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Evren I, Hacıislamoğlu A, Ekşi M, Yavuzsan AH, Baytekin F, Çolakoğlu Y, Canoğlu D, Tugcu V. The impact of single positive surgical margin features on biochemical recurrence after robotic radical prostatectomy. Int Braz J Urol 2019; 45:45-53. [PMID: 30325603 PMCID: PMC6442133 DOI: 10.1590/s1677-5538.ibju.2017.0702] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 06/11/2018] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Parameters predictive of biochemical or clinical recurrence after Radical Prostatectomy (RP) were determined as pre-treatment PSA value, pathologic tumor stage, tumor grade and presence of Positive Surgical Margin (PSM), extracapsular extension and seminal vesicle invasion and the status of pelvic lymph nodes. The aim of our study is to evaluate the effect of additional features in patients undergoing RP in our clinic. MATERIALS AND METHODS We studied 556 RP operations performed between 2009 and 2016 for prostate cancer at this clinic. Preoperative and postoperative data of the patients were retrospectively reviewed. RP specimens were examined by two pathologists specialized in this subject. Of these patients, 78 (14.02%) patients with PSM were included in the study. The pathology slides of these patients were reassessed. The length of PSM (mm), localization (apex, basis and posterolateral) and Gleason pattern at this margin was determined and statistical correlations with BCR were calculated. RESULTS The mean follow-up after the RP of 41 patients included in the study was 37.4 ± 13.2 months. During the follow-up period of the patients, BCR was observed in 16 patients (39.02%). No statistically significant difference was observed in age and prostate volume between the groups with and without BCR development (p > 0.05). Preoperative PSA level was found to be statistically significantly higher in the group with BCR development compared to the group without recurrence (p = 0.004). In-group comparisons in each aforementioned Gleason score groups were performed in terms of BCR development and the preoperative Gleason score in the group with development of recurrence was found to be statistically significantly higher compared to the group without recurrence (p = 0.007). The length of the surgical margin was measured as 7.4 ± 4.4 mm in the BCR-developing group and 4.7 ± 3.8 mm in the no-BCR- developing group; it was statistically significantly higher in the group with development of recurrence (p = 0.03). CONCLUSION Length and location of the PSM and the Gleason score detected in the PSM region could not predict biochemical recurrence according to the results of this present study. However high preoperative PSA value is an independent prognostic factor for biochemical recurrence.
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Affiliation(s)
- Ismail Evren
- Department of Urology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Hacıislamoğlu
- Department of Urology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Mithat Ekşi
- Department of Urology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Abdullah Hizir Yavuzsan
- Department of Urology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Firat Baytekin
- Department of Pathology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Yunus Çolakoğlu
- Department of Urology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Didem Canoğlu
- Department of Pathology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Volkan Tugcu
- Department of Urology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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Lipman D, Pieters BR, De Reijke TM. Improving postoperative radiotherapy following radical prostatectomy. Expert Rev Anticancer Ther 2017; 17:925-937. [PMID: 28787182 DOI: 10.1080/14737140.2017.1364994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Prostate cancer has one of the highest incidences in the world, with good curative treatment options like radiotherapy and radical prostatectomy. Unfortunately, about 30% of the patients initially treated with curative intent will develop a recurrence and need adjuvant treatment. Five randomized trials covered the role of postoperative radiotherapy after radical prostatectomy, but there is still a lot of debate about which patients should receive postoperative radiotherapy. Areas covered: This review will give an overview on the available literature concerning post-operative radiotherapy following radical prostatectomy with an emphasis on the five randomized trials. Also, new imaging techniques like prostate-specific membrane antigen positron emission tomography (PSMA-PET) and multiparametric magnetic resonance imaging (mp-MRI) and the development of biomarkers like genomic classifiers will be discussed in the search for an improved selection of patients who will benefit from postoperative radiotherapy following radical prostatectomy. With new treatment techniques like Intensity Modulated Radiotherapy, toxicity profiles will be kept low. Expert commentary: Patients with biochemical recurrence following radical prostatectomy with an early rise in prostate-specific antigen (PSA) will benefit most from postoperative radiotherapy. In this way, patients with only high risk pathological features can avoid unnecessary treatment and toxicity, and early intervention in progressing patients would not compromise the outcome.
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Affiliation(s)
- D Lipman
- a Department of Radiation Oncology , Academic Medical Center/University of Amsterdam , Amsterdam , The Netherlands
| | - B R Pieters
- a Department of Radiation Oncology , Academic Medical Center/University of Amsterdam , Amsterdam , The Netherlands
| | - Theo M De Reijke
- b Department of Urology , Academic Medical Center/University of Amsterdam , Amsterdam , The Netherlands
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Ohnuma H. 4. Pathology of Prostate Cancer. Nihon Hoshasen Gijutsu Gakkai Zasshi 2017; 73:571-577. [PMID: 28724869 DOI: 10.6009/jjrt.2017_jsrt_73.7.571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Hideyuki Ohnuma
- Department of Diagnostic Pathology, Shimane Prefectural Central Hospital
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4
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Long-term oncological outcomes of apical positive surgical margins at radical prostatectomy in the Shared Equal Access Regional Cancer Hospital cohort. Prostate Cancer Prostatic Dis 2016; 19:423-428. [DOI: 10.1038/pcan.2016.45] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 06/26/2016] [Accepted: 07/12/2016] [Indexed: 11/08/2022]
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5
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Kang SG, Schatloff O, Haidar AM, Samavedi S, Palmer KJ, Cheon J, Patel VR. Overall rate, location, and predictive factors for positive surgical margins after robot-assisted laparoscopic radical prostatectomy for high-risk prostate cancer. Asian J Androl 2016; 18:123-8. [PMID: 25966623 PMCID: PMC4736340 DOI: 10.4103/1008-682x.148723] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report the overall rate, locations and predictive factors of positive surgical margins (PSMs) in 271 patients with high-risk prostate cancer. Between April 2008 and October 2011, we prospectively collected data from patients classified as D'Amico high-risk who underwent robot-assisted laparoscopic radical prostatectomy. Overall rate and location of PSMs were reported. Stepwise logistic regression models were fitted to assess predictive factors of PSM. The overall rate of PSMs was 25.1% (68 of 271 patients). Of these PSM, 38.2% (26 of 68) were posterolateral (PL), 26.5% (18 of 68) multifocal, 16.2% (11 of 68) in the apex, 14.7% (10 of 68) in the bladder neck, and 4.4% (3/68) in other locations. The PSM rate of patients with pathological stage pT2 was 8.6% (12 of 140), 26.6% (17 of 64) of pT3a, 53.3% (32/60) of pT3b, and 100% (7 of 7) of pT4. In a logistic regression model including pre-, intra-, and post-operative parameters, body mass index (odds ratio [OR]: 1.09; 95% confidence interval [CI]: 1.01-1.19, P= 0.029), pathological stage (pT3b or higher vs pT2; OR: 5.14; 95% CI: 1.92-13.78; P = 0.001) and percentage of the tumor (OR: 46.71; 95% CI: 6.37-342.57; P< 0.001) were independent predictive factors for PSMs. The most common location of PSMs in patients at high-risk was the PL aspect, which reflects the reported tumor aggressiveness. The only significant predictive factors of PSMs were pathological outcomes, such as percentage of the tumor in the specimen and pathological stage.
