The Positive Surgical Margin after Radical Prostatectomy—Why do we Still not Really Know What it Means?

Re-defining 18 F-DCFPyl prostate-specific membrane antigen positron emission tomography detected local recurrence from radical prostatectomy histopathology

OBJECTIVE

To assess topographic concordance between the histopathological features of patients' radical prostatectomy (RP) specimens and the location of the prostate-specific membrane antigen positron emission tomography (PSMA PET) local recurrences, qualitatively and quantitatively.

PATIENTS AND METHODS

Our cohort was selected from the 100 men who received a 18 F-DCFPyL PET scan in the IMPPORT trial (Australian New Zealand Clinical Trials Registry Number: ACTRN12618001530213), a prospective non-randomised study completed by GenesisCare Victoria. Eligibility included patients with a rising prostate-specific antigen (PSA) level (>0.2 ng/mL) after RP and PSMA PET detected local recurrence. Histopathological parameters collated included the location of tumour, extraprostatic extension (EPE), and positive margins. Criteria for the location and 'concordance' between histopathological features and local recurrences were pre-defined.

RESULTS

A total of 24 patients were eligible; the median age was 71 years, the median PSA level was 0.37 ng/mL, and the time between RP and PSMA PET was 2.6 years. In all, 15 patients had recurrences within the vesicourethral anastomotic region and nine within the lateral surgical margins. There was 100% concordance in the left-right plane between tumour location and local recurrence, with 79% of these lesions concordant three-dimensionally; across craniocaudal, left-right, and anterior-posterior planes. In all, 10 of the 16 (63%) patients with EPE and five of the nine patients with positive margins had three-dimensional concordance between their pathology and their local recurrence. In quantitative assessment, 17 of the 24 patients, had local recurrences that correlated with the location of their original tumour in the craniocaudal plane.

CONCLUSION

Local recurrence is highly concordant with the position of the tumour within the prostate. Predicting the location of local recurrence using the location of the EPE and positive margins is less helpful. Further investigation into this field, could impact surgical technique and salvage radiotherapy clinical target volume.

Indications for postoperative radiotherapy in patients with prostate cancer after surgery with positive surgical margins

AIM OF THE STUDY

Prostate cancer is the second most prevalent cancer among men in Poland. The main methods of radical treatment are radical prostatectomy and radiotherapy. In patients who have been correctly qualified for surgery, a positive surgical margin is always an unexpected and undesirable factor. The aim of this prospective study was to evaluate the incidence of positive margins in more than 100 consecutive patients with prostate cancer undergoing radical prostatectomy.

MATERIAL AND METHODS

The study included 114 patients aged 44-78 years (mean 61.5 years) who underwent surgery for prostate cancer in stage cT1-3N0/M0 (according to the TNM staging system) in the years 2010-2011 in the Clinical Department of Oncological Urology in the Center of Oncology in Bydgoszcz.

RESULTS

The presence of positive surgical margins was found in 45 (39.47%) patients, and in 20 (17.54%) margins were assessed as close (1-2 mm). Among the patients with positive surgical margins about 22% had biochemical recurrence. Among patients with negative surgical margins 13% of pT2c and 12.5% of pT3a had biochemical recurrence. Patients with positive surgical margins, along with patients diagnosed with tumor extending beyond the prostate (pT3a) or invading seminal vesicles (pT3b), are at an increased risk of recurrence and progression, reaching up to 30-50% over 10 years. The risk is 2-4 times higher than in patients without positive operating margins.

Stage migration in localized prostate cancer has no effect on the post-radical prostatectomy Kattan nomogram

OBJECTIVE

To investigate the effect of prostate-specific antigen (PSA) testing on stage migration in an Australian population, and its consequences on the prognostic accuracy of the post-radical prostatectomy (RP) Kattan nomogram, as in North America widespread PSA testing has resulted in prostate cancer stage migration, questioning the utility of prognostic nomograms in this setting.

PATIENTS AND METHODS

The study comprised 1008 men who had consecutive RP for localized prostate cancer between 1991 and 2001 at one institution. Two groups were assessed, i.e. those treated in 1991-96 (group 1, the early PSA era), and 1997-2001 (group 2, the contemporary PSA era). Differences in clinicopathological features between the groups were analysed by chi-squared testing and survival modelling. Individual patient data were entered into the post-RP Kattan nomogram and the efficacy assessed by receiver- operating characteristic curve analysis.

