摘要
目的探讨荧光显像腹膜后淋巴结清扫在根治性前列腺切除术(RP)后淋巴结复发患者中的疗效。方法回顾性分析2017年1月至2020年12月中山大学附属第三医院25例RP术后^(68)Ga-PSMA PET/CT检查诊断为淋巴结复发行荧光显像腹膜后淋巴结清扫患者的临床资料。中位年龄67(59~77)岁。淋巴结复发时中位前列腺特异性抗原(PSA)7.7(0.5~12.6)ng/ml。根治术后病理分期T_(2)期4例,T_(3)期17例,T_(4)期4例;N0期10例,N1期15例;国际泌尿病理协会(ISUP)分级分组<3组2例,4组9例,5组14例。根治术至淋巴结复发的中位时间为43(27~56)个月。25例均曾生化复发,行雄激素剥夺治疗(ADT),提示为激素敏感性前列腺癌。25例均行^(68)Ga-PSMA PET/CT检查,诊断为淋巴结复发。25例行荧光显像腹膜后淋巴结清扫,在荧光模式下的暗视野行盆腔淋巴结检测,发现荧光阳性淋巴结,切换为白光模式,进行清扫、记录并送检。对于术前PSMA PET/CT检查提示的转移淋巴结,无论荧光阳性与否,均常规清扫,其余部位无荧光阳性的淋巴结,则仅做常规检查。分析患者围手术期数据,随访观察患者PSA反应、影像学检查等情况。术后PSA完全反应定义为术后40 d,PSA下降至0.2 ng/ml以下。结果25例淋巴结清扫时间中位值21(15~28)min,失血量中位值30(20~50)ml,住院时间中位值4(3~5)d。无严重并发症(Clavien分级≥Ⅱ级)发生。25例病理均证实淋巴结转移;25例共清扫43枚淋巴结,其中荧光阳性淋巴结37枚,病理证实转移淋巴结32枚;每例清扫淋巴结中位值2(1~3)枚。25例均获随访,中位随访时间27(15~57)个月。25例中24例(96%)达PSA完全反应,其中1例术后6个月出现生化复发,1例PSA完全反应后12个月出现影像学复发(髂骨转移,PSA为0.33ng/ml),此2例均予ADT后PSA降至0.2 ng/ml以下。1例术后PSA未达完全反应,予ADT治疗,3个月后进展为去势抵抗性前列腺癌。淋巴结清扫术后3例PSA>0.2 ng/ml的患者,影像学检查腹膜后淋巴结清扫区域未见淋巴结复发。结论对于RP术后^(68)Ga-PSMA PET/CT检查诊断为淋巴结复发的患者,采用荧光显像腹膜后淋巴结清扫术治疗手术范围相对较小,术中并发症少,术后PSA反应率高,复发率低。
Objective To explore the efficacy of fluorescent retroperitoneal lymph node dissection in the comprehensive treatment of lymph node recurrence after radical prostatectomy(RP).Methods From January 2017 to December 2020,25 patients with lymph node recurrence diagnosed by ^(68)Ga-PSMA PET/CT after RP in our hospital were enrolled in this study.The patients were 67(59-77)years old.The median PSA was 7.7(0.5-12.6)ng/ml at lymph node recurrence,and was treated with androgen deprivation therapy(ADT),suggesting hormone-sensitive prostate cancer.Before recurrence,4 cases were in T_(2) stage,17 cases in T_(3),4 cases in T_(4),10 cases in N0,and 15 cases in N1stage,25 cases in M0stage.2 cases diagnosed as ISUP grade group<3,9 cases in group 4,and 14 cases in group 5.The median time from radical resection to recurrence was 43(27-56)months.All 25 cases were diagnosed as lymph node recurrence by ^(68)Ga-PSMA PET/CT examination.Fluorescence retroperitoneal lymph node dissection was performed.Pelvic lymph nodes were detected in the dark field under the fluorescence mode,and positive lymph nodes were found.The white light mode was switched,and the lymph nodes were cleaned,and recorded.For metastatic lymph nodes indicated by preoperative PSMA PET/CT,routine dissection was performed regardless of whether the lymph nodes were fluorescently positive or not.The only routine examination was performed if there were no lymph nodes with fluorescently positive staining in other sites.Perioperative data,biochemical recurrence(BCR)rate,radiological recurrence(RAR)rate,and follow-up data were collected and analyzed.Results 25 patients were pathologically diagnosed with lymph node metastasis.The median lymph node dissection time was 21(15-28)min,estimated blood loss was 30(20-50)ml,hospital days was 4(3-5)d without any severe complications(<Clavien 2).Lymph node dissection and postoperative pathology:25 cases were pathologically confirmed as lymph node metastasis.43 lymph nodes of 25 cases were dissected,among which,37 lymph nodes showed fluorescent positive,32 lymph nodes were confirmed as metastatic pathologically.The median number of dissected lymph nodes was 2(1-3).All 25 cases were followed up,with a median follow-up time of 27(15-57)months.24 cases achieved complete PSA response(PSA<0.2 ng/ml)in this study,of which 1 case developed BCR 6 months after surgery,and 1 case developed RAR 12 months after complete PSA response(ilium,PSA was 0.33 ng/ml).1 case did not reach the PSA response and progressed to castration-resistant prostate cancer within 3 months after the operation.Conclusions For patients diagnosed with lymph node recurrence by ^(68)Ga-PSMA PET/CT examination,fluorescence imaging retroperitoneal lymph node dissection has a relatively small surgical range,few intraoperative complications and a low postoperative recurrence rate.
作者
王喻
梁伟聪
孙卓伦
狄金明
刘小彭
李腾成
李科
温星桥
高新
Wang Yu;Liang Weicong;Sun Zhuolun;Di Jinming;Liu Xiaopeng;Li Tengcheng;Li Ke;Wen Xingqiao;Gao Xin(Department of Urology,Third Affiliated Hospital,Sun Yat-Sen University,Guangzhou 510630,China)
出处
《中华泌尿外科杂志》
CAS
CSCD
北大核心
2021年第9期666-669,共4页
Chinese Journal of Urology
关键词
前列腺肿瘤
淋巴结复发
腹膜后淋巴结清扫
荧光显像
Prostatic neoplasms
Lymph node recurrence
Retroperitoneal lymph node dissection
Fluorescence
