 ≤7 12 60 >7 29 51 术后Gleason评分 5.910 0.015 ≤7 11 55 >7 30 56 PI-RADS评分 19.681 <0.001 ≤4 8 65 >4 33 46 前列腺体积(cm3) 3.839 0.050 ≤24.9 12 15 >24.9 29 96 肿瘤部位 19.881 <0.001 外周带 14 68 中央腺体 14 30 二者均有 13 13 肿瘤最大径(mm) 23.531 <0.001 ≤18.0 12 77 >18.0 29 34 MRI累及包膜 14.017 <0.001 是 26 32 否 15 79 MRI累及精囊 0.061 0.804 是 5 9 否 36 102 病理包膜侵犯 5.734 0.017 是 28 45 否 13 66 病理精囊侵犯 4.224 0.040 是 13 17 否 28 94 切缘阳性 0.030 0.862 是 24 66 否 17 45 临床T分期 12.318 0.002 ≤T2c 15 75 T3a 20 25 T3b及T4 6 11 注:BMI为身体质量指数;PSA为前列腺特异性抗原;PSAD为前列腺特异性抗原密度;PI-RADS为前列腺影像报告和数据系统;MRI为磁共振成像;BCR为生化复发 表 1 152例前列腺癌患者根治性切除术后生化复发的 单因素分析
Table 1. Univariate analysis of biochemical recurrence after radical prostatectomy in 152 patients with prostate cancer
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单因素分析结果显示,BMI、术前PSA及PSAD水平、穿刺和术后Gleason评分、PI-RADS评分、肿瘤部位、肿瘤最大径、MRI累及包膜、病理包膜侵犯和精囊侵犯、临床T分期是术后BCR的危险因素(均P<0.05,表1)。
多因素分析结果显示,BMI、术前PSA水平及MRI累及包膜是PCa术后BCR的独立危险因素(均P<0.05,表2)。PCa患者根治性切除术前的mpMRI见图1。
因素 B值 SE Wald HR 95%CI P值 BMI 1.175 0.414 8.042 3.238 1.437~7.293 0.005 术前PSA水平 0.984 0.479 4.221 2.675 1.046~6.841 0.040 术前PSAD水平 −0.073 0.412 0.032 0.929 0.414~2.085 0.859 穿刺Gleason评分 0.236 0.398 0.352 1.266 0.581~2.760 0.553 PI-RADS评分 0.761 0.633 1.444 2.139 0.619~7.397 0.230 肿瘤最大径 0.476 0.575 0.684 1.610 0.521~4.971 0.408 肿瘤部位 0.240 0.247 0.941 1.271 0.783~2.064 0.332 MRI累及包膜 1.155 0.559 4.264 3.175 1.061~9.502 0.039 临床T分期 −0.678 0.405 2.800 0.508 0.230~1.123 0.094 注:BMI为身体质量指数;PSA为前列腺特异性抗原;PSAD为前列腺特异性抗原密度;PI-RADS为前列腺影像报告和数据系统;MRI为磁共振成像;HR为风险比 表 2 152例前列腺癌患者根治性切除术后生化复发的 多因素分析
Table 2. Multivariate analysis of biochemical recurrence after radical prostatectomy in 152 patients with prostate cancer
多参数MRI特征和临床因素与前列腺癌术后生化复发风险的相关性分析
The correlation analysis of multi-parametric MRI features and clinical factors with the risk of biochemical recurrence after radical prostatectomy
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摘要:
目的 探究多参数MRI(mpMRI)特征和临床因素与前列腺癌(PCa)根治性切除术后生化复发(BCR)风险的相关性。 方法 回顾性分析2013年9月至2020年10月于青岛大学附属医院行PCa根治性切除术前行mpMRI检查的152例男性患者的影像学资料及临床资料,年龄44~82(69.0±7.2)岁。根据前列腺影像报告和数据系统(PI-RADS)分析MRI特征,主要包括PI-RADS评分、前列腺体积、肿瘤最大径、肿瘤部位、是否累及包膜或精囊、mpMRI临床T分期。采用最新的PI-RADS V2.1进行mpMRI图像评分。将发生BCR作为随访的终点。应用X-tile统计软件确定连续变量的最佳临界值。采用Log-rank检验和Cox比例风险回归模型对PCa术后BCR的独立危险因素进行单因素和多因素分析。 结果 中位随访时间13个月,术后BCR发生率为27%(41/152)。单因素分析结果显示,身体质量指数(BMI)、术前前列腺特异性抗原(PSA)水平及前列腺特异性抗原密度(PSAD)水平、穿刺和术后Gleason评分、PI-RADS评分、肿瘤部位、肿瘤最大径、MRI累及包膜、病理包膜侵犯和精囊侵犯、mpMRI临床T分期是PCa术后BCR的危险因素(χ2=4.224~23.531,均P<0.05)。多因素分析结果显示,BMI 、术前PSA水平及MRI累及包膜是PCa术后BCR的独立危险因素(HR=3.238、2.675、3.175,95%CI:1.437~7.293、1.046~6.841、1.061~9.502,均P<0.05)。 结论 低BMI、术前高PSA水平及MRI累及包膜与PCa根治性切除术后BCR密切相关。 Abstract:Objective To investigate the correlation of multi-parametric magnetic resonance imaging (mpMRI) features and clinical factors with the risk of biochemical recurrence (BCR) after radical prostatectomy. Methods A retrospective analysis was performed on the imaging data and clinical data of 152 male patients who were aged 44–82 (69.0±7.2) years and underwent mpMRI before radical prostatectomy in the Affiliated Hospital of Qingdao University from September 2013 to October 2020. Magnetic resonance imaging (MRI) features were analyzed according to the Prostate Imaging Report and Data System (PI-RADS), which