Significance and Treatment of Positive Margins or Seminal Vesicle Invasion After Radical Prostatectomy

Evaluating radical prostatectomy specimens: therapeutic and prognostic importance

The pathologic staging of prostate cancer involves determination of the anatomic extent and burden of tumor based on the best available data. Proper examination of radical prostatectomy specimens is critical in determining cancer stage, stratifying patient need for adjuvant treatment, and prediction of patient outcome. Differences exist in methods of handling and sampling specimens, although publication of practice protocols in recent years has led to convergence of opinion. In this report, we evaluate the current aspects of pathologic staging of prostate cancer and assessment of prostatectomy specimens. Recent international agreement on pathologic staging of prostate cancer should allow valid comparisons of surgical treatment from different institutions. The vanishing cancer phenomenon is also briefly discussed.

Evaluation of serum prostate-specific antigen velocity after radical prostatectomy to distinguish local recurrence from distant metastases

OBJECTIVE

Serum prostate-specific antigen (PSA) values are most useful for prediction of disease recurrence after surgery. It is unknown whether a detectable PSA level after surgery indicates a local recurrence potentially benefiting from pelvic irradiation or distant metastases requiring hormonal treatment.

METHODS

We analyzed postoperative rate of change of serum PSA levels as a predictor of local versus distant disease recurrence after radical prostatectomy. Between 1982 and 1991, 1,058 men underwent radical prostatectomy for localized prostate cancer and follow-up consisted of determining serum PSA levels and digital rectal examinations. Clinical follow-up of 542 men for four or more years and 78 men for eight or more years yielded ten-year actuarial disease recurrence rates of 4 percent for local recurrence, 8 percent for distant metastases, and 23 percent for an isolated elevation of serum PSA level only. Fifty-one patients with isolated elevations of PSA levels only were followed expectantly until they were diagnosed with either local or distant metastases.

RESULTS

A linear mixed effects regression analysis was used to model these data. Using these models, the time to a serum PSA level of 0.5 ng/mL, the PSA level one year following surgery, pathologic stage, Gleason sum, and the rate of change of PSA (PSA velocity [PSAV]) were tested as predictors of local versus distant metastases. A combination of PSAV, pathologic stage, and Gleason grade best distinguished local from distant metastases.

CONCLUSIONS

These data suggest that PSAV in men with an isolated elevation of PSA levels following radical prostatectomy might aid in clinical decision making.

Rate of relapse following treatment for localized prostate cancer: a critical analysis of retrospective reports

PURPOSE

Controversy exists over the optimal treatment for patients with clinically localized prostate cancer. Almost all of the treatment results are from non-randomized trials and interseries comparison is difficult since the apparent success of a treatment, as judged by the actuarial freedom from relapse and survival data, depends on patient selection criteria and post-treatment evaluation, in addition to the efficacy of the therapeutic intervention. In this report the calculation of a hazard function is used to estimate and compare the rate of relapse for the different treatments.

METHODS AND MATERIALS

Clinical reports from major surgery and radiation oncology treatment institutions were analyzed. The actuarial recurrence data were used to calculate the annual rate of recurrence within each series.

RESULTS

For all but the lowest volume tumors, patients continue to be at risk of relapse for as long as these series have been followed. Despite the heterogeneity of patient populations, the recurrence rates by stage are similar for patients treated with surgery or irradiation. This result is consistent with pathologic data from prostatectomy specimens which indicate that for lesions > 12 cm3 (approx. 3 cm in diameter) there is high likelihood of extraprostatic disease.

CONCLUSION

Treatment outcome for patients with localized prostate cancer may be more dependent on the inherent tumor biology than the particular type of treatment. Accordingly, the expectation and recommendation of a treatment must take into consideration the continued risk of relapse with either radiation therapy or surgery. There are, as yet, insufficient data regarding the impact of screening and earlier diagnosis on the curability of patients with localized prostate cancer.

Analysis of risk factors associated with prostate cancer extension to the surgical margin and pelvic node metastasis at radical prostatectomy

We analyzed data from 107 consecutive patients with clinical stage B prostate cancer in an attempt to identify those at high risk for having involved margins or nodal metastasis. Each patient underwent transrectal ultrasound-guided sextant biopsies of the prostate. Patient age, surgical approach to prostatectomy, pre-biopsy prostate specific antigen (PSA) level, and number, location and maximum Gleason score of positive biopsies were statistically evaluated for all patients groups. Prostate volume and PSA density (PSAD) were calculated for all patients undergoing prostatectomy. Of the 101 patients who underwent radical prostatectomy 64 had negative margins, 37 had at least 1 positive margin and 11 of the 37 had more than 1 positive margin. Involved margins were most common at the apex (62%) and mid portion (59%) of the gland. Prostatectomy was not performed on 6 patients with nodal metastases evident on frozen section examination. Therefore, 43 patients are considered to be at high risk for having residual disease after surgery. The mean PSAD, PSA level and number of positive biopsies were significant (p < 0.05) predictors of tumor extension to the surgical margin. The mean number of positive biopsies, biopsy Gleason score and PSA level were significantly greater (p < 0.05) in patients with nodal metastases. Only 15% of the patients with a single positive biopsy had positive margins versus 47% of those with multiple positive biopsies (p < 0.05). Of the patients with tumor positive nodes on frozen section 67% had 5 or more positive biopsies, whereas only 9% of all others had that many positive biopsies (p < 0.05). The number of positive biopsy sites, PSAD and PSA level were significantly associated with tumor at the surgical margin or metastatic to the pelvic nodes.