Two Positive Nodes Represent a Significant Cut-off Value for Cancer Specific Survival in Patients with Node Positive Prostate Cancer. A New Proposal Based on a Two-Institution Experience on 703 Consecutive N plus Patients Treated with Radical Prostatectomy, Extended Pelvic Lymph Node Dissection and Adjuvant Therapy-猫眼课题宝

DOI：

10.1016/j.eururo.2008.09.043

发表时间：

2009-02-01

期刊：

EUROPEAN UROLOGY

影响因子：

23.4

通讯作者：

中科院分区：

医学1区

文献类型：

作者：

Briganti, Alberto;Karnes, Jeffrey R.;Blute, Michael L.

背景资料：目前，2002年美国癌症联合委员会（AJCC）的前列腺癌分期系统不包括根据阳性淋巴结数量对患者进行任何分层。然而，淋巴结阳性（N+）患者根据淋巴结浸润（LNI）程度的不同，其预后也不尽相同。目的：检测如果根据阳性淋巴结的数量对淋巴结阳性患者进行分层，是否可以提高癌症特异性生存（CSS）预测的准确性。研究队列包括1988年9月至2003年1月在两个大型学术机构接受根治性盆腔淋巴结切除术（RP）和扩大盆腔淋巴结清扫术（ePLND）治疗的703例N+ MO患者。根据预测CSS的最具信息性的截止值，将阳性淋巴结数量二分。Kaplan-Meier曲线评估癌症特异性存活率。当前N分期和新N分类在预测CSS中的预测准确性在调整病理（T）分期后用Harrell一致性指数量化，并用200个boostrap重新采样进行内部验证。结果和局限性：平均随访时间为113.7个月（中位数：112.5，范围3.5-243）。切除的平均淋巴结数量为13.9（范围：2-52）。平均阳性淋巴结数为2.3（范围：1-31）。在预测CSS中，阳性节点的最具信息性的截止值为2。其中532例（75.7%）患者有2个或以下阳性淋巴结，171例（24.3%）患者有2个以上阳性淋巴结。在15年随访时，与2个以上阳性淋巴结的患者相比，2个或更少阳性淋巴结的患者的CSS结局显著更好（84% vs 62%; p < 0.001）。校正病理分期后，新N分期的多变量预测准确性（2个阳性淋巴结）为65.0%，不考虑阳性淋巴结数为60.1（4.9%增益; p < 0.001）。我们证明了多达2个阳性淋巴结的患者经历了极好的CSS，这与具有多于2个阳性淋巴结的患者相比显著更高。此外，当考虑正节点的数量时，CSS预测得到了显着改善。因此，我们的研究结果加强了根据阳性淋巴结的数量对淋巴结阳性患者进行分层的必要性，并可能在下一次病理TNM分类修订中值得考虑。(c)2008年欧洲泌尿外科协会。Elsevier B. V.出版，保留所有权利。

Background: Currently, the 2002 American Joint Committee on Cancer (AJCC) staging system of prostate cancer does not include any stratification of patients according to the number of positive nodes. However, node positive (N+) patients share heterogeneous outcomes according to the extent of lymph node invasion (LNI).Objective: To test whether the accuracy of cancer specific survival (CSS) predictions may be improved if node positive patients are stratified according to the number of positive nodes.Design, Setting, and Participants: The study cohort included 703 N+ MO patients treated with radical prostatectomy (RP) and extended pelvic lymph node dissection (ePLND) between September 1988 and January 2003 at two large Academic Institutions. Number of positive nodes was dichotomized according to the most informative cut-off predicting CSS. Kaplan-Meier curves assessed cancer specific survival rates. Predictive accuracy of the current N stage and of the new N classification in predicting CSS was quantified with Harrell's concordance index after adjusting for pathological (T) stage and internally validated with 200 boostraps resamples. Differences in predictive accuracy were compared with the Mantel-Haentzel test.Results and Limitations: Mean follow-up was 113.7 months (median: 112.5, range 3.5-243). The mean number of nodes removed was 13.9 (range: 2-52). The mean number of positive nodes was 2.3 (range: 1-31). The most informative cut-off of positive nodes in predicting CSS was 2. Of all, 532 (75.7%) patients had 2 or less positive nodes, while 171 (24.3%) had more than 2 positive nodes. Patients with 2 or less positive nodes had significantly better CSS outcome at 15 year follow-up compared to patients with more than 2 positive nodes (84% vs 62%; p < 0.001). After adjusting for pathological stage, multivariable predictive accuracy of the new N staging ( 2 positive nodes) was 65.0% vs 60.1% when the number of positive nodes was not considered (4.9% gain; p < 0.001).Conclusions: We demonstrated that patients with up to 2 positive nodes experienced excellent CSS, which was significantly higher compared to patients with more than 2 positive nodes. Moreover, a significant improvement in CSS prediction was reached when the number of positive nodes was considered. Thus, our results reinforce the need for a stratification of node positive patients according to the number of positive nodes and may warrant consideration in the next revision of the pathologic TNM classification. (c) 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved.

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