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

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Thursday, 12 June 2008

BERKELEY, CA

(UroToday.com) - Positive surgical margins (PSM) are an adverse outcomes

variable in patients undergoing radical prostatectomy (RP) and is the one

variable that can be influenced by surgical technique. In the current

literature, studies evaluating the impact of a PSM often exclude the effect of

adjuvant therapy (AT), usually by excluding these patients. In a Journal of

Urology May 2008 supplement, an important paper by Dr. Swindle and associates

at Memorial Sloan Kettering

Cancer Center

and Baylor College of Medicine is revisited regarding this issue. The study

used multiple methods of statistical analysis to account for the use of AT in a

series of 1,389 patients operated on by 2 surgeons.

The data

was analyzed by proportional hazards models and dealt with patients who

received AT in 5 ways; 1) exclusion. 2) inclusion (AT ignored), 3) censoring at

the time of AT, 4) failing at the time of AT, 5) considering AT as a time

dependent covariate. So this meant that the probability of recurrence was

analyzed by first excluding all patients who received AT from the analysis,

then by including those who received AT and ignoring the AT, then by censoring

those patients at the time of AT, and finally by considering AT as treatment

failure or recurrence.

A total

of 179 of the men had a PSM (12.9%). There was a median follow-up of 50 months

and biochemical recurrence was defined as a PSA >0.4ng/ml and reconfirmed on

a second PSA test. The incidence of PSM increased with increasing PSA,

pathologic Gleason score and stage. The overall progression-free survival (PFS)

for those with a PSM was 58%, compared with 81% for patients with negative

surgical margins. A PSM was a significant predictor of cancer recurrence when

analyzed by methods 1, 3, 4, and 5, but not method 2 in which AT was ignored.

Pretreatment PSA, pathologic stage and grade were all independent predictors of

progression in all 5 methods analyzed. A PSM was a significant predictor of

progression for all methods of analysis, except for method 2. For patients with

extra-capsular extension, a PSM was significant using all methods of examining

patients who received AT. However, this decreased from 31.7% before 1990 to

11.1% after 2000. The year of surgery and presence of organ confined cancer

contributed to the decrease in PSM incidence. These data are important as

surgical techniques are again changing with the advent of robotic assisted

laparoscopic radical prostatectomy.

Swindle

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

J

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

doi: 10.1016/j.juro.2008.03.137

PubMed

Abstract

PMID: 18405751