Prognostic significance of positive surgical margins in patients with extraprostatic carcinoma after radical prostatectomy

Abstract

BACKGROUND A significant number of prostate adenocarcinoma patients undergoing radical prostatectomy are found to have microscopic extraprostatic disease extension. A majority of these patients have focal extraprostatic extension limited to one or both sides of the prostate. In addition, positive surgical margins are a common pathologic finding in this patient subgroup. In the current study, the authors evaluated the impact of positive surgical margins as an independent predictive factor for prostate specific antigen (PSA) progression in patients with pT3a/b N0M0 carcinoma. METHODS The Mayo Clinic prostate cancer registry list provided 1202 patients with pT3a/b NO prostate carcinoma (no seminal vesicle or regional lymph node involvement) who underwent a radical prostatectomy between 1987–1995. To reduce confounding variables, patients who received preoperative therapy or adjuvant therapy were excluded, resulting in 842 patients who were eligible for analysis. RESULTS A total of 354 patients (42%) had ≥ 1 positive surgical margins whereas 488 patients (58%) demonstrated no margin involvement. The sites of margin positivity were as follows: apex (n = 163), base (n = 47), posterior prostate (n = 227), and anterior prostate (n = 11). A total of 111 patients had ≥ 2 positive surgical margins. The 5‐year survival free of clinical recurrence and/or biochemical failure (postoperative PSA level > 0.2 ng/mL) for patients with no positive surgical margins was 76% and was 65% for patients with 1 positive surgical margin (P = 0.0001). There was no significant difference in biochemical disease progression between patients with 1 versus those with ≥ 2 surgical margins (65% vs. 62%). Multivariate analysis revealed that positive surgical margins were a significant predictor (P = 0.0017) of clinical disease recurrence and biochemical failure (relative risk, 1.55; 95% confidence interval, 1.18–2.04) after controlling for preoperative PSA, Gleason score, and DNA ploidy. CONCLUSIONS In the current study, positive surgical margins were found to be a significant predictor of disease recurrence in patients with pT3a/b NO prostate carcinoma, a finding that is independent of PSA, Gleason score, and DNA ploidy. The benefit of adjuvant therapy in optimizing recurrence‐free survival remains to be tested. Cancer 2002;95:1215–9. © 2002 American Cancer Society. DOI 10.1002/cncr.10871

Impact of capsular incision on biochemical recurrence after radical perineal prostatectomy

“…7,8 In addition to the pre-operative serum PSA, Gleason score on pathology specimen, the seminal vesicle invasion and lymph node status, and a positive surgical margin with extraprostatic extension (EPE) are significant predictors of clinical and biochemical recurrence (BCR). [9][10][11][12][13] However, the prognostic implication of capsular incision (CI), tumor extending to the inked margins without a histologically documented EPE, remains to be defined. Most of the earlier studies evaluated the retropubic approach.…”

International Society of Urological Pathology (ISUP) Consensus Conference on Handling and Staging of Radical Prostatectomy Specimens. Working group 3: extraprostatic extension, lymphovascular invasion and locally advanced disease

“…Extraprostatic extension is a well-established adverse prognostic factor for prostate carcinoma, [1][2][3][4][5] and accurate identification of this feature is required for optimal patient management after radical prostatectomy. [1][2][3][4] Despite this, disagreement exists as to what features define extraprostatic extension, especially at the prostatic apex and bladder neck.…”

“…[1][2][3][4] Despite this, disagreement exists as to what features define extraprostatic extension, especially at the prostatic apex and bladder neck. 5,6 Although infiltration of the urinary bladder and rectum by prostatic adenocarcinoma is associated with a poor outcome, there is debate as to the appropriate staging category that should be applied and specifically whether tumor involvement of the urinary bladder should be categorized as pT4 or M1 disease.…”

Adjuvant and salvage treatment options for patients with high-risk prostate cancer treated with radical prostatectomy

“…The recent data from the Mayo clinic indicate that 65% of men with a single-positive surgical margin and no other treatment remain biochemically/ clinically free from disease at 5 years; 62% men with two or more positive margins had no evidence of disease at 5 years. 27 Therefore, it is possible that a majority of men could receive adjuvant EBRT for a positive margin unnecessarily.…”