Biochemical Recurrence After Radical Prostatectomy: Multiplicative Interaction Between Surgical Margin Status and Pathological Stage

The impact of solitary and multiple positive surgical margins on hard clinical end points in 1712 adjuvant treatment-naive pT2-4 N0 radical prostatectomy patients

BACKGROUND

Positive surgical margins (PSMs) increase the risk of biochemical recurrence (BCR) after radical prostatectomy (RP), but their impact on hard clinical end points is a topic of ongoing discussion.

OBJECTIVE

To evaluate the influence of solitary PSMs (sPSMs) and multiple PSMs (mPSMs) on important clinical end points.

DESIGN, SETTING, AND PARTICIPANTS

Data from 1712 patients from the Centre Hospitalier Universitaire de Québec with pT2-4 N0 prostate cancer (PCa) and undetectable prostate-specific antigen after RP were analyzed.

INTERVENTION

RP without neoadjuvant or adjuvant treatment.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Kaplan-Meier analysis estimated survival functions, and Cox proportional hazards models addressed predictors of clinical end points.

RESULTS AND LIMITATIONS

Median follow-up was 74.9 mo. A total of 1121 patients (65.5%) were margin-negative, 281 patients (16.4%) had sPSMs, and 310 patients (18.1%) had mPSMs. A total of 280 patients (16.4%) experienced BCR, and 197 patients (11.5%) were treated with salvage radiotherapy (SRT). Sixty-eight patients (4.0%) received definitive androgen deprivation therapy, 19 patients (1.1%) developed metastatic disease, and 15 patients (0.9%) had castration-resistant PCa (CRPC). Thirteen patients (0.8%) died from PCa, and 194 patients (11.3%) died from other causes. Ten-year Kaplan-Meier estimates for BCR-free survival were 82% for margin-negative patients, 72% for patients with sPSMs, and 59% for patients with mPSMs (p<0.0001). Time to metastatic disease, CRPC, PCa-specific mortality (PCSM), or all-cause mortality did not differ significantly among the three groups (p=0.991, p=0.988, p=0.889, and p=0.218, respectively). On multivariable analysis, sPSMs and mPSMs were associated with BCR (hazard ratio [HR]: 1.711; p=0.001 and HR: 2.075; p<0.0001), but sPSMs and mPSMs could not predict metastatic disease (p=0.705 and p=0.242), CRPC (p=0.705 and p=0.224), PCSM (p=0.972 and p=0.260), or all-cause death (p=0.102 and p=0.067). The major limitation was the retrospective design.

CONCLUSIONS

In a cohort of patients who received early SRT in 70% of cases upon BCR, sPSMs and mPSMs predicted BCR but not long-term clinical end points. Adjuvant radiotherapy for margin-positive patients might not be justified, as only a minority of patients progressed to end points other than BCR. PCSM was exceeded 15-fold by competing risk mortality.

Prediction of biochemical recurrence after radical prostatectomy using peritumoral lymphatic vessel density in biopsy specimens in patients with localized prostate cancer

INTRODUCTION

Lymphatic invasion has been associated with biochemical recurrence (BCR), and many patients with postoperative elevation of prostate-specific antigen (PSA) develop distant metastases within several years. We previously found peritumoral lymphatic vessel density (PTLD) in biopsy cores to be an independent predictor of lymphatic invasion in radical prostatectomy specimens, so we speculate that PTLD parameters in biopsy specimens could also be independent predictors of BCR after surgery.

PATIENTS AND METHODS

We obtained positive biopsy cores from 110 patients who underwent radical prostatectomy at our institution. Biopsy cores were immunostained with the D2-40 monoclonal antibody, which specifically and selectively detects lymphatic endothelium. We evaluated differences between the BCR-free survival rates and used univariate and multivariate analyses to detect independent predictors of BCR.

RESULTS

The results of a Cox proportional hazards model showed that lymphatic invasion in prostatectomy specimens was one of the independent postoperative prognostic factors for BCR (p = 0.0338). An additional model showed that one PTLD parameter, maximal PTLD, was among the independent preoperative predictors of lower BCR-free survival rates (p = 0.0200).

CONCLUSIONS

Information about PTLD in prostate biopsy specimens could be helpful for selecting patients as radical prostatectomy candidates, and patients with high PTLD values should be carefully monitored after surgery.

Prognostic significance of positive surgical margins after radical prostatectomy among pT2 and pT3a prostate cancer

OBJECTIVE

To investigate the prognostic significance of positive surgical margins (PSM)s among patients who underwent radical prostatectomy (RP) for pT2 and pT3a prostate cancer.

PATIENTS AND METHODS

We reviewed the records of 658 patients who were revealed to have pT2 and pT3a prostate cancer after undergoing RP without neoadjuvant or adjuvant treatment. For our analysis, patients were subgrouped as the following: group 1: 406 (61.7%) with negative surgical margins (NSM)s and no extracapsular extension of tumor (ECE); group 2: 99 (15.0%) with PSMs and no ECE; group 3: 63 (9.6%) with NSMs and ECE; and group 4: 90 (13.7%) with PSMs and ECE. The effects of various variables on biochemical recurrence (BCR)-free survival were assessed via uni- and multivariate analyses.

RESULTS

During median follow-up of 36 months, group 1 had significantly higher BCR-free survival compared with the other 3 groups (P < 0.001). However, no significant differences in BCR-free survivals were observed among the group 2, 3, and 4 (all P > 0.05). In multivariate analysis, PSM (P = 0.009) was observed to be significantly associated with BCR-free survival among groups 1 and 2 combined. Among groups 3 and 4, pathologic Gleason score (P = 0.002), but not PSM (P = 0.668), was the only significant predictor for BCR-free survival in multivariate analysis.

