Urologic Oncology: Seminars and Original Investigations
Review articleRadical prostatectomy: Positive surgical margins matter☆
Introduction
Surgical margin status at radical prostatectomy (RP) has many implications for the patient. Aggressive or advanced disease may be cured in men with negative surgical margins. Positive surgical margins (PSMs), however, even with organ-confined cancers, are associated with higher rates of biochemical recurrence (BCR) and result in the increased burden of further treatment [1]. In this review, we discuss the incidence, anatomy, and management of PSMs after RP.
Section snippets
Definition of PSM
In prostate cancer (CaP), a PSM is defined as tumor cells at the inked surgical margin of the RP specimen [2]. The cause of a PSM is often multifactorial. In cases with extracapsular extension (EPE), a PSM is more likely to occur if the surgeon does not resect widely enough around the prostate, often the result of an overzealous attempt at preserving the neurovascular bundles. A PSM can also occur in cases of organ-confined disease if the surgeon resects too close to the prostate (often
Incidence of PSM
The reported overall rates of PSM vary tremendously, reflecting differences in pathology (e.g., specimen processing, diligence of the pathologist in reviewing the tissue), patient selection, and surgical technique (Table 1). Analysis of the national Surveillance, Epidemiology and End Results (SEER) Program database identified a median PSM rate of 21.2% for all 13 regional SEER registries participating from 1998 to 2006 [4]. There was a 2-fold variance in the recorded rates of PSMs among
The apex
A number of series have shown that PSMs are most common at the apex (Table 2). For the surgeon, the apex is challenging because of the broad extent of the dorsal venous complex and its location under the pubic bone and proximity to the neurovascular bundles. Anatomically, the apex has the least capsule, and even benign glands are admixed with skeletal muscles [7]. Anatomical studies using preoperative MRI have demonstrated that the depth of the prostatic apex within the pelvis is an independent
Size of the PSM
Are all PSMs equivalent? This question has been addressed by multiple studies. Cao et al. evaluated almost 300 PSMs and found a mean length of 3.90 mm [23]. The authors stratified the length of PSMs into 3 groups: ≤1 mm, 1 mm to 3 mm, and >3 mm, but were unable to establish a length at which a PSM did not affect BCR. While there was no difference in rates of BCR in patients with PSMs 3 mm, patients with PSMs > 3 mm had a significantly shorter time to BCR and higher overall rates of BCR. In an
Oncologic outcomes
A man with a PSM after RP is more likely to develop BCR [25]. In a large multi-institutional study of almost 6,000 men undergoing RP, PSM was associated with a 3.7-fold risk of BCR [1]. Often associated with aggressive disease, PSMs are not independent of other clinical and pathologic features. Stephenson et al., using a multivariate model that included age, Gleason score, PSA, EPE, and SVI, followed more than 7,000 patients in a large multi-institutional study and found that PSMs were
Management of PSMs
Men with a PSM are almost twice as likely to receive radiotherapy (XRT) after RP than men with a negative margin, even after adjusting for cancer grade, stage, and EPE [30]. Three randomized controlled trials have attempted to address the need for adjuvant XRT after RP. The Southwest Oncology Group (SWOG) 8794 trial began in 1988 and randomized 425 men with pT3 cancer after RP to either 60–64 Gy of external beam radiation to the prostatic fossa or observation [31]. Men had at least 1 adverse
Role of the surgeon
One of the most important predictors of a PSM and subsequent BCR is the surgeon. An evaluation of the surgical learning curve of 72 surgeons operating on 7,765 patients at 4 major institutions found that PSMs significantly decreased from 40% after 10 cases to 25% after 250 cases [39]. As witnessed by most surgeons who originally performed open or laparoscopic prostatectomy and are now performing robotic prostatectomy, PSMs decrease over time with increased experience. In a review of their first
Conclusion
We describe the incidence, anatomy, and management of PSM after RP. While the management of PSM is controversial, the surgical margin remains one of the surgeon's most important contributions to patient outcome by preventing the need for further treatment and, potentially, disease recurrence.
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This work was supported by the Sidney Kimmel Center for Prostate and Urologic Cancers.