Association of Anterior and Lateral Extraprostatic Extensions with Base-Positive Resection Margins in Prostate Cancer

Imaging classification of prostate cancer with extracapsular extension and its impact on positive surgical margins after laparoscopic radical prostatectomy

Abstract

To explore the impact of different imaging classifications of prostate cancer (PCa) with extracapsular extension (EPE) on positive surgical margins (PSM) after laparoscopic radical prostatectomy.

Methods

Clinical data were collected for 114 patients with stage PT3a PCa admitted to Ningbo Yinzhou No. 2 Hospital from September 2019 to August 2023. Radiologists classified the EPE imaging of PCa into Type I, Type II, and Type III. A chi-square test or t-test was employed to analyze the factors related to PSM. Multivariate regression analysis was conducted to determine the factors associated with PSM. Receiver operating characteristic curve analysis was used to calculate the area under the curve and evaluate the diagnostic performance of our model. Clinical decision curve analysis was performed to assess the clinical net benefit of EPE imaging classification, biopsy grade group (GG), and combined model.

Results

Among the 114 patients, 58 had PSM, and 56 had negative surgical margins. Multivariate analysis showed that EPE imaging classification and biopsy GG were risk factors for PSM after laparoscopic radical prostatectomy. The areas under the curve for EPE imaging classification and biopsy GG were 0.677 and 0.712, respectively. The difference in predicting PSM between EPE imaging classification and biopsy GG was not statistically significant (P>0.05). However, when used in combination, the diagnostic efficiency significantly improved, with an increase in the area under the curve to 0.795 (P<0.05). The clinical decision curve analysis revealed that the clinical net benefit of the combined model was significantly higher than that of EPE imaging classification and biopsy GG.

Conclusions

EPE imaging classification and biopsy GG were associated with PSM after laparoscopic radical prostatectomy, and their combination can significantly improve the accuracy of predicting PSM.

Comprehensive analysis of predictive factors for upstaging in intraprostatic cancer after radical prostatectomy: Different patterns of spread exist in lesions at different locations

BACKGROUND

Accurate assessment of the clinical staging is crucial for determining the need for radical prostatectomy (RP) in prostate cancer (PCa). However, the current methods for PCa staging may yield incorrect results. This study aimed to comprehensively analyze independent predictors of postoperative upstaging of intraprostatic cancer.

METHODS

We conducted a retrospective analysis of data from intraprostatic cancer patients who underwent radical surgery between March 2019 and December 2022. Intraprostatic cancer was defined as a lesion confined to the prostate, excluding cases where multiparameter magnetic resonance imaging (mpMRI) showed the lesion in contact with the prostatic capsule. We assessed independent predictors of extraprostatic extension (EPE) and analyzed their association with positive surgical margin (PSM) status. In addition, based on the distance of the lesion from the capsule on mpMRI, we divided the patients into non-transition zone and transition zone groups for further analysis.

RESULTS

A total of 500 patients were included in our study. Logistic regression analysis revealed that biopsy Gleason grade group (GG) (odds ratio, OR: 1.370, 95% confidence interval, CI: 1.093-1.718) and perineural invasion (PNI) (OR: 2.746, 95% CI: 1.420-5.309) were predictive factors for postoperative EPE. Both biopsy GG and PNI were associated with lateral (GG: OR: 1.270, 95% CI: 1.074-1.501; PNI: OR: 2.733, 95% CI: 1.521-4.911) and basal (GG: OR: 1.491, 95% CI: 1.194-1.862; PNI: OR: 3.730, 95% CI: 1.929-7.214) PSM but not with apex PSM (GG: OR: 1.176, 95% CI: 0.989-1.399; PNI: OR: 1.204, 95% CI: 0.609-2.381) after RP. Finally, PNI was an independent predictor of EPE in the transition zone (OR: 11.235, 95% CI: 2.779-45.428) but not in the non-transition zone (OR: 1.942, 95% CI: 0.920-4.098).

CONCLUSION

PNI and higher GG may indicate upstaging of tumors in patients with intraprostatic carcinoma. These two factors are associated with PSM in locations other than the apex of the prostate. Importantly, cancer in the transition zone of the prostate is more likely to spread externally through nerve invasion than cancer in the non-transition zone.

Tumor Location and a Tumor Volume over 2.8 cc Predict the Prognosis for Japanese Localized Prostate Cancer

(1) Objective: Our study investigated the prognostic value