The importance of surgical margins in prostate cancer

Abstract

Positive surgical margins (PSM) after radical prostatectomy (RP) are a predictor of biochemical recurrence (BCR), and highly dependent on surgeon, experience, and skill. The length and location PSMs are important, with significant differences between open and robotic RP. The impact of PSMs on BCR remains secondary to other clinico-pathologic variables: Gleason Score, pathologic stage, and baseline PSA. However, lower PSM rates are associated with reduced use of secondary interventions and patient anxiety of cancer recurrence.

Defining Clinically Meaningful Positive Surgical Margins in Patients Undergoing Radical Prostatectomy for Localised Prostate Cancer

“…The rate of positive surgical margins (PSMs) on final pathology in patients treated with radical prostatectomy (RP) for clinically localised prostate cancer (PCa) ranges between 6% and 22% [1,2], and varies according to disease characteristics as well as surgical experience [3]. In case of documented PSMs, the European Association of Urology guidelines recommend the administration of adjuvant radiotherapy (RT) in the setting of non-organ-confined disease [4].…”

Improving postoperative radiotherapy following radical prostatectomy

“…The only true PSM is the first situation in which the resection has gone through tumor tissue. In patients operated with roboticassisted laparoscopic prostatectomy (RALP) the rate of iatrogenic intraprostatic incision seems higher because of the lack of tactile feedback from the robotic arms [14]. A positive surgical resection margin finding also depends on the technique of the pathologist used to examine the specimen.…”

“…It contains almost no prostatic capsule in contrast to the body of the prostate and therefore is difficult to differentiate between prostate and surrounding tissue. Because of this difficulty making a distinction between organ-confined tumors (pT2) and extraprostatic extension (pT3) is also complex, resulting in higher rate of false PSMs [14,37]. The EAU guidelines state that tumors at the apex mixed with skeletal muscle does not constitute extra prostatic extension (https://uroweb.org/ wp-content/uploads/09-Prostate-Cancer_LR.pdf).…”

Ex vivo fluorescence confocal microscopy: the first application for real‐time pathological examination of prostatic tissue

“…Prostate cancer is the most commonly diagnosed male cancer worldwide and its management is a delicate balance between optimum postoperative functional outcomes and oncological radicalness . Several recent diagnostic and managerial innovations have been introduced, including multiparametric MRI (mpMRI), mpMRI‐ultrasonography fusion targeted biopsy, neurovascular bundle‐sparing radical prostatectomy (RP) technique, and robot‐assisted laparoscopic approach to RP (RALP) .…”

“…However, the ‘gold standard’ pathological assessment of prostate cancer is still a conventional, time‐consuming approach . Moreover, a cancer‐free surgical margin is considered a critical part of prostate cancer surgery, as positive surgical margins (PSMs) can be found in up to 38% of patients after RP . PSM is one of the major ‘surgically controlled’ concerns of RP, as it is associated with an increased risk of recurrence, the need for adjuvant therapy, and increased management costs .…”