UroToday - Do Margins Matter? The Prognostic Significance of Positive Surgical Margins in Radical Prostatectomy Specimens - Abstract

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Does the skill of the surgeon or the type of surgical

procedure impact on the surgical margins?

Written by Administrator

Monday, 05 May 2008

Department

of Urology, Memorial Sloan-Kettering Cancer Center,

New York, New York

10021, USA.

The

prognostic significance of positive surgical margins (PSM) in radical

prostatectomy (RP) specimens remains unclear. While most studies have concluded

that a PSM is an independent adverse prognostic factor, others report that

surgical margin status has no effect on prognosis. One reason for these

discordant conclusions is the variable number of patients with a PSM who

receive adjuvant therapy and the differing statistical methods used to account

for the effects of the time course of adjuvant treatment on recurrence. We

evaluated the prognostic significance of PSMs using multiple methods of

analysis accounting for patients who received adjuvant therapy.

We

analyzed 1,389 consecutive patients with clinical stage T1-3 prostate cancer

treated with RP by 2 surgeons from 1983 to 2000. Of 179 patients with a PSM, 37

received adjuvant therapy (AT), 29 radiation therapy and 8 received hormonal

therapy. Because the method used to account for men receiving AT can affect the

outcome of the analysis, data were analyzed by the proportional hazards

technique accounting for patients receiving AT using 5 methods: 1) exclusion,

2) inclusion (AT ignored), 3) censoring at time of AT, 4) failing at time of AT

and 5) considering AT as a time dependent covariate.

Overall

179 patients (12.9%) had a PSM, including 6.8% of 847 patients with pT2 and 23%

of 522 patients with pT3 disease. A PSM was a significant predictor of cancer

recurrence when analyzed using methods 1, 3, 4 and 5 (p=0.005, p=0.014,

p=0.0005, p=0.002, respectively). However, it was not a predictor of recurrence

using method 2 in which AT was ignored (p=0.283). Using method 5 multivariate

analysis demonstrated that a PSM (p=0.002) was an independent predictor of

10-year progression-free probability (PFP) along with Gleason score (p=0.0005),

extracapsular extension (p=0.0005), seminal vesicle invasion (p <0.0005),

positive lymph nodes (p <0.0005) and preoperative serum prostate specific

antigen (p <0.0001). Using method 5 the 10-year PFP was 58% +/- 12% and 81%

+/- 3% for patients with and without a PSM, respectively (p <0.00005). The

relative risk of recurrence in men with a PSM using method 5 was 1.52 (95%

confidence interval 1.06-2.16).

We

confirm that a PSM has a significant adverse impact on PFP after RP in

multivariate analysis using multiple statistical methods to account for

patients who received AT. While prostate cancer screening strategies have

resulted in a majority of men having organ confined disease at RP, surgeons

should continue to strive to reduce the rate of positive surgical margins to

improve cancer control outcomes.

Written

by

Swindle P, Eastham JA, Ohori M, Kattan MW, Wheeler T, Maru N, Slawin K, Scardino

PT.

Reference

J Urol. 2008 May;179(5 Suppl):S47-51.

doi:10.1016/j.juro.2008.03.137

PubMed

Abstract

PMID:18405751