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Affiliation(s)
| | | | | | | | | | | | - Vipul R Patel
- From the Global Robotics Institute, Florida Hospital Celebration Health, Celebration, and University of Central Florida School of Medicine, Orlando, Florida, USA
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Zhang H, Desai P, Koike Y, Houghton J, Carlin S, Tandon N, Touijer K, Weber WA. Dual-Modality Imaging of Prostate Cancer with a Fluorescent and Radiogallium-Labeled Gastrin-Releasing Peptide Receptor Antagonist. J Nucl Med 2016; 58:29-35. [PMID: 27516447 DOI: 10.2967/jnumed.116.176099] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 07/12/2016] [Indexed: 11/16/2022] Open
Abstract
Gastrin-releasing peptide (GRP) receptors (GRPr) are frequently overexpressed in human prostate cancer, and radiolabeled GRPr affinity ligands have shown promise for in vivo imaging of prostate cancer with PET. The goal of this study was to develop a dual-modality imaging probe that can be used for noninvasive PET imaging and optical imaging of prostate cancer. METHODS We designed and synthesized an IRDye 650 and DOTA-conjugated GRPr antagonist, HZ220 (DOTA-Lys(IRDye 650)-PEG4-[D-Phe6, Sta13]-BN(6-14)NH2), by reacting DOTA-Lys-PEG4-[D-Phe6, Sta13]-BN(6-14)NH2 (HZ219) with IRDye 650 N-hydroxysuccinimide (NHS) ester. Receptor-specific binding of gallium-labeled HZ220 was characterized in PC-3 prostate cancer cells (PC-3), and tumor uptake in mice was imaged with PET/CT and fluorescence imaging. Receptor binding affinity, in vivo tumor uptake, and biodistribution were compared with the GRPr antagonists HZ219, DOTA-PEG4-[D-Phe6, Sta13]-BN(6-14)NH2 (DOTA-AR), and DOTA-(4-amino-1-carboxymethyl-piperidine)-[D-Phe6, Sta13]-BN(6-14)NH2 (DOTA-RM2). RESULTS After hydrophilic-lipophilic balance cartridge purification, 68Ga-HZ220 was obtained with a radiochemical yield of 56% ± 8% (non-decay-corrected), and the radiochemical purity was greater than 95%. Ga-HZ220 had a lower affinity for GRPr (inhibitory concentration of 50% [IC50], 21.4 ± 7.4 nM) than Ga-DOTA-AR (IC50, 0.48 ± 0.18 nM) or Ga-HZ219 (IC50, 0.69 ± 0.18 nM). Nevertheless, 68Ga-HZ220 had an in vivo tumor accumulation similar to 68Ga-DOTA-AR (4.63 ± 0.31 vs. 4.07 ± 0.29 percentage injected activity per mL [%IA/mL] at 1 h after injection) but lower than that of 68Ga-DOTA-RM2 (10.4 ± 0.4 %IA/mL). The tumor uptake of 68Ga-HZ220 was blocked significantly with an excessive amount of GRP antagonists. IVIS spectrum imaging also visualized PC-3 xenografts in vivo and ex vivo with a high-contrast ratio. Autoradiography and fluorescent-based microscopic imaging with 68Ga-HZ220 consistently colocated the expression of GRPr. 68Ga-HZ220 displayed a higher kidney uptake than both 68Ga-DOTA-AR and 68Ga-DOTA-RM2 (16.9 ± 6.5 vs. 4.48 ± 1.63 vs. 5.01 ± 2.29 %IA/mL). CONCLUSION 68Ga-HZ220 is a promising bimodal ligand for noninvasive PET imaging and intraoperative optical imaging of GRPr-expressing malignancies. Bimodal nuclear/fluorescence imaging may not only improve cancer detection and guide surgical resections, but also improve our understanding of the uptake of GRPr ligands on the cellular level.
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Affiliation(s)
- Hanwen Zhang
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Pooja Desai
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yusuke Koike
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Jacob Houghton
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean Carlin
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nidhi Tandon
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Karim Touijer
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Wolfgang A Weber
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York .,Molecular Pharmacology and Chemistry Program, Memorial Sloan Kettering Cancer Center, New York, New York
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Kang YJ, Abalajon MJ, Jang WS, Kwon JK, Yoon CY, Lee JY, Cho KS, Ham WS, Choi YD. Association of Anterior and Lateral Extraprostatic Extensions with Base-Positive Resection Margins in Prostate Cancer. PLoS One 2016; 11:e0158922. [PMID: 27391650 PMCID: PMC4938503 DOI: 10.1371/journal.pone.0158922] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 06/23/2016] [Indexed: 12/01/2022] Open
Abstract
Introduction Positive surgical margins (PSM) detected in the radical prostatectomy specimen increase the risk of biochemical recurrence (BCR). Still, with formidable number of patients never experiencing BCR in their life, the reason for this inconsistency has been attributed to the artifacts and to the spontaneous regression of micrometastatic site. To investigate the origin of margin positive cancers, we have looked into the influence of extraprostatic extension location on the resection margin positive site and its implications on BCR risk. Materials & Methods The clinical information and follow-up data of 612 patients who had extraprostatic extension and positive surgical margin at the time of robot assisted radical prostatectomy (RARP) in the single center between 2005 and 2014 were modeled using Fine and Gray’s competing risk regression analysis for BCR. Extraprostatic extensions were divided into categories according to location as apex, base, anterior, posterior, lateral, and posterolateral. Extraprostatic extensions were defined as presence of tumor beyond the borders of the gland in the posterior and posterolateral regions. Tumor admixed with periprostatic fat was additionally considered as having extraprostatic extension if capsule was vague in the anterior, apex, and base regions. Positive surgical margins were defined as the presence of tumor cells at the inked margin on the inspection under microscopy. Association of these classifications with the site of PSM was evaluated by Cohen’s Kappa analysis for concordance and logistic regression for the odds of apical and base PSMs. Results Median follow-up duration was 36.5 months (interquartile range[IQR] 20.1–36.5). Apex involvement was found in 158 (25.8%) patients and base in 110 (18.0%) patients. PSMs generally were found to be associated with increased risk of BCR regardless of location, with BCR risk highest for base PSM (HR 1.94, 95% CI 1.40–2.68, p<0.001) after adjusting for age, initial prostate-specific antigen, pathologic Gleason score, and pathologic T stage in the multivariate model. Logistic regression for PSM site revealed no significant correlation of apex PSM with extraprostatic extension location, while base PSM was associated with increased odds of anterior (OR 2.513, 95% CI 1.425–4.430, p = 0.001) and lateral (OR 2.715, 95% CI 1.735–4.250, p<0.001) extraprostatic extension. Conclusion Extension into the extraprostatic tissue on some specific locations do not share the same recur risk due to the different anatomical structures surrounding the organ. Anterior and lateral EPEs are prone to leave PSM on the base of the prostate, probably because of the lack of anatomical barricades slowing down the direct invasion process. More study on the pattern of spread of the tumors found to have extraprostatic extension is suggested for optimal planning of the operation extent and of the adjuvant radiotherapy.
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Affiliation(s)
- Yong Jin Kang
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Mark Joseph Abalajon
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Won Sik Jang
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Kyou Kwon
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Cheol Yong Yoon
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joo Yong Lee
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kang Su Cho
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Won Sik Ham
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Deuk Choi
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
- * E-mail:
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Sooriakumaran P, Dev HS, Skarecky D, Ahlering T. The importance of surgical margins in prostate cancer. J Surg Oncol 2016; 113:310-5. [DOI: 10.1002/jso.24109] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 11/14/2015] [Indexed: 11/07/2022]
Affiliation(s)
| | - Harveer S. Dev
- Department of Urology; University of Cambridge; Cambridge United Kingdom
| | - Douglas Skarecky
- Department of Urology; University of California; Irvine California
| | - Thomas Ahlering
- Department of Urology; University of California; Irvine California
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Schade GR, Wright JL, Lin DW. Prognostic Significance of Positive Surgical Margins and Other Implications of Pathology Report. Prostate Cancer 2016. [DOI: 10.1016/b978-0-12-800077-9.00033-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Turo R, Bromage S, Smolski M, Thygesen H, Cleaveland P, Esler R, Hartley S, Thompson A, Adeyoju A, Brown SCW, Brough R, Oakley N, Sinclair A, Collins GN. The changes in prostate cancer and its management in the North West of England over a 10-year period. JOURNAL OF CLINICAL UROLOGY 2015. [DOI: 10.1177/2051415815575218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Objectives: Our aim was to evaluate changes in prostate cancer diagnosis and management and to examine changes in the stage and grade of newly diagnosed prostate cancer in the North West of England over a 10-year period. Materials and methods: Data was collected concerning the diagnosis (including stage and grade) and management of newly diagnosed prostate cancer in the North West of England. There were three time points: 2003, 2007 and 2011 including a total of 648 patients. For assessment of median time changes Spearman’s Rank correlation test was used, for the assessment of changes in Gleason grade and clinical stage Mann–Whitney U test was used, and assessment of positive margin rates was done with Fisher’s test. Results: Median time from management decision to surgery has reduced from 46 (2003), 34 (2007) to 27 days (2011) ( p=0.074). The proportion of patients managed with active surveillance has remained relatively constant over time (18%, 16% and 21% respectively). More minimally invasive, nerve-sparing prostatectomies are now performed, and positive margin rates have significantly reduced from 53% (2003) to 23% (2011) ( p<0.001). Gleason grade significantly increased over time ( p<0.001); Gleason 7 disease was diagnosed in 23% of patients in 2003, 32% in 2007 and 49% in 2011 ( p<0.001). There was an increase in Gleason 8 disease; 6% (2003) to 8.6% (2011), but this was not significant ( p=0.27). Increase in clinical stage was also noted over time; identification of T3 disease rose from 2% (2003 and 2007) to 5% (2011) ( p=0.045) (excluding cases with non-recorded stage). Conclusion: Prostate cancer management in the North West of England has evolved over the last decade, with overall improvements in management quality. We have demonstrated an increase in the presenting stage and grade of prostate cancer over a 10-year period.