mainly included PI-RADS score, prostate volume, maximum tumor diameter, tumor site, involvement of capsule and seminal vesicle, and mpMRI clinical T staging. mpMRI images were scored using the latest prostate PI-RADS V2.1. The occurrence of BCR was used as the end point of follow-up. X-tile statistical software was used to determine the optimal critical value of continuous variables. Univariate and multivariate analyses were performed using log-rank test and Cox proportional risk regression model to analyze the independent risk factors of BCR after radical prostatectomy. Results The median follow-up was 13 months, and BCR rate was 27% (41/152). The results of univariate analysis showed that body mass index (BMI), preoperative prostate specific antigen (PSA) levels and prostate specific antiqen density (PSAD) levels, biopsy and postoperative pathologica Gleason score, PI-RADS score, tumor site, maximum diameter of tumor lesion, MRI involvement of the capsule, pathological capsule invasion, seminal vesicle invasion, and mpMRI clinical T stage were the risk factors for BCR (χ2=4.224–23.531, all P<0.05). The results of multivariate analysis showed that BMI, preoperative PSA levels, and MRI involvement of the capsule were independent risk factors for BCR after radical prostatectomy (HR=3.238, 2.675, 3.175; 95%CI: 1.437–7.293, 1.046–6.841, 1.061–9.502; all P<0.05). Conclusion Low BMI, high PSA level, and MRI involvement of the capsule were closely associated with BCR after radical prostatectomy. -
表 1 152例前列腺癌患者根治性切除术后生化复发的 单因素分析
Table 1. Univariate analysis of biochemical recurrence after radical prostatectomy in 152 patients with prostate cancer
因素 BCR组(n=41) 非BCR组(n=111) χ2值 P值 年龄(岁) 3.008 0.083 ≤64 13 21 >64 28 90 BMI(kg/m2) 10.681 0.001 ≤21.2 9 6 >21.2 32 105 术前PSA水平(ng/ml) 13.562 <0.001 ≤17.2 6 57 >17.2 35 54 术前PSAD水平[ng(ml·cm3)] 7.410 0.006 ≤2.0 29 101 >2.0 12 10 穿刺Gleason评分 8.105 0.004 ≤7 12 60 >7 29 51 术后Gleason评分 5.910 0.015 ≤7 11 55 >7 30 56 PI-RADS评分 19.681 <0.001 ≤4 8 65 >4 33 46 前列腺体积(cm3) 3.839 0.050 ≤24.9 12 15 >24.9 29 96 肿瘤部位 19.881 <0.001 外周带 14 68 中央腺体 14 30 二者均有 13 13 肿瘤最大径(mm) 23.531 <0.001 ≤18.0 12 77 >18.0 29 34 MRI累及包膜 14.017 <0.001 是 26 32 否 15 79 MRI累及精囊 0.061 0.804 是 5 9 否 36 102 病理包膜侵犯 5.734 0.017 是 28 45 否 13 66 病理精囊侵犯 4.224 0.040 是 13 17 否 28 94 切缘阳性 0.030 0.862 是 24 66 否 17 45 临床T分期 12.318 0.002 ≤T2c 15 75 T3a 20 25 T3b及T4 6 11 注:BMI为身体质量指数;PSA为前列腺特异性抗原;PSAD为前列腺特异性抗原密度;PI-RADS为前列腺影像报告和数据系统;MRI为磁共振成像;BCR为生化复发 表 2 152例前列腺癌患者根治性切除术后生化复发的 多因素分析
Table 2. Multivariate analysis of biochemical recurrence after radical prostatectomy in 152 patients with prostate cancer
因素 B值 SE Wald HR 95%CI P值 BMI 1.175 0.414 8.042 3.238 1.437~7.293 0.005 术前PSA水平 0.984 0.479 4.221 2.675 1.046~6.841 0.040 术前PSAD水平 −0.073 0.412 0.032 0.929 0.414~2.085 0.859 穿刺Gleason评分 0.236 0.398 0.352 1.266 0.581~2.760 0.553 PI-RADS评分 0.761 0.633 1.444 2.139 0.619~7.397 0.230 肿瘤最大径 0.476 0.575 0.684 1.610 0.521~4.971 0.408 肿瘤部位 0.240 0.247 0.941 1.271 0.783~2.064 0.332 MRI累及包膜 1.155 0.559 4.264 3.175 1.061~9.502 0.039 临床T分期 −0.678 0.405 2.800 0.508 0.230~1.123 0.094 注:BMI为身体质量指数;PSA为前列腺特异性抗原;PSAD为前列腺特异性抗原密度;PI-RADS为前列腺影像报告和数据系统;MRI为磁共振成像;HR为风险比 -
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