局部治疗 (focal therapy,FT) 是治疗局限性前列腺癌 (prostate cancer,PCa) 的一种治疗方式,主要
针对低中危局限性前列腺癌,以减少全腺体治疗,如根治性前列腺切除术 (radical prostatectomy, RP) 或根治
性外放疗的不良反应,FT优点是在控制肿瘤的同时,更多地保留性功能和膀胱功能。FT的治疗靶点统称为主要
病灶 (index lesion,IL),多通过影像学确定,目前最常用的是多参数磁共振成像 (multiparametric magnetic
resonance imaging,mpMRI)。大量回顾性研究指出 FT 可降低再活检的阳性率、获得良好的短期肿瘤控制效
果,但仍然缺乏大样本的前瞻性随机对照数据。本文将对应用于 PCa治疗的 FT进行简要综述,包括 FT的治疗
基础、靶病灶的确定和相关临床研究数据等。
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[1]赵强,杨勇,杜鹏.前列腺癌局灶治疗研究进展[J].泌尿外科杂志(电子版),2022,14(03):3-7.DOI:10.20020/j.CNKI.1674-7410.2022.03.02
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前列腺癌 (prostate cancer,PCa) 是世界范围内男性最常见的恶性肿瘤之一,2020年发病数占男 性所有恶性肿瘤的14.1%,位列第2,死亡数占6.8%, 位列第 5[1] ,我国 PCa 发病率有逐年升高的趋势,但 死亡率相对趋稳[2] ,这与前列腺特异性抗原(prostatespecific antigen,PSA) 在 PCa 筛查的逐渐普及有关,使得早期局限性 PCa的比例有明显提升[3] 。对于局限性 PCa,根治性手术和外放疗是常用的治愈性手段,预后相对较好,5 年生存率可达 100%,但无论是手术还是外放疗,都是针对全腺体的治疗方法, 即将前列腺全部切除或对前列腺整体放疗。除了早 期 PCa 患者比例升高,随着解剖、技术、设备等方 面的改进,局部治疗的应用逐渐增多,随之而来的 是全腺体治疗对性功能、尿控等方面的负面影响降 低患者生活质量的问题更加突出[4] 。据统计,手术后平均 30%~90%的患者会出现勃起障碍、5%~20%的患者会出现尿失禁,放疗可能会造成 5%~20%的患 者出现直肠毒性反应。考虑到大部分低危和预后良 好的中危局限性 PCa 发展缓慢,观察等待或主动监 测可以作为此类患者的治疗策略,等待PSA明显进展 或出现症状时再进行抗肿瘤治疗[5-6] ,但对于穿刺国际泌尿病理学会 (International Society of Urological Pathology,ISUP) 分组≥3 的局限性PCa,进展风险较高,期望对于此类局限性患者可以找到既可控制肿瘤、又可保留功能的治疗方法,局灶治疗 (focal therapy,FT) 便是其中之一。FT 是一种针对前列 腺腺体内主要病灶 (index lesion,IL) 进行针对性 治疗的的方法,包括冷冻消融、高频聚焦超声、光动力、射频消融等不同的能量平台[7] ,影像学、穿刺 活检可以帮助确定 IL 是否可以涵盖全部或大部分具 有临床意义的前列腺癌病灶 (clinically significant prostate cancer,csPCa)。目前针对 FT 治疗 PCa的 研究大部分为小样本、回顾性、非随机对照研究, 受限于证据等级不高、设备仪器要求高等因素,指 南并未做常规推荐。随着 PSA 筛查的进一步普及和 影像技术的进展,FT 有机会扩展应用,本文将对应 用于 PCa治疗的 FT进行简要综述。
1 影像学可见、范围局限的主要病灶 (IL) 是 FT 治疗的前提
1.1 PCa 具有多中心、多病灶的特点,早期确诊为 局限性疾病提供了更高的可能性
1.2 FT 治疗的前提是 IL 为 csPCa
2 影像学是诊断 IL 的关键方法
3 FT 的治疗手段和相关治疗数据
3.1 冷冻消融
3.2 HIFU
3.3 IRE
3.4 VTP
4 总结和展望
对于局限性前列腺癌,特别是低中危的患者, 影像学具有明确、范围局限的 IL,可以选择性地采用 FT 治疗,在控制肿瘤的同时,对患者的性功能、 排尿功能、直肠症状等影响较小。影像学的进步使 IL 的确定更佳精准,在筛选过程中影像检查需要有孤立、清晰的 IL,对于多病灶、IL 不明确或局限进展性前列腺癌患者一般不推荐应用。FT 治疗局限性 前列腺癌的短期疗效明确,治疗靶区内的病理复发率较低,多数复发发生在治疗靶区外,但仍缺乏前 瞻性的随机对照研究和长期随访结果,临床实践中 大部分以临床试验的方式开展。随着分子影像学的 进展和前列腺癌筛查的普及,早期前列腺癌患者比 例会逐渐增多、IL的确定会有更多的工具,相信 FT 治疗在前列腺癌中会有更广泛的应用,在此基础上 开展多中心的前瞻性研究非常必要。
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