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Affiliation(s)
- R Turo
- Department of Urology, Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, UK
| | - S Bromage
- Department of Urology, Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, UK
| | - M Smolski
- Department of Urology, Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, UK
| | - H Thygesen
- Section of Experimental Oncology, Leeds Institute of Cancer Studies and Pathology, St James’s University Hospital, UK
| | - P Cleaveland
- Department of Urology, Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, UK
| | - R Esler
- Department of Urology, Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, UK
| | - S Hartley
- Department of Urology, Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, UK
| | - A Thompson
- Department of Urology, Wrightington, Wigan and Leigh NHS Foundation Trust, Royal Albert Edward Infirmary, Wigan, UK
| | - A Adeyoju
- Department of Urology, Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, UK
| | - SCW Brown
- Department of Urology, Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, UK
| | - R Brough
- Department of Urology, Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, UK
| | - N Oakley
- Department of Urology, Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, UK
| | - A Sinclair
- Department of Urology, Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, UK
| | - GN Collins
- Department of Urology, Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, UK
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Effect of positive surgical margins on biochemical failure, biochemical recurrence-free survival, and overall survival after radical prostatectomy: Median long-term results. Kaohsiung J Med Sci 2014; 30:510-4. [DOI: 10.1016/j.kjms.2014.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 01/23/2014] [Accepted: 02/05/2014] [Indexed: 11/19/2022] Open
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12
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Ploussard G, Drouin SJ, Rode J, Allory Y, Vordos D, Hoznek A, Abbou CC, de la Taille A, Salomon L. Location, extent, and multifocality of positive surgical margins for biochemical recurrence prediction after radical prostatectomy. World J Urol 2014; 32:1393-400. [DOI: 10.1007/s00345-014-1243-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 01/13/2014] [Indexed: 10/25/2022] Open
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13
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Presence of positive surgical margin in patients with organ-confined prostate cancer equals to extracapsular extension negative surgical margin. A plea for TNM staging system reclassification. Urol Oncol 2013; 31:1497-503. [DOI: 10.1016/j.urolonc.2012.04.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 04/14/2012] [Accepted: 04/16/2012] [Indexed: 11/21/2022]
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Do robotic prostatectomy positive surgical margins occur in the same location as extraprostatic extension? World J Urol 2013; 32:761-7. [PMID: 24096432 DOI: 10.1007/s00345-013-1149-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 08/06/2013] [Indexed: 10/26/2022] Open
Abstract
PURPOSE Positive surgical margins (PSMs) may reflect incomplete surgical resection, while extraprostatic extension (EPE) could suggest that complete tumor resection is more difficult. This study evaluated cases with both EPE and PSMs in robotic-assisted radical prostatectomy (RARP) specimens to determine the respective locations of each. METHODS A single institutional retrospective review of RARP performed between 2007 and 2009 was conducted to identify cases with both EPE and PSM. Prostates were entirely submitted and processed in whole mount format. All locations of EPE and PSM were recorded as was the size of the largest focus of EPE and PSM. RESULTS About 8.5 % (112/1,315) of RARP had both EPE and PSM. Analysis of cases with concurrent EPE and PSM revealed that EPE occurred most commonly in the mid-gland, particularly in the posterolateral mid-prostate. In contrast, PSM was most frequent at the base (bladder neck), specifically the anterior base. 51.8 % of the cases had EPE and PSM in discordant locations, 19.6 % had EPE and PSM in the same location, and 28.6 % had areas of EPE and PSM both in the same location as well as in different locations. Cases with both concordant and discordant locations of EPE and PSM had significantly more high-risk features including higher tumor volume, more frequent positive nodes, and more frequent Gleason score ≥ 8 compared to concordant or discordant subgroups. CONCLUSION PSMs frequently did not occur in the same location as EPE. A better understanding of where EPE and PSMs occur may help guide surgical technique to decrease residual tumor.
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Swanson GP, Lerner SP. Positive margins after radical prostatectomy: Implications for failure and role of adjuvant treatment. Urol Oncol 2013; 31:531-41. [DOI: 10.1016/j.urolonc.2011.06.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 05/20/2011] [Accepted: 06/13/2011] [Indexed: 11/29/2022]
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McClure TD, Margolis DJA, Reiter RE, Sayre JW, Thomas MA, Nagarajan R, Gulati M, Raman SS. Use of MR Imaging to Determine Preservation of the Neurovascular Bundles at Robotic-assisted Laparoscopic Prostatectomy. Radiology 2012; 262:874-83. [DOI: 10.1148/radiol.11103504] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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17
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Cheng L, Montironi R, Bostwick DG, Lopez-Beltran A, Berney DM. Staging of prostate cancer. Histopathology 2011; 60:87-117. [DOI: 10.1111/j.1365-2559.2011.04025.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Santos PB, Graça B, Lourenço M, Coelho MF, Ribeiro F, Fonseca J, Cardoso AP, Varregoso J, Ferrito F, Gomes FC. Impact of positive surgical margins on biochemical relapse after radical retropubic prostatectomy (RRP). Cent European J Urol 2011; 64:223-8. [PMID: 24578898 PMCID: PMC3921750 DOI: 10.5173/ceju.2011.04.art7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Revised: 09/07/2011] [Accepted: 09/12/2011] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION RP (radical prostatectomy) technique continues the major treatment option for men with potential cure and life expectancy exceeding 10 years. The aim of the study is to assess the impact of PSM on BR (biochemical relapse), to identify PSM risk factors, to clarify the factors involved in BR in the absence of PSM. MATERIAL AND METHODS Consultation of 171 medical-records from patients submitted to RRP (radical retropubic prostatectomy) between January/2000-December/2005. Mean-age: 64 yr. Mean - PSA (positive surgical margin): 11.88 ng/ml. Clinical staging: 67.8% cT1, 32.2% cT2. GS: ≤6 (66.1%), =7 (21.1%), 8-10 (12.3%). PS: pT0 1.2%, pT2 50.3%, pT3a 36.3%, pT3b 12.9%, pT4 0.6%. pathological Gleason score: ≤6 39.2%, =7 40.9%, 8-10 19.3%. RB definition was PSA ≥0.2 ng/ml. Adjusted Odds-Ratios with 95% confidence intervals (CI) were estimated through univariate logistic regression. RESULTS There were PSM in 46 specimens, 28 had single PSM and 18 multiple PSM (≥2). BR occurred in 57 patients (33.3%), with an average time after surgery of 23.5 months - 26 patients had PSM and 31 had not. Statistical significant results for BR in variables PSA, PS and PSM. Quadruples if PSM (p <0.0001), triples in single PSM (p = 0.01) and is 6x higher in multiple PSM (p = 0.001). Regarding factors that influence the presence of PSM, only PS ≥pT3a reach statistical significance (p <0.0001). Patients with BR but without PSM (54.38%), variables statistically significant were: initial PSA >10, (p = 0.029) and pathological Gleason score ≥8 with a risk nearly 4x higher than pathological Gleason score ≤6 (p = 0.027). CONCLUSIONS Statistical risk analysis concluded that the presence of PSM in RRP is strongly influenced by PS ≥pT3a. The presence of PSM and their number increase significantly the risk of BR compared to other factors. In the absence of PSM, the factors that seem to be crucial and with greater impact on BR are initial PSA>10 and pathological Gleason score ≥8.
