Zusammenfassung
Mehr als 80% der Männer, bei denen heutzutage ein Prostatakarzinom (PCA) durch Screening diagnostiziert wird, sterben nicht mehr an den Folgen dieser Erkrankung. Etwa 70% befinden sich in einem frühen, auf die Prostata begrenzten Stadium, nahezu die Hälfte der PCA sind klein (<5 cm3) und zeigen oft über Jahre keine Progression (insignifikantes PCA). Man geht heute davon aus, dass durch das PSA-Screening die Karzinomdiagnose um etwa 9 Jahre vorverlegt wird und eine sofortige radikale Prostatektomie oder Strahlentherapie bei etwa jedem 3. Patienten eine Übertherapie darstellt. Die aktive Überwachung („active surveillance“) solcher Patienten mit einer auf den medizinisch oder persönlich erforderlichen Zeitpunkt verschobenen Intervention könnte möglicherweise für viele Patienten eine gute Alternative zur sofortigen kurativen Therapie darstellen. Dies setzt aber die sichere Identifizierung von Patienten mit hohem Progressionsrisiko voraus. Der zuverlässigen Aufarbeitung und detaillierten, über die alleinige Karzinomdiagnose hinausgehenden Befundung von Prostatastanzbiopsien kommt dabei eine zentrale Rolle zu. Ein Gleason-Score ≤6 und eine Tumorinfiltration in weniger als 3 Stanzen sind Prädiktoren des insignifikanten PCA. Neben dem gezielten Gleason-Training ist auch das Erkennen solcher Befunde von Bedeutung, bei denen sich von vornherein ein Zuwarten verbietet.
Abstract
Today, more than 80% of men diagnosed with prostate cancer (PCA) by PSA screening do not die from the sequelae of their disease. About 70% present with early, organ-confined cancer and almost half of them are small (<5 cm3) without evidence of progression over years (insignificant PCA). It is assumed that screening brings the diagnosis of PCA forward by about 9 years and that in almost one third of these cases immediate radical prostatectomy or radiotherapy would result in overtreatment. Thus, the treatment strategy of “active surveillance” with selective but delayed intervention for patients with organ-confined PCA could be an attractive alternative to the known curative therapy options. However, a prerequisite of such a therapeutic approach would be a precise identification of patients at high risk for cancer progression. Careful work-up of prostate core needle biopsies including improved pre-embedding preparation and detailed interpretation are of the utmost importance. A Gleason score ≤6 and tumor in only one or two cores are considered predictive of organ-confined cancer. Pathologists should concentrate on correct Gleason scoring in core needle biopsies and identification of lesions that exclude a patient from active surveillance.
Literatur
Albertsen PC, Hanley JA, Fine J (2005) 20-year outcomes following conservative management of clinically localized prostate cancer. JAMA 293: 2095–2101
Amin MB, de-Peralta Venturina M, Merchant SH (2008) The morphology of capsular zone and predicting extracapsular extension on needle biopsies of prostate. Mod Pathol 21(1): 145A
Bangma CH, Roemeling S, Schröder FH (2007) Overdiagnosis and overtreatment of early detected prostate cancer. World J Urol 25: 3–9
Batzler WU, Giersiepen K, Hentschel S et al. (2008) Krebs in Deutschland 2003 – 2004. Häufigkeiten und Trends. 6. überarbeitete Auflage. Robert Koch-Institut (Hrsg) und die Gesellschaft der epidemiologischen Krebsregister in Deutschland e. V. (Hrsg) Berlin
Berney DM, Fisher G, Kattan MW et al. (2007) Trans-Atlantic Prostate Group. Major shifts in the treatment and prognosis of prostate cancer due to changes in pathological diagnosis and grading. BJU Int 100: 1240–1244
Berney DM, Gopalan A, Kudahetti S (2008) Ki-67 is an independent predictor of outcome in conservatively treated clinically localised prostate cancer. Mod Pathol 21(1): 148A
Bill-Axelson A, Holmberg L, Ruutu M et al. (2005) Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 352: 1977–1984
Bonkhof H (2005) Die Prognose des Prostatakarzinom. Pathologe 26: 433–443
Carswell BM, Woda BA, Wang X et al. (2006) Detection of prostate cancer by alpha-methylacyl CoA racemase (P504S) in needle biopsy specimens previously reported as negative for malignancy. Histopathology 48: 668–673
Cuzick J, Fisher G, Kattan MW et al. (2006) Long-term outcome among men with conservatively treated localised prostate cancer. Br J Cancer 95: 1186–1194
Czeloth K, Albers P (2008) Active Surveillance des lokalisierten Prostatakarzinoms. Onkologe
D’Amico AV, Whittington R, Malkowicz SB et al. (1998) Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA 280: 969–974
D’Amico AV, Chen MH, Roehl KA et al. (2004) Preoperative PSA velocity and the risk of death from prostate cancer after radical prostatectomy. N Engl J Med 351: 125–135
