攝護腺癌病患具攝護腺前脂肪墊淋巴結侵犯之特徵

之前文獻報告中提到攝護腺前脂肪墊(prostatic anterior fat pad, PAFP) 內存在有淋巴結(lymph node, LN)。攝護腺癌的病人，骨盆腔淋巴結或是攝護腺前脂肪墊若有癌症轉移，病理分期就是第四期。在以往，攝護腺前脂肪墊並沒有例行性接受病理檢查；若是骨盆腔淋巴結沒有癌症轉移，攝護腺前脂肪墊沒有接受病理分析，此類病患可能會被誤歸類為第二或第三期。我們收共849例攝護腺癌病患，分別來自童綜合醫院及台中榮民總醫院，統計及分析攝護腺前脂肪墊淋巴結(PAFP LNs) 存在的比例。這些病患之前因為攝護腺特異指數(prostate specific antigen, PSA) 異常或肛門指診異常接受經直腸攝護腺切片、或是經尿道刮除之攝護腺檢體經病理科醫師確診為攝護腺癌，後續接受機器人輔助腹腔鏡攝護腺根除手術(robotic-assisted laparoscopic radical prostatectomy, RALRP) 合併骨盆淋巴結清除手術(bilateral pelvic lymph node dissection, BPLND) 。除此之外，這些病患的攝護腺前脂肪墊皆送至病理檢驗，來確認是否有淋巴結存在，以及有無攝護腺癌轉移至此淋巴結。在接受攝護腺根除的病人裡，76 (9.0%) 位病人有淋巴結存在於攝護腺前脂肪墊。11 (1.3%) 位病患，有攝護腺癌轉移於攝護腺前脂肪墊，其中有5 (0.6%) 位病患，骨盆腔淋巴結沒有腫瘤，但PAFP LNs有攝護腺癌轉移，癌症分期因此由第三期提高到第四期。統計發現，術前的clinical T stage、術後病理檢查的seminal vesicle invasion、N stage及Gleason Score與攝護腺前脂肪墊存在淋巴結與否有關。與癌症轉移至脂肪墊淋巴結有關的因子為術前的PSA、切片的Gleason Score、clinical stage。術後病理檢查的T stage、N stage、Gleason Score及seminal vesicle invasion。移除PAFP可以讓攝護腺旁的構造看的更清楚，在具有高風險特徵的攝護腺癌病人中，PAFP更應該送至病理分析，可以得到更正確的病理分期。

The presence of lymph nodes (LNs) within the prostatic anterior fat pads (PAFP) has been reported in several reports. Metastatic cancer can be found in PAFP LNs. Until now, no literature well describe the characteristics of patients who have PAFP LNs metastasis among Taiwanese patients. The prostate cancer patients who were diagnosed of stage II or stage III could be upstaged as a result of positive nodes metastases in PAFPs. From December 2006 to May 2015, 849 consecutive patients were enrolled from Tungs’Taichung MetroHarbor Hospital (TTMHH) and Taichung Veterans General Hospital (TCVGH). These patients were all pathologically confirmed to have prostate cancer by transrectal prostate biopsy or transurethral resection of prostate. They received subsequent robot-assisted laparoscopic radical prostatectomy (RALRP) with bilateral pelvic lymph nodes dissection (BPLND). Each PAFP was also removed for pathological examination to evaluate the presence of lymphoid tissue and the involvement of prostate cancer. Statistics showed 76 (9.0%) patients were found to have lymph nodes in PAFPs. Eleven (1.3%) had prostatic cancer involvement in PAFP LNs. Five (0.6%) out of the eleven patients got up-staged due to positive metastases of PAFP LNs but negative in pelvic LNs. PAFP LNs appear more in chance among the patients with higher clinical T stage (cT stage), seminal vesicle invasion(SVI), pathological N stage (pN stage), and surgical Gleason Score (GS). In the group of positive nodes involvement in PAFP, these patients had significant differences in the preoperative (Pre-op) PSA, Pre-op GS, cT stage, pathological T stage (pT stage), SVI, pN stage, and surgical GS. PAFP excision facilitates clearer view of prostate anatomic structure and surgical landmarks. We recommend the PAFP should be removed in all patient during radical prostatectomy (RP), but the routine pathological analysis of PAFP could only be done among those who had high risk preoperative features.