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Affiliation(s)
- Pedro Bargão Santos
- Department of Urology, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Bruno Graça
- Department of Urology, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Miguel Lourenço
- Department of Urology, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | | | - Fernando Ribeiro
- Department of Urology, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Júlio Fonseca
- Department of Urology, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - A Pepe Cardoso
- Department of Urology, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - João Varregoso
- Department of Urology, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Fernando Ferrito
- Department of Urology, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
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Alkhateeb SS, Alibhai SM, Finelli A, Fleshner NE, Jewett MA, Zlotta AR, Trachtenberg J. Does nerve-sparing radical prostatectomy increase the risk of positive surgical margins and biochemical progression? Urol Ann 2011; 2:58-62. [PMID: 20882155 PMCID: PMC2943681 DOI: 10.4103/0974-7796.65107] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2010] [Accepted: 05/31/2010] [Indexed: 11/05/2022] Open
Abstract
Background: Since the introduction of nerve-sparing radical prostatectomy (NSRP), there have been concerns about the increased risks of positive surgical margins (PSM) and biochemical progression (BP). We examined the relationship of NSRP with PSM and BP using a large, mature dataset. Materials and Methods: Patients who underwent RP for clinically localized prostate cancer at our center between 1997 and 2008 were identified. Patients who received neoadjuvant therapy were excluded. We examined the relation of NSRP to the rate of PSM and BP in univariate and multivariate analyses adjusting for clinical and pathological variables including age, pretreatment prostate-specific antigen (PSA) levels and doubling time, and pathological stage and grade. Results: In total, 856 patients were included, 70.9% underwent NSRP and 29.1% had non-NSRP. PSM rates were 13.5% in the NSRP group compared to 17.7% in non-NSRP (P=0.11). In a multivariate analysis, non-NSRP was preformed in patients with a higher pathological stage (HR 1.95, 95% CI 1.25–3.04, P=0.003) and a higher baseline PSA level (HR 1.04, 95% CI 1.01–1.08, P=0.005). With a median follow-up of 41 months, BP-free survival was 88% for non-NSRP compared to 92% for the NSRP group (log rank P=0.018); this difference was not significant in a multivariate Cox regression analysis (HR 0.54, 95% CI 0.28–1.06, P=0.09). Conclusion: When used in properly selected patients, NSRP does not seem to increase the risk of PSM and disease progression. The most effective way of resolving this issue is through a randomized clinical trial; however, such a trial is not feasible.
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Affiliation(s)
- Sultan Saud Alkhateeb
- Division of Urology, Department of Surgical Oncology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Canada
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Surgical margin status of specimen and oncological outcomes after laparoscopic radical prostatectomy: experience after 400 procedures. World J Urol 2011; 30:245-50. [PMID: 21698420 DOI: 10.1007/s00345-011-0711-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 05/29/2011] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To analyse the surgical margins status of prostatic glands, resected by laparoscopic radical prostatectomy (LRP) for prostate cancer, and to correlate it with biochemical free survival rate (BFSR). METHODS Data were collected prospectively from 405 patients undergoing LRP from 2000 to 2009 at a single institution. Patients undergoing neoadjuvant and/or adjuvant therapy were excluded from the study. Three hundred patients matched all the criteria: 232 of these had negative surgical margins (NSM) and 68 positive surgical margins (PSM). The median follow-up was 62 months. PSM were classified based on the following: (a) the number of margins, monofocal and multifocal, (b) the location, apical or non-apical and (c) the extension, ≤2.8 mm or >2.8 mm. These data were then entered into a multivariate analysis. RESULTS Overall BFSR rate was 67.6% in PSM group and 88.8% in NSM group (P < 0.001). We registered a HR of 3.78 in multivariate analysis (P < 0.001). In terms of the extension, BFSR in univariate survival analysis was 77.8% in ≤2.8 mm PSM and 38.9% in >2.8 mm PSM (P = 0.003), with a HR of 5.68 (P = 0.011) in multivariate analysis. BFSR was 59% for apical margins and 77% for non-apical margins (P = 0.038). In monofocal margins, BFSR was 73%, while 53% in multifocal (P = 0.014). CONCLUSIONS We recommend careful evaluation of patients with PSM following LRP, especially if they are more than 2.8 mm, and in these cases, adjuvant therapy should be considered after radical surgery.
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Ye H, Kong X, He TW, Jolis T, Choi K, Lepor H, Melamed J. Intraoperative frozen section analysis of urethral margin biopsies during radical prostatectomy. Urology 2011; 78:399-404. [PMID: 21624646 DOI: 10.1016/j.urology.2011.03.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 03/11/2011] [Accepted: 03/13/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To evaluate the accuracy and potential clinical value of intraoperative frozen section analysis (FSA) on urethral margin (UM) tissue during radical prostatectomy. Positive surgical margins increase the risk of post-operative cancer recurrence. Positive surgical margins are frequently found at the apex. The utility of intraoperative FSA of the margins is controversial. METHODS We reviewed a consecutive series of radical prostatectomy cases (n = 1669) performed at our institution, in which UMs were routinely evaluated by intraoperative FSA. RESULTS The submitted UM tissue contained cancer glands in 111 cases (6.7%). On FSA, the pathologists detected cancer in 55 cases (3.3%), missed cancer in 38 (2.3%), and reported atypical glands in 18 (1.1%). FSA of the UMs had a sensitivity of 59.1%, specificity of 99.8%, and positive and negative predictive value of 94.8% and 97.6%, respectively. The low sensitivity resulted from a substantial false-negative rate (n = 38), which was largely attributed to limited sampling on FSA (n = 31). Of the 55 patients (3.3%) whose positive UMs were detected by FSA, 20 (1.2%) had cancer-free margins after tissue re-excision. A positive final UM was associated with greater biochemical recurrence (P = .0073). However, the few patients limited the statistical analysis of the benefit of margin conversion through tissue re-excision (P = .35). CONCLUSIONS Although experienced pathologists can evaluate the UMs on FSA with good accuracy, FSA has a relatively low sensitivity. Our data have indicated a low yield and a questionable value of routine FSA during radical prostatectomy.
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Affiliation(s)
- Huihui Ye
- Department of Pathology, New York University School of Medicine, New York, New York 10016, USA
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Psutka SP, Feldman AS, Rodin D, Olumi AF, Wu CL, McDougal WS. Men with organ-confined prostate cancer and positive surgical margins develop biochemical failure at a similar rate to men with extracapsular extension. Urology 2011; 78:121-5. [PMID: 21411125 DOI: 10.1016/j.urology.2010.10.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Revised: 10/11/2010] [Accepted: 10/16/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To define the role of positive surgical margins (PSMs) after radical retropubic prostatectomy as a predictor of biochemical failure (BCF) in prostate cancer with respect to pathologic stage. METHODS A retrospective cohort study of 300 patients who had undergone radical retropubic prostatectomy from 1993 to 1995 was performed. The role of margin status and the length of the PSM in the progression to BCF was defined after controlling for the preoperative prostate-specific antigen level, Gleason score, tumor stage, tumor volume, seminal vesical invasion, lymphovascular invasion, and perineural invasion using a multivariate regression model. The median follow-up time was 12 years. RESULTS The presence of PSMs correlated with a shorter time to BCF in men with Stage pT2 disease (P<.0001) but not in men with Stage pT3 disease (P=.66). Of the patients with Stage pT2 disease and PSMs, the PSM length did not correlate with progression to BCF. PSMs predicted a shorter time to progression to BCF in patients with high- and low-volume pT2 disease (P=.0261 and P=.0003, respectively). Only PSMs predicted a shorter time to BCF on multivariate analysis in patients with Stage pT2 cancer (hazard ratio 2.33, 95% confidence interval 1.495-3.723). In patients with Stage pT3 disease, PSMs were not associated with an increased risk of BCF (hazard ratio 0.747, 95% confidence interval 0.328-1.703). CONCLUSIONS Surgical margin status did not affect the risk of BCF in patients with Stage pT3a disease; however, it did affect patients with Stage pT2 disease, irrespective of PSM length or disease volume. During 12 years of follow-up, the patients with PSMs and Stage pT2 disease had a risk of BCF similar to that of the patients with Stage pT3 disease.
