前列腺癌淋巴结转移的特点及其临床意义

摘要

目的 探讨前列腺癌淋巴结转移的规律及其临床意义. 方法 回顾性分析2004年1月至2014年1月收治的103例前列腺癌患者的临床病理资料.年龄49 ～ 77岁,平均65岁.术前PSA值3.7～ 52.0 μg/L,平均14.7 μg/L.术前活检Gleason评分5～10分,平均7分.危险因素分级低、中、高危组分别为44、31、28例.103例均行根治性前列腺切除+扩大分区盆腔淋巴结清扫术.将盆腔淋巴结按解剖部位分为5组9区:髂外组、髂总组、闭孔组、髂内组,每组左、右侧各为l区;骶前组为1区.比较各组切除的淋巴结数目、转移率、转移密度及分布情况. 结果 本组103例,共切除淋巴结2 136枚,每例切除淋巴结13～37枚,平均21枚.22例(21％)发生淋巴结转移.低、中、高危组的转移率分别为2％(1/44)、26％(8/31)、46％(13/28),差异有统计学意义(P＜0.05).各组淋巴结转移率由高到低分别为髂内组59％ (13/22)、闭孔组50％(11/22)、髂外组36％(8/22)、骶前组14％ (3/22)、髂总组5％ (1/22),差异有统计学意义(P＜0.05).转移密度由高到低排列为闭孔组37％(19/53)、骶前组33％(3/9)、髂内组28％(21/74)、髂外组25％ (8/32)、髂总组,差异无统计学意义(P＞0.05). 结论 行根治性前列腺切除术时,对低危患者可不实施扩大分区盆腔淋巴结清扫,中-高危者必须行淋巴结清扫;对淋巴结转移率及转移密度均较高的闭孔、髂内和髂外区域必须清扫;术中对骶前区域要重点检查,如发现可疑淋巴结要完整清扫;髂总区域不必常规清扫.%Objective To evaluate the features about metastasis of different pelvic lymph node groups and their significance in radical prostatectomy.Methods From January 2004 to January 2014,the data of 103 patients with prostate cancer,who accepted the radical prostatectomy and extended pelvic lymph node dissection (e-PLND),were analyzed,retrospectively.The mean age was 64.9 years old (range 49-77years) and the mean preoperative PSA level was 14.7 μg/L (range 3.7-52.0 μg/L).The Gleason scores ranged from 5 to 10 scores (mean 6.9 scores).Risk group assessment showed low risk in 44 cases,intermediate risk in 31 cases and high risk in 28 cases.The pelvic lymph nodes were divided into 9 regions and 5groups according to the common guideline,including the external iliac,internal iliac,obturator and common iliac lymph nodes bilaterally,and the presacral lymph nodes.The frequency and density of pelvic lymphatic nodes metastasis in these patients were compared.Results Complete pathological information was available for 103 patients.Totally,2 136 lymph nodes were dissected.The numbers of dissected lymphatic nodes in each patients ranged from 13 to 37 (mean 21).Among them,22 patients were found the evidence of lymphatic node metastasis,including 2％ (1/44) with low risk group,26％ (8/31) with intermediate risk group and 46％ (13/28) in high risk group (P＜0.05).The metastatic total rate and degree of dissected lymph nodes were 21％.The metastatic frequency of lymph node groups in these patients from higher to Lower were as follows:59％ (13/22) in internal iliac region,50％ (11/22) in obturator region,36％ (8/22)in external iliac region,14％ (3/22) in presacral region and 5％ (1/22) in common iliac region,with a statistically significant difference in those groups (P＜0.05).The metastatic density of the lymph node groups from higher to lower were demonstrated as follows:37％ (19/53) in obturator region,33％ (3/9) in presaoral region,28％ (21/74) in internal iliae region,25％ (8/32) in external iliac region and 20％ (1/5) in common iliac region,with no statistically significant difference in those groups (P＞0.05).Conclusions In radical prostatectomy for the treatment of prostate cancer,it is not necessary to perform e-PLND in the low-risk group.It is suggested that the regional lymph nodes with intermediate-and high-risk group should be resected necessarily.Our study also suggested that the regional lymph nodes,including obturator,internal iliac and external iliac nodes,should be resected completely,due to the high metastatic rate and density.The presacral region should be the key to be checked,while regular dissection in common iliac region is not necessary.