CONCLUSIONS

According to our results, PSM is significantly associated with biochemical outcome after RP in pT2 prostate cancer. Meanwhile, patients with pT2 tumor and PSM appear to have comparable biochemical outcome compared with those with stage pT3a tumor independent of their marginal status.

Frequency of positive surgical margin at prostatectomy and its effect on patient outcome

A positive surgical margin at prostatectomy is defined as tumor cells touching the inked edge of the specimen. This finding is reported in 8.8% to 42% of cases (median about 20%) in various studies. It is one of the main determinants of eventual biochemical (PSA) failure, generally associated with a doubled or tripled risk of failure. The effect of a positive margin on outcome can be modified by stage or grade and the length, number and location of positive margins, as well as by technical operative approach and duration of operator experience. This paper tabulates data from the past decade of studies on margin status.

[Value of positive resection margins in patients with pT2 prostate cancer. Implications for adjuvant treatment]

OBJECTIVE

To analyse the impact on the recurrence-free biochemical survival of tumour involvement of surgical resection margins in patients with localized prostate cancer (pT2) in the prostatectomy specimen and its implications for adjuvant treatment.

MATERIALS AND METHOD

Retrospective study of 536 patients with stage pT2 prostate cancer, treated with radical prostatectomy between 1996 and 2007. Subsequent to the prostatectomy, the following variables were collected: Gleason score, pathological stage, capsular invasion, surgical margins and perineural invasion. We performed a univariate analysis and subsequently adjusted it by means of a Cox proportional hazard model (enter method).

RESULTS

21.7% presented positive surgical margins and 20.9% developed biochemical recurrence after a mean follow-up of 57 months. 37.9% of the patients with pathological involvement of the resection surgical margins presented biochemical recurrence against 16% that did not have it (p<0.001). In the multivariate analysis, only the surgical margin (p<0.001) and the Gleason score greater or equal to 8 (p<0.001) behaved as independent biochemical recurrence factors. On stratifying the series according to these two variables, we found that the patients with positive surgical margins and a Gleason score of ≤ 7 have a recurrence probability at 5 and 10 years of 35% and 50% against 74% and 87% in the group with positive surgical margins and a Gleason score of ≥ 8 (p=0.002).

CONCLUSION

Patients with pT2 prostate cancer, positive surgical margins and a Gleason score of ≥ 8 will benefit from adjuvant radiotherapy. 50% of the patients with positive margins and a Gleason score of ≤ 7 will not recur, which means that the indication of adjuvant radiotherapy continues to be controversial.

Stage-by-stage effects of surgical margin status on biochemical failure after radical prostatectomy in patients with clinically localized prostate cancer

PURPOSE

To evaluate the effects of pathological stage and surgical margin status on biochemical failure rates after radical prostatectomy (RP).

MATERIALS AND METHODS

The records of 205 patients who underwent RP for clinically localized prostate cancer (CaP) were evaluated. Known risk factors for biochemical failure (BF) were analyzed using univariate and multivariate logistic regression analysis. The effects of surgical margin status together with pathological stage on BF were evaluated. p values lower than 0.05 were accepted to be statistically significant.

RESULTS

Pathological stage, positive surgical margin (PSM), seminal vesicle invasion, lymph node involvement, biopsy Gleason score and postoperative Gleason score were the factors associated with BF in univariate analysis. Logistic regression analysis revealed that pT3a patients with PSM had a significant BF rate when compared to pT2 patients with a negative surgical margin (NSM) (OR 7.46, p = 0.002). pT3a patients with a NSM had a similar BF rate to that of pT2 patients with PSM.

CONCLUSIONS

pT2 patients with PSM had a similar biochemical prognosis to that of pT3a patients without PSM, implicating that a PSM may have a negative effect on prognosis similar to that of extracapsular invasion.

Prognostic relevance of number and bilaterality of positive surgical margins after radical prostatectomy

Purpose

Positive surgical margin (PSM) status following radical prostatectomy (RP) is a well-established prognostic factor. The aim of the present study is to evaluate whether number of PSMs or bilaterality of PSMs might have prognostic significance for biochemical recurrence (BCR) in the population with a PSM status following RP.

Methods

We evaluated 1,395 RP pathology reports from our center between 1980 and 2006. All patients who underwent (neo)-adjuvant therapy were excluded, leaving a cohort of 1,009 patients, with 249 (24.7%) subjects having a PSM at RP of whom 29.4% had multiple PSMs (≥ 2 sites), while 13.6% had bilateral PSMs. Median follow-up was 40 months (range 0–258 months). We used BCR-free survival as the primary study outcome. BCR was defined as any rise in PSA above or equal to 0.2 ng/ml.

Results

Of patients with a PSM status, 41% (95% CI: 33–49%) developed BCR within 5 years, compared to 12% (95% CI: 9–15%) in the population without a PSM. Multivariable analysis identified PSA at diagnosis and RP Gleason score as independent predictive factors for BCR. Increasing number and/or bilaterality of PSM did not lead to significant higher rates of BCR.

Conclusion

In patients with a PSM, the number of positive sites or bilaterality of PSM status does not add prognostic information for risk of BCR. Survival curve slopes were different for patients with bilateral PSM, showing a significant tendency to progress to BCR earlier during follow-up than patients with unilateral PSM.