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Affiliation(s)
- Sarah P Psutka
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA
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Gillitzer R, Thüroff C, Fandel T, Thomas C, Thüroff JW, Brenner W, Wiesner C, Jones J, Hansen T, Hampel C. Intraoperative peripheral frozen sections do not significantly affect prognosis after nerve-sparing radical prostatectomy for prostate cancer. BJU Int 2010; 107:755-759. [DOI: 10.1111/j.1464-410x.2010.09591.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Fleshner NE, Evans A, Chadwick K, Lawrentschuk N, Zlotta A. Clinical significance of the positive surgical margin based upon location, grade, and stage. Urol Oncol 2010; 28:197-204. [DOI: 10.1016/j.urolonc.2009.08.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Alkhateeb S, Alibhai S, Fleshner N, Finelli A, Jewett M, Zlotta A, Nesbitt M, Lockwood G, Trachtenberg J. Impact of positive surgical margins after radical prostatectomy differs by disease risk group. J Urol 2010; 183:145-50. [PMID: 19913824 DOI: 10.1016/j.juro.2009.08.132] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Indexed: 11/15/2022]
Abstract
PURPOSE Positive surgical margins have a negative impact on disease outcomes after radical prostatectomy, yet their prognostic value may vary depending on specific pathological characteristics. We examined the relationship of positive surgical margins to biochemical progression according to several clinicopathological features. MATERIALS AND METHODS We analyzed data from 1,268 patients who underwent radical prostatectomy for clinically localized prostate cancer at our center between 1992 and 2008, and did not receive any neoadjuvant or adjuvant treatment. We examined the relation of age, pretreatment prostate specific antigen, pathological T stage, radical prostatectomy Gleason score, disease risk group and surgical margin status to biochemical progression-free survival. RESULTS The overall positive surgical margin rate was 20.8% and median followup was 79 months. The impact of positive surgical margins was dependent on risk group. Biochemical progression-free survival was 99.6% for the negative surgical margin group vs 94.9% for the positive surgical margin group in low risk disease (log rank p = 0.53), 93.5% for the negative surgical margin group vs 83% for the positive surgical margin group in intermediate risk disease (log rank p <0.001) and 78.5% for the negative surgical margin group vs 57.1% for the positive surgical margin group in high risk disease (log rank p = 0.003). These differences remained significant in a multivariate Cox regression model adjusting for other clinicopathological features. CONCLUSIONS Positive surgical margins are an independent predictor of biochemical progression in patients with intermediate and high risk prostate cancer. Patients with low risk disease have a favorable long-term outcome regardless of margin status and may be candidates for expectant management even with positive surgical margins, sparing them the side effects and costs of treatment.
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Affiliation(s)
- Sultan Alkhateeb
- Division of Urology, Department of Surgical Oncology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Canada
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Impact of Positive Apical Surgical Margins on Likelihood of Biochemical Recurrence After Radical Prostatectomy. J Urol 2009; 182:2695-701. [DOI: 10.1016/j.juro.2009.08.054] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Indexed: 11/21/2022]
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Thanigasalam R, Rasiah KK, Stricker PD, Haynes AM, Sutherland SIM, Sutherland RL, Henshall SM, Horvath LG. Stage migration in localized prostate cancer has no effect on the post-radical prostatectomy Kattan nomogram. BJU Int 2009; 105:642-7. [PMID: 19751263 DOI: 10.1111/j.1464-410x.2009.08842.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Ruban Thanigasalam
- Cancer Research Program, Garvan Institute of Medical Research, Sydney, Australia
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Stephenson AJ, Wood DP, Kattan MW, Klein EA, Scardino PT, Eastham JA, Carver BS. Location, extent and number of positive surgical margins do not improve accuracy of predicting prostate cancer recurrence after radical prostatectomy. J Urol 2009; 182:1357-63. [PMID: 19683274 DOI: 10.1016/j.juro.2009.06.046] [Citation(s) in RCA: 153] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Indexed: 11/30/2022]
Abstract
PURPOSE Positive surgical margins increase the risk of biochemical recurrence after radical prostatectomy by 2 to 4-fold. The risk of biochemical recurrence may be influenced by the anatomical location and extent of positive surgical margins. In a multicenter study we analyzed the predictive usefulness of several subclassifications of positive surgical margins. MATERIALS AND METHODS The clinical information and followup data of 7,160 patients treated with radical prostatectomy alone at 1 of 3 institutions between 1995 and 2006 were modeled using Cox proportional hazards regression analysis for biochemical recurrence. Positive surgical margins were analyzed as solitary vs multiple, focal vs extensive and apical location vs other. The usefulness of these subclassifications was assessed by the improvement in predictive accuracy of nomograms containing these parameters compared to one in which the surgical margin was modeled simply as positive vs negative. RESULTS The 7-year progression-free probability was 60% in patients with positive surgical margins. A positive surgical margin was significantly associated with biochemical recurrence (HR 2.3, p <0.001) after adjusting for age, prostate specific antigen, pathological Gleason score, pathological stage and year of surgery. An increased risk of biochemical recurrence was associated with multiple vs solitary positive surgical margins (adjusted HR 1.4, p = 0.002) and extensive vs focal positive surgical margins (adjusted HR 1.3, p = 0.004) on multivariable analysis. However, neither parameter improved the predictive accuracy of a nomogram compared to one in which surgical margin status was modeled as positive vs negative (concordance index 0.851 vs 0.850 vs 0.850). CONCLUSIONS The number and extent of positive surgical margin significantly influence the risk of biochemical recurrence after radical prostatectomy. However, the empirical prognostic usefulness of subclassifications of positive surgical margins is limited.
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Affiliation(s)
- Andrew J Stephenson
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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Sasaki H, Miki J, Kimura T, Sanuki K, Miki K, Takahashi H, Egawa S. Lateral view dissection of the prostato-urethral junction to reduce positive apical margin in laparoscopic radical prostatectomy. Int J Urol 2009; 16:664-9. [DOI: 10.1111/j.1442-2042.2009.02328.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ha US, Kim SI, Kim SJ, Cho HJ, Hong SH, Lee JY, Kim JC, Kim SW, Hwang TK. Oncologic Outcome following Laparoscopic Radical Prostatectomy and the Difference in Oncologic Outcomes according to the Site of the Positive Margin: Comparison of the Apical Positive Margin with the Non-Apical Positive Margin. Korean J Urol 2009. [DOI: 10.4111/kju.2009.50.10.955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- U-Syn Ha
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Sung In Kim
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Su Jin Kim
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hyuk-Jin Cho
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Sung-Hoo Hong
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Ji Youl Lee
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Joon Chul Kim
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Sae Woong Kim
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Tae-Kon Hwang
- Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Korea
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Guru KA, Perlmutter AE, Sheldon MJ, Butt ZM, Zhang S, Tan W, Wilding G, Kim HL, Mohler JL. Apical Margins after Robot-Assisted Radical Prostatectomy: Does Technique Matter? J Endourol 2009; 23:123-7. [DOI: 10.1089/end.2008.0398] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Khurshid A. Guru
- Department of Urologic Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Adam E. Perlmutter
- Department of Urologic Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Matthew J. Sheldon
- School of Medicine and Biomedical Sciences, State University of New York, Buffalo, New York
| | - Zubair M. Butt
- Department of Urologic Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Shaozeng Zhang
- Department of Pathology, Roswell Park Cancer Institute, Buffalo, New York
| | | | - Gregory Wilding
- Department of Biostatistics, Roswell Park Cancer Institute Buffalo, New York
| | - Hyung L. Kim
- Department of Urologic Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - James L. Mohler
- Department of Urologic Oncology, Roswell Park Cancer Institute, Buffalo, New York
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Pfitzenmaier J, Pahernik S, Tremmel T, Haferkamp A, Buse S, Hohenfellner M. Positive surgical margins after radical prostatectomy: do they have an impact on biochemical or clinical progression? BJU Int 2008; 102:1413-8. [PMID: 18537951 DOI: 10.1111/j.1464-410x.2008.07791.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Jesco Pfitzenmaier
- Department of Urology, Medical Center, University of Heidelberg, Heidelberg, Germany.