RESULTS

Patients in group 2 had lower pathological stage disease (P = 0.01) and fewer cancers with Gleason score > or =8 (P < 0.001) than group 1. Multivariate analysis identified preoperative serum PSA level (P < 0.01) and Gleason score (P < 0.01) as strong predictors of biochemical relapse in both groups. In group 2 pathological stage was not significant, but margin involvement became highly significant (P = 0.004). There was no difference in the predictive accuracy of the Kattan nomogram between the groups (P = 0.253).

CONCLUSIONS

These findings show a downward stage migration towards organ-confined disease after the introduction of widespread PSA testing in an Australian cohort. Despite this, the Kattan nomogram remains a robust prognostic tool in clinical practice.

Adverse prognostic impact of capsular incision at radical prostatectomy for Japanese men with clinically localized prostate cancer

OBJECTIVES

The objective of this study was to evaluate the significance of capsular incision (CI) at radical prostatectomy (RP) for men with prostate cancer.

MATERIALS AND METHODS

This study included 267 men who underwent RP without neoadjuvant therapy and were pathologically diagnosed as having organ-confined disease. CI was defined as exposing benign or malignant glands at the inked margin without documented extraprostatic extension.

RESULTS

Pathological examinations identified CI in 53 RP specimens (19.9%), while CI was not detected in the remaining 214 specimens (80.1%). The locations of CIs in RP specimens from these 53 patients were as follows: 39 (73.6%) at the apex, 11 (20.0%) at the anterior site, 4 (7.5%) at the posterior site and 12 (22.6%) at the bladder neck. The incidence of CI was significantly affected by surgical procedure, preoperative serum PSA and microvenous invasion in RP specimen. During the observation period of this study, biochemical recurrence occurred in 10 (18.9%) of the 53 with CI and 20 (9.3%) of the 214 without CI, and the biochemical recurrence-free survival in patients with CI was significantly poorer than those without CI. Furthermore, of several factors examined, biochemical recurrence was significantly associated with preoperative serum PSA, Gleason score, perineural invasion and capsular incision, among which only preoperative serum PSA appeared to be an independent predictor of biochemical recurrence.

CONCLUSIONS

Despite the lack of independent significance, the presence of CI has an adverse impact on biochemical outcome in patients undergoing RP for clinically localized prostate cancer.

Positive surgical margins after radical prostatectomy: do they have an impact on biochemical or clinical progression?

OBJECTIVE

To prospectively examine the effects of the margin status after radical prostatectomy (RP), the location, and the number of positive surgical margins (PSMs) on biochemical and clinical outcome, as even if there seems to be little debate that there is a higher risk of both local and distant recurrence of prostate cancer in the face of a PSM the significance of a PSM after RP is only followed for biochemical progression in most studies.

PATIENTS AND METHODS

From our prospective database, 406 consecutive well-described patients without neoadjuvant and 'direct postoperative' adjuvant therapy who underwent RP were included. The median age was 64.7 years, the median preoperative PSA level was 7.9 ng/mL, and the median follow-up was 5.2 years. We analysed pathological tumour stage, grading, number and location of PSMs, PSA-free survival, local recurrence-free survival, metastasis-free survival, prostate cancer-specific and, overall survival prospectively.

RESULTS

The overall rate of PSMs was 17.2%. The number was higher in higher stage (P < 0.001) and higher grade tumours (P = 0.041). For a PSM the PSA recurrence rate was 64.3%, the local recurrence rate was 18.6%, the development of distant metastasis was 15.7% and therefore much higher than in patients with negative margins (20.5%, 2.7%, and 1.5%). A PSM was an adverse predictor for PSA-free survival (P < 0.001), local recurrence-free survival (P = 0.002), and development of metastasis (P = 0.003) on multivariate analysis. The number and location of PSMs was of no additional prognostic value.

CONCLUSIONS

A PSM increases the risk of biochemical and clinical e.g. local, disease progression after RP. The number and location of PSMs is of minor importance. Although only approximately 20% of patients with a PSM will develop local recurrence, surgeons should continue to strive to reduce the rate of PSMs to improve cancer control.