前列腺腺癌的Gleason评分进展和新的预后分组纲要•Gleason分级最新进展•Gleason评分规则的应用•新的预后分组信息(Newprognosticgradingsystem)WHOclassificationofTumouroftheUrinarySystemandMaleGenitalOrgans(2016)Gleason分级最新进展•主要改变的内容有三点1.对具有特殊组织学形态的前列腺癌Gleason评分达成一致如:筛状形态、肾小球样腺体、粘液腺癌2.新增导管内癌(IDC-P)3.对前列腺癌亚型的分级如泡沫状癌,萎缩型癌,假增生型癌、导管腺癌、印戒细胞癌等•Gleasongradingsystem(Gleason分级系统)•Themostwidelyusedgradingsystemforprostaticadenocarcinoma•Developedin1966byDr.DonaldGleason•Basedongeneralhistologicappearance(notmitoticcountorcelltypes)•5patterns(patter1topattern5)(Gleasongrade1to5:分级)•Furtherrefinedin1974,1977,1992,2005,20142005年Gleason分级2015修订版Gleason分级最新进展对特殊组织学形态的共识ISUP2005ISUP2014筛状腺体小的边界圆滑的:Gleason3边界不规则的:Gleason4大的筛状腺体:Gleason4均为Gleason4(100%)肾小球样腺体没有达成一致意见50%认为是Gleason4其余50%认为目前生物学行未知,不给GleasongradeGleason4(100%)粘液腺癌大约50%专家认为是Gleason4其余50%认为根据粘液腺癌的结构根据粘液腺癌本身的结构(91%):多数为Gleason4,少量为3Gleason分级最新进展1现为Gleason4原为Gleason3和Gleason4现均为Gleason4多数为Gleason4,少数Gleason3,看腺体结构而定Gleason分级最新进展1新增导管内癌(IDC-P)•Intraductalcarcinomaofprostate:IDCP‐•1985年首先由Kovi提出•目前最常用的诊断标准:2006年GuoandEpstein提出诊断标准:Malignantepithelialcellsfillinglargeaciniandprostaticducts,withpreservationofbasalcellsandeitherasolidordensecribriformpatternoraloosecribriformormicropapillarypatternwitheithermarkednuclearatypia(nuclearsize6xnormal)orcomedonecrosisGleason分级最新进展2粉刺状IDC-P实体型IDC-P筛状型IDC-PGleason分级最新进展2•临床意义•根治标本中IDC-P常与高级别浸润癌共存,•与Gleason评分、肿瘤容积、前列腺外扩散、精囊腺侵犯和淋巴结转移均密切相关•根治标本中存在IDC-P为生化复发和总体生存率的独立预测指标•IDC-P的存在提示病人更易进展为去势抵抗型或者对放疗不敏感Gleason分级最新进展2IsThereanyPrognosticImpactofIntraductalCarcinomaofProstateDiagnosedAggressivelyMetastaticProstateCancer?Taozhao,etal,TheProstate75;225-232(2015)278例转移性前列腺癌本组转移性前列腺癌患者初诊时IDC-P比例为20.5%(57/278)IDC-P为转移性前列腺癌CRPC和OS的独立预测指标不同IDC-P亚型预后不同Gleason评分高的浸润性癌中出现IDC-P,仍有预后意义Gleason分级最新进展2IDC-P影响内分泌治疗和化疗反应•初次活检诊断转移性前列腺癌45例内分泌治疗进展为mCRPC再次活检比较两次穿刺标本IDC-P及其他临床病理指标多西他塞化疗(24例)评估IDC-P与化疗效果的关系ZhibinChen,NiChen,etal.ThePresenceandClinicalImplicationofIntraductalCarcinomaofProstateinMetastateCastrationResistantProstateCancer.Prostate.2015Sep;75(12):1247-54.Gleason分级最新进展2不同ICD-P亚型对内分泌治疗反应不同实体型IDC-P无明显反应筛状型IDC-P部分反应无IDC-P病例反应好Gleason分级最新进展2IDC-P影响多西他赛化疗效果转移性前列腺癌患者进展为CRPC后IDC-P检出率明显升高不同IDC-P组织学亚型对内分泌治疗反应不同存在IDC-P的患者对多西他赛化疗敏感性降低患者进入CRPC阶段,化疗前再行活检有助于评估化疗效果存在IDC-P对内分泌和多西他赛化疗不敏感的机制需进一步研究ZhibinChen,NiChen,etal.ThePresenceandClinicalImplicationofIntraductalCarcinomaofProstateinMetastateCastrationResistantProstateCancer.Prostate.2015Sep;75(12):1247-54.Gleason分级最新进展2对前列腺癌亚型的分级泡沫腺体腺癌foamyglandadenocarcinoma萎缩性腺癌(atrophicadenocarcinoma)假增生性腺癌(ps...