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Van der Kwast TH, Bolla M, Van Poppel H, Van Cangh P, Vekemans K, Da Pozzo L, Bosset JF, Kurth KH, Schröder FH, Collette L. Identification of Patients With Prostate Cancer Who Benefit From Immediate Postoperative Radiotherapy: EORTC 22911. J Clin Oncol 2007; 25:4178-86. [PMID: 17878474 DOI: 10.1200/jco.2006.10.4067] [Citation(s) in RCA: 226] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The randomized controlled European Organisation for Research and Treatment of Cancer (EORTC) trial 22911 studied the effect of radiotherapy after prostatectomy in patients with adverse risk factors. Review pathology data of specimens from participants in this trial were analyzed to identify which factors predict increased benefit from adjuvant radiotherapy. Patients and Methods After prostatectomy, 1,005 patients with stage pT3 and/or positive surgical margins were randomly assigned to a wait-and-see (n = 503) and an adjuvant radiotherapy (60 Gy conventional irradiation) arm (n = 502). Pathologic review data were available for 552 patients from 11 participating centers. The interaction between the review pathology characteristics and treatment benefit was assessed by log-rank test for heterogeneity (P < .05). Results Margin status assessed by review pathology was the strongest predictor of prolonged biochemical disease-free survival with immediate postoperative radiotherapy (heterogeneity, P < .01): by year 5, immediate postoperative irradiation could prevent 291 events/1,000 patients with positive margins versus 88 events/1,000 patients with negative margins. The hazard ratio for immediate irradiation was 0.38 (95% CI, 0.26 to 0.54) and 0.88 (95% CI, 0.53 to 1.46) in the groups with positive and negative margins, respectively. We could not identify a significant impact of the positive margin localization. Conclusion Provided careful pathology of the prostatectomy is performed, our results suggest that immediate postoperative radiotherapy might not be recommended for prostate cancer patients with negative surgical margins. These findings require validation on an independent data set.
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Affiliation(s)
- Theodorus H Van der Kwast
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital and University Health Network, Toronto, Canada.
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Kübler HR, Szukala SA, Madden JF, Tseng TY, Paulson DF, Vieweg J, Dahm P. Apical soft tissue biopsies predict biochemical failure in radical perineal prostatectomy patients with apical cancer involvement. Prostate Cancer Prostatic Dis 2006; 10:72-6. [PMID: 17179978 DOI: 10.1038/sj.pcan.4500926] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The aim of the study was to prospectively assess the role of apical soft tissue biopsies in radical perineal prostatectomy (RPP) patients with documented apical prostate cancer (PCA) involvement. Between June 1998 and May 1999, 77 consecutive men with localized PCA and documented invasion of the prostatic apex underwent RPP by a single surgeon. Soft tissue biopsies were systematically obtained from the prostatic fossa overlying the apex at the time of surgery. Time to biochemical failure was calculated using the Kaplan-Meier method. The rates of positive apical margins and positive apical soft tissue biopsies were 23.4% (18/77) and 15.6% (12/77). The sensitivity, specificity and positive predictive value of positive apical margins for residual apical disease as determined by apical soft tissue biopsy were 41.7, 80, and 28%, respectively. The overall biochemical failure rate was 28.6% (22/77) with a median follow-up of 51 months (range 3-73 months). The 36-month biochemical recurrence-free survival rate was 55.9+/-14.9% for patients with positive apical biopsies and 78.7+/-5.3% for those with negative biopsies (P=0.023). In conclusion, positive apical soft tissue biopsy is an independent predictor of biochemical failure in patients with apical PCA who undergo RPP. Positive apical surgical margins poorly predict residual apical disease that is frequently identifiable by apical soft tissue biopsy. Apical soft tissue biopsies should therefore be obtained in patients with known extensive apical cancer involvement at the time of RPP.
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Affiliation(s)
- H R Kübler
- Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Vis AN, Schröder FH, van der Kwast TH. The Actual Value of the Surgical Margin Status as a Predictor of Disease Progression in Men with Early Prostate Cancer. Eur Urol 2006; 50:258-65. [PMID: 16413660 DOI: 10.1016/j.eururo.2005.11.030] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2005] [Revised: 11/10/2005] [Accepted: 11/24/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The surgical margin status after radical prostatectomy for prostate cancer has long been considered a powerful prognostic factor, as well as an important risk factor for local recurrent disease after radical prostatectomy. In this study, a critical analysis of the predictive value of the surgical margin status was performed. METHODS A well-described cohort of 281 participants of a population-based randomized screening trial who underwent radical prostatectomy between 1994 and 2000 was analyzed. Besides pathologic tumor stage, Gleason score, percentage of high-grade cancer, and tumor volume, the prognostic value of the surgical margin status for disease outcome (prostate-specific antigen [PSA] relapse, local recurrence) was statistically evaluated. Specifically, site ('apical' or 'circumferential') and extent of surgical margin negativity ('negative', or 'close') or positivity ('focal' or 'extensive') was assessed. RESULTS At a median follow-up of 7 yr (range, 5-120 mo), 39 (13.9%) and 7 (2.5%) men had biochemical failure (PSA >/=0.1ng/ml), and local relapse, respectively. The surgical margin status was positive in 66 (23.5%), with 26 (9.3%) at the prostatic apex. The margin status was an independent statistically significant risk factor for biochemical relapse, though not for local relapse. Of those with positive margins, 22 (33.3%) had PSA relapse and 4 (6.1%) had local recurrence, whereas these figures were 17 (7.9%) and 3 (1.4%) for those with a negative surgical margin, respectively. The extent of margin positivity was not predictive of PSA relapse nor was the site of the surgical margin. CONCLUSIONS In surgically treated prostate cancer, the surgical margin status has, although being a statistically significant prognostic factor, only limited predictive value for PSA relapse and local recurrent disease. The majority of men with (extensive) positive surgical margins will not experience PSA relapse nor local disease progression, even in absence of adjuvant radiotherapy. So, cases with a positive margin of resection may still be cured, although the procedure in itself was not 'radical'.
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Affiliation(s)
- André N Vis
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands.
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Srigley JR. Key issues in handling and reporting radical prostatectomy specimens. Arch Pathol Lab Med 2006; 130:303-17. [PMID: 16519557 DOI: 10.5858/2006-130-303-kiihar] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Patients with prostatic adenocarcinoma commonly undergo radical prostatectomy, and it is often difficult and time consuming to handle the resulting specimens and to report the findings. Pathologic information derived from the radical prostatectomy specimen is used for selecting adjuvant therapy, such as radiotherapy and hormone therapy, and for determining a patient's prognosis. The prostate specimen must be handled in a systematic fashion to derive the appropriate prognostic parameters. OBJECTIVE To review the prognostic factors of relevance in classifying radical prostatectomy specimens, using the College of American Pathologists categorization system, including a detailed survey of the morphologic-based factors but excluding other factors such as DNA ploidy and novel phenotypic and genotypic markers. CONCLUSIONS Gleason score, pathologic stage, and margin status are considered category 1 prognostic factors, which are of proven prognostic significance and are useful in patient management. Factors such as tumor volume (intraglandular extent) and tumor subtype are considered category 2 prognostic factors, which show significant promise but require validation in multivariate analysis. Lymphovascular space invasion is a promising category 3 prognostic factor that needs additional study. Perineural invasion is an almost ubiquitous finding in radical prostatectomy specimens and is considered a category 3 prognostic factor. After prognostic factors have been analyzed at the histologic level, it is critical to report the findings in a clear and unambiguous fashion. The synoptic style of reporting is ideal for describing complex cancer resection specimens. A synoptic report based on an evidence-based checklist, such as the one developed by the College of American Pathologists, effectively communicates complex cancer-related data, such as radical prostatectomy specimen findings. This information is used not only for individual case management with respect to treatment and prognostication but also for purposes such as education, research, quality monitoring, and system planning.
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Affiliation(s)
- John R Srigley
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada.
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Dillenburg W, Poulakis V, Witzsch U, de Vries R, Skriapas K, Altmansberger HM, Becht E. Laparoscopic Radical Prostatectomy: The Value of Intraoperative Frozen Sections. Eur Urol 2005; 48:614-21. [PMID: 16054291 DOI: 10.1016/j.eururo.2005.06.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2005] [Accepted: 06/17/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To examine the clinical and pathological value of intraoperative frozen section (IFS) in patients undergoing laparoscopic radical prostatectomy (L-RPE) for clinically localized prostate cancer. METHODS The study includes 198 consecutive cases of L-RPE. After removal of the prostate, a 2-3mm circumferential specimen was obtained from the apical and bladder neck soft-tissue margin and submitted for IFS examination. In cases suspicious for capsular incision (n=57), IFS were taken from the neurovascular bundle/lateral pedicle. RESULTS The IFS diagnosis from the apical, bladder neck, and neurovascular bundle/lateral pedicle soft-tissue margins was adenocarcinoma in 12 (6%), 1 (0.5%), and 2 (1%) cases, respectively. Patient age, clinical stage, and mean specimen weight were not associated with cancer at the apical IFS. The accuracy, sensitivity, specificity, positive and negative predictive value of the apical IFS to predict cancer in the permanent section of the apical soft-tissue margin was 96%, 70%, 97%, 58%, and 98%, respectively. All the patients (n=15) with cancer at IFS had wide resections of additional tissue in the area of positive soft-tissue margin and all had no cancer in the additional resected tissue. Especially at the apex, IFS decreases the overall PSM status on surgical specimen by 5.1% (apical PSM from 8.6% to 3.5%). CONCLUSION Because of the low predictive value of IFS of bladder neck and neurovascular bundle/lateral pedicle their use is not recommended. IFS of the apex should be performed to reduce the PSM rate.