de Vries SH, Postma R, Raaijmakers R et al. (2007) Overall and disease-specific survival of patients with screen-detected prostate cancer in the European randomized study of screening for prostate cancer section Rotterdam. Eur Urol 21: 291–292
Dhir R, Vietmeier B, Arlotti J et al. (2004) Early identification of individuals with prostate cancer in negative biopsies. J Urol 171: 1419–1423
Ellinger J, Haan K, Heukamp LC et al. (2008) CpG island hypermethylation in cell-free serum DNA identifies patients with localized prostate cancer. Prostate 68: 42–49
Epstein JI, Chan DW, Sokoll LJ et al. (1998) Non-palpable stage T1c prostate cancer: prediction of insignificant disease using free/total prostate specific antigen levels and needle biopsy findings. J Urol 160: 2407–2411
Eskew LA, Bare RL, McCullough DL (1997) Systematic 5 region prostate biopsy is superior to sextant method for diagnosing carcinoma of the prostate. J Urol 157: 199–202
Griffiths DFR, Melia J, McWilliam LJ (2006) A study of Gleason score interpretation in different groups of UK pathologists; techniques for improving reproducibility. Histopathology 48: 655–662
Guo CC, Epstein JI (2006) Intraductal carcinoma of the prostate on needle biopsy: histologic features and clinical significance. Mod Pathol 19: 1528–1535
Haas GP, Delongchamps NB, Jones RF et al. (2007) Needle biopsies on autopsy prostates: sensitivity of cancer detection based on true prevalence. J Natl Cancer Inst 99: 1484–1489
Harnden P, Coleman D, Moss S et al. (2008) Prostatic pathology reporting in the UK: development of a national external quality assurance scheme. Histopathology 52: 147–157
Klotz L (2006) Active surveillance versus radical treatment for favorable-risk localized prostate cancer. Curr Treat Options Oncol 7: 355–362
Kulkarni GS, Lockwood G, Evans A et al. (2007) Clinical predictors of Gleason score upgrading: implications for patients considering watchful waiting, active surveillance, or brachytherapy. Cancer 109: 2432–2438
Leman ES, Cannon GW, Trock BJ et al. (2007) EPCA-2: a highly specific serum marker for prostate cancer. Urology 69: 714–720
Lin KK (2008) Prostate cancer at one end of a needle biopsy core is associated with advanced pathology stage. Mod Pathol 21(1): 166A
Melia J, Moseley R, Ball RY (2006) A UK-based investigation of inter- and intra-observer reproducibility of Gleason grading of prostatic biopsies. Histopathology 48: 644–654
Miick S, Kwon GY, Wixom C (2008) Direct detection of TMPRSS2:ETS family Gene fusion mRNAs in prostatectomy tissue: Prevalence and correlation with clinicopathologic data. Mod Pathol 21: 171A
Miyake H, Kurahashi T, Takenaka A (2007) Improved accuracy for predicting the Gleason score of prostate cancer by increasing the number of transrectal biopsy cores. Urol Int 79: 302–306
Ochiai A, Trpkov K, Yilmaz A et al. (2007) Validation of a prediction model for low volume/low grade cancer: application in selecting patients for active surveillance. J Urol 177: 907–910
Rubin MA, Mucci LA, Pawitan Y (2008) Testing a multigene model to predict lethal prostate cancer. Mod Pathol 21: 178A
Schmitz BA, Marston AP, Schmechel SC (2008) Cross-Study microarray evaluation of aggressiveness factors in prostate cancer. Mod Pathol 21: 180A
Shi D, Guan H, Sakr WA (2008) Is there a grade progression of prostate cancer with advancing age? An analysis of needle biopsy, radical prostatectomy and autopsy databases. Mod Pathol 21(1): 181A
Stegmaier C (2008) Früherkennung Prostatakarzinom - Aktuelle epidemiologische Daten Deutschland. Vortrag 28. Deutscher Krebskongress Berlin
Steineck G, Helgesen F, Adolfsson J et al. (2002) Quality of life after radical prostatectomy or watchful waiting. N Engl J Med 347: 790–796
Sved PD, Gomez P, Manoharan M et al. (2004) Limitations of biopsy Gleason grade: implications for counseling patients with biopsy Gleason score 6 prostate cancer. J Urol 172: 98–102
van der Kwast TH, Lopes C, Santonja C et al. (2003) Guidelines for processing and reporting of prostatic needle biopsies. J Clin Pathol 56: 336–340
Warlick C, Trock BJ, Landis P et al. (2006) Delayed versus immediate surgical intervention and prostate cancer outcome. J Natl Cancer Inst 98: 355–357
Wu AJ, Daignault S, Wasco MJ et al. (2008) Correlation of biopsy and radical prostatectomy Gleason Score in contemporary extended ≥12 core biopsies practice: Improved correlation with biopsy worst Gleason Score. Mod Pathol 21(1): 190A
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Rüschoff, J., Middel, P. & Albers, P. Active Surveillance des lokalisierten Prostatakarzinoms. Pathologe 29, 339–347 (2008). https://doi.org/10.1007/s00292-008-1013-3
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DOI: https://doi.org/10.1007/s00292-008-1013-3
Schlüsselwörter
- Insignifikantes Prostatakarzinom
- Active Surveillance
- Gleason-Score
- Prostatastanzbiopsie
- Standardisierte Aufbereitung