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Affiliation(s)
- Wolfgang Dillenburg
- Department of Urology, Northwest Hospital, Stiftung Hospital zum Heiligen Geist, Steinbacher Hohl 2-26, D-60488 Frankfurt/Main, Germany.
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Ojea Calvo A, González Piñeiro A, Domínguez Freire F, Alonso Rodrigo A, Rodríguez Iglesias B, Benavente Delgado J. [Prognostic implications of positive margins in radical prostatectomy specimens]. Actas Urol Esp 2005; 29:641-56. [PMID: 16180314 DOI: 10.1016/s0210-4806(05)73314-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
UNLABELLED To evaluate the histopathologic implication of positive margins of prostatectomy specimens in the biochemical recurrence. MATERIAL AND METHODS The study group consisted of 290 patients with clinically localized prostate cancer who were treated by radical retropubic prostatectomy. Patients with neoadjuvant hormonal therapy and positive lymph nodes were excluded. The mean age at the time of surgery was 63 years (range 47-73); 166 (57.2%) patients were T1c and 124 (42.8%) T2; the average time of folow-up was of 4 years (range 1-12). Positive surgical margins were defined as the presence of cancer cells at the surface inked of prostatectomy specimens. They were classified as: Margin for capsular incision (without extraprostatic extension evidence)/ margin for extraprostatic extension, margin with smooth rounded surface/margin with irregular surface, margin < or = 4 mm/margin > 4 mm, unifocal margin/multifocal margin. We define biochemical recurrence if the PSA exceeds 0.20 ng/ml in two consecutive determinations. RESULTS The overall rate of positive margins was 65/290 (22.4%). The 5-year survival free of biochemical recurrence was as follows: Negative margins 71% vs positive margins 44% (p < 0.001); positive margins for capsular incision 84% vs positive margins for extraprostatic extension 33% (p < 0.01); positive margins with smooth rounded surface 58% vs positive margins with irregular surface 26% (p < 0.01); positive margins < or = 4 mm 57% vs positive margins > 4 mm 32% (p < 0.05); unifocal margins 53% vs multifocal margins 0% (p < 0.01). The multivariate analysis revealed that preoperative PSA, Gleason score and pathological classification were the best predictors of biochemical recurrence. CONCLUSIONS Two groups are established of positive margin. The first group with high probability of biochemical recurrence: margin for extraprostatic. The second group with less probability of biochemical recurrence: margin for capsular incision, margin with smooth rounded surface, margin < or = 4 mm and unifocal margin.
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Affiliation(s)
- A Ojea Calvo
- Servicio de Urología, Complejo Hospitalario Universitario de Vigo, Pontevedra.
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Fromont G, Cathelineau X, Rozet F, Prapotnich D, Validire P, Vallancien G. Impact of margin size on the incidence of local residual tumor after laparoscopic radical prostatectomy. J Urol 2005; 172:1845-7. [PMID: 15540735 DOI: 10.1097/01.ju.0000140266.51848.92] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Since October 2001 we have performed intraoperative frozen section (IFS) on the posterolateral areas of the radical prostatectomy specimen with bilateral nerve sparing. In cases of positive surgical margin (SMs) the corresponding neurovascular bundle (NVB) was resected. We evaluated the impact of several biological and pathological parameters on the incidence of local residual tumor in the NVB. MATERIALS AND METHODS A total of 487 laparoscopic radical prostatectomies with bilateral nerve sparing and IFS were performed between October 2001 and December 2003. When IFS was positive, the whole NVB was removed and analyzed after fixation in serial sections. The size of the positive SM was measured in its largest dimension. The association of NVB residual tumor with positive SM size, preoperative prostate specific antigen, pathological stage and Gleason score was analyzed using the t and chi-square tests, and logistic regression. RESULTS Of the 487 patients 84 had a positive SM on IFS. In 25 of the 84 additionally resected NVBs we found residual tumor. On univariate and multivariate analysis the only predictor of residual tumor was positive SM size (p<0.001). In all cases of a positive SM of 0.1 cm or less we found no residual tumor cells in the NVB. CONCLUSIONS In case of a positive SM in the posterolateral area of the prostatectomy specimen margin size is predictive of the incidence of residual tumor in the corresponding NVB. This finding could help management and the decision about local adjuvant treatment.
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Affiliation(s)
- Gaëlle Fromont
- Department of Pathology, Institut Montsouris, Paris, France.
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Pettus JA, Weight CJ, Thompson CJ, Middleton RG, Stephenson RA. Biochemical failure in men following radical retropubic prostatectomy: impact of surgical margin status and location. J Urol 2004; 172:129-32. [PMID: 15201752 DOI: 10.1097/01.ju.0000132160.68779.96] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The significance of isolated positive apical surgical margins in radical retropubic prostatectomy (RRP) specimens remains controversial. We examine the effects of margin status and location on biochemical recurrence rates in patients undergoing RRP. MATERIALS AND METHODS Of 800 patients with RRP we identified 498 without pathological evidence of lymph node, seminal vesicle or adjacent organ involvement and with at least 6 months of followup. Patients were subdivided into apex only positive (AM+), nonapical isolated positive (OM+), multiple positive (MM+) and negative (SM-) surgical margins. The rate and interval to biochemical disease recurrence were determined in each group. Univariate and multivariate analysis as well as Kaplan-Meier curves were used to test differences among these groups. RESULTS Of the 498 men who met our inclusion criteria 400 were SM-, 28 were AM+, 57 were OM+ and 13 were MM+ at a median followup of 49, 59, 64 and 83 months, respectively. Biochemical recurrence rates for SM-, AM+, OM+ and MM+ were 9.3%, 21.4%, 26.3% and 30.8%, respectively. Median time to biochemical failure in the SM-, AM+, OM+ and MM+ groups was 34, 19.5, 46.0 and 6.8 months, respectively. Biochemical recurrence was not statistically different among the AM+, OM+ and MM+ groups. On univariate analysis AM+, OM+ and MM+ were significant predictors of recurrence (p < 0.05, < 0.005, and <0.05, respectively). On multivariate models only pretreatment prostate specific antigen and OM+ were independent predictors of biochemical recurrence. CONCLUSIONS A positive surgical margin conveys increased risk for biochemical recurrence. Patients with AM+ experienced biochemical recurrence more frequently and rapidly than those with SM-. AM+ conveys a similar risk of recurrence compared with OM+ and MM+. Apical margin status did not independently predict biochemical recurrence.
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Affiliation(s)
- Joseph A Pettus
- Division of Urology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Lepor H, Kaci L. Role of intraoperative biopsies during radical retropubic prostatectomy. Urology 2004; 63:499-502. [PMID: 15028445 DOI: 10.1016/j.urology.2003.10.017] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2003] [Accepted: 10/02/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To determine the value of intraoperative biopsy during radical retropubic prostatectomy. METHODS Between October 2000 and August 2002, 500 men with clinically localized prostate cancer underwent radical retropubic prostatectomy by a single surgeon. A 2 to 3-mm circumferential biopsy was routinely obtained from the apical and bladder neck soft-tissue margin and submitted for frozen section examination. In selective cases suspicious for capsular incision, a biopsy was sent from what was believed to be the contiguous neurovascular bundle/lateral pedicle. RESULTS Prostate cancer was observed in 4.5%, 0.8%, and 1.6% of the intraoperative biopsies sent from the apical, bladder neck, and neurovascular bundle/lateral pedicle soft-tissue margins, respectively. Patient age, Gleason score, perineural invasion on diagnostic prostate biopsy, and clinical stage were not associated with prostate cancer at the apical soft-tissue margin. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the surgical specimen to predict cancer in the apical soft-tissue margin was 57.7%, 98.2%, 62%, 97.7%, and 96%, respectively. Intraoperative biopsy of the apical soft-tissue margin reduced the positive margin rate by 3.8%. CONCLUSIONS The yield of intraoperative biopsy of the bladder neck and neurovascular bundle/lateral pedicle is too low to justify it in routine practice. Biopsy of the apical soft tissue should be routinely performed to reduce the positive surgical margin rate.
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Affiliation(s)
- Herbert Lepor
- Department of Urology, New York University School of Medicine, New York, New York 10016, USA
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Freedland SJ, Aronson W, Presti JC, Kane CJ, Terris MK, Elashoff D, Amling CL. Should a positive surgical margin following radical prostatectomy be pathological stage T2 or T3? Results from the SEARCH database. J Urol 2003; 169:2142-6. [PMID: 12771736 DOI: 10.1097/01.ju.0000061760.23169.be] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE The finding of a positive surgical margin associated with extracapsular extension at radical prostatectomy is a poor prognostic factor. However, whether a positive surgical margin with no documented extracapsular extension portends a similarly poor prognosis is unclear. We examined the significance of the pathological features of positive surgical margin and extracapsular extension for predicting biochemical failure following radical prostatectomy. MATERIALS AND METHODS We examined data on 1,621 men from the SEARCH Database of patients treated with radical prostatectomy without lymph node metastasis. Patients were separated into 5 groups based on the pathological findings of positive surgical margin, extracapsular extension, and/or seminal vesicle invasion. Preoperative clinical variables were compared across the groups and the groups were compared for time to biochemical recurrence using Cox proportional hazards analysis. RESULTS Men with seminal vesicle invasion had the highest prostate specific antigen (PSA) recurrence rates, while men with a negative surgical margin and no extracapsular extension had the lowest PSA recurrence rates. There were no differences in PSA failure rates between men with a positive surgical margin and no extracapsular extension versus men with a negative surgical margin and extracapsular extension versus men with extracapsular extension and a positive surgical margin. In this subset of patients with a positive surgical margin and/or extracapsular extension but no seminal vesicle invasion only serum PSA was a significant independent predictor of biochemical recurrence. CONCLUSIONS Men with a positive surgical margin but no extracapsular extension had PSA recurrence rates similar to those in men with extracapsular extension with or without positive margins. Men with extracapsular extension had similar biochemical recurrence rates whether the surgical margin was positive or negative. If confirmed at other institutions, consideration should be given to modifying the current TNM staging system to reflect these findings.
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Affiliation(s)
- Stephen J Freedland
- Department of Urology, University of California-Los Angeles and Department of Surgery, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California 90095, USA
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Hong H, Koch MO, Foster RS, Bihrle R, Gardner TA, Fyffe J, Ulbright TM, Eble JN, Cheng L. Anatomic distribution of periprostatic adipose tissue: a mapping study of 100 radical prostatectomy specimens. Cancer 2003; 97:1639-43. [PMID: 12655520 DOI: 10.1002/cncr.11231] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Because the prostatic capsule is often indistinct, recognition of extraprostatic extension by carcinoma depends heavily on the identification of carcinoma cells in the periprostatic adipose tissue. However, the distribution of adipose tissue along the prostatic surfaces has not been studied extensively. METHODS The authors analyzed the periprostatic adipose tissue in specimens from 100 patients treated with radical retropubic prostatectomy and bilateral pelvic lymphadenectomy for prostatecarcinoma. Each specimen was totally embedded and examined by the whole mount method. The presence or absence of adipose tissue on the anterior, posterior, right, and left surfaces of the prostate was determined and analyzed. RESULTS Periprostatic adipose tissue was present on 48% of all prostatic surfaces examined. The distribution of periprostatic adipose tissue varied among the different surfaces of the prostate, with the anterior, posterior, right, and left surfaces showing 44%, 36%, 59%, and 57% adipose tissue, respectively. The amount of periprostatic adipose tissue was similar among specimens from operations performed by different surgeons (P = 0.72). However, nerve-sparing procedures resulted in less adipose tissue (46%) than non-nerve-sparing procedures (54%) (P = 0.01). CONCLUSIONS Less than half of the prostatic surfaces examined were covered by adipose tissue. The absence of adipose tissue over large areas of the prostatic surface, especially the posterior surface, makes the evaluation of extraprostatic extension difficult and unreliable. Further refinement of the prostate carcinoma staging system is needed.
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Affiliation(s)
- Heng Hong
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Prognostic Significance of Positive Surgical Margins. Prostate Cancer 2003. [DOI: 10.1016/b978-012286981-5/50037-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Berger AP, Volgger H, Rogatsch H, Strohmeyer D, Steiner H, Klocker H, Bartsch G, Horninger W. Screening with low PSA cutoff values results in low rates of positive surgical margins in radical prostatectomy specimens. Prostate 2002; 53:241-5. [PMID: 12386925 DOI: 10.1002/pros.10167] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND In the literature, positive margins in radical prostatectomy specimens, the rate of which ranges between 7% and 46%, are associated with adverse patient survival. The aim of the present study was to determine the predictive value of preoperative serum prostate specific antigen (PSA) values for the rate of positive margins in radical retropubic prostatectomy. METHODS The study included a cohort of 845 patients who underwent radical retropubic prostatectomy between October of 1993 and December of 1999. All patients were stratified in groups on the basis of their preoperative PSA values: PSA group I, 0-1.99 ng/ml; PSA group II, 2-3.99 ng/ml; PSA group III, 4-5.99 ng/ml; PSA group IV, 6-7.99 ng/ml; PSA group V, 8-9.99 ng/ml; and PSA group VI, >10 ng/ml. For each group, the pathologic stage, Gleason score, and the incidence of positive margins were analyzed. For statistical analysis, the Mann Whitney U-test was used. RESULTS Our data show a significantly higher rate of organ-confined prostate cancers and a significantly lower rate of positive surgical margins in patients with preoperative total PSA values of less than 4 ng/ml compared with patients with higher preoperative total PSA levels. CONCLUSION As tumor stage and surgical margin status after radical prostatectomy are important predictors of the likelihood of PSA recurrence, which necessitates additional therapy, these findings support the concept of PSA screening by using low PSA cutoff levels.
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Affiliation(s)
- Andreas P Berger
- Department of Urology, University of Innsbruck, Innsbruck, Austria.
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Positive Surgical Margins After Radical Retropubic Prostatectomy: The Influence of Site and Number on Progression. J Urol 2002. [DOI: 10.1016/s0022-5347(05)65003-3] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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49
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Positive Surgical Margins After Radical Retropubic Prostatectomy: The Influence of Site and Number on Progression. J Urol 2002. [DOI: 10.1097/00005392-200206000-00024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Straub B, Müller M, Krause H, Goessl C, Schrader M, Heicappell R, Miller K. Molecular staging of surgical margins after radical prostatectomy by detection of telomerase activity. Prostate 2001; 49:140-4. [PMID: 11582593 DOI: 10.1002/pros.1128] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The further course of prostate cancer (PC) after radical prostatectomy (RPX) is decisively influenced by the local tumor stage. Although it is thus far possible to assess the risk of local recurrence from the pathohistology, precise predictions cannot be made. A more precise evaluation would be desirable, mainly for early planning of adjuvant therapy. Other authors have shown that telomerase activity may be a marker for malignant potential. We assessed the detection of telomerase activity using the telomeric repeat amplification protocol (TRAP) in surgical margins compared to conventional histopathological examination. METHODS Ninety-two patients with local PC who underwent RPX were examined. After RPX biopsies were obtained from four defined areas of the prostatic fossa and processed by TRAP assay for telomerase activity using a standard protocol. RESULTS In 5 of 48 patients (10.4%) with organ-confined prostate carcinoma (pT2) telomerase activity could be detected. Seven of 47 patients (14.9%) with locally advanced PC (> pT2) had at least one positive specimen. CONCLUSIONS The results obtained in our study indicate that detection of telomerase activity by TRAP assay may be a suitable parameter for molecular staging of surgical margins, because of the high tumor-specificity. Further follow-up must clarify whether patients with positive molecular detection have an increased risk of local recurrence.
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Affiliation(s)
- B Straub
- Department of Urology, Universitätsklinikum Benjamin Franklin, Freie Universität Berlin, Berlin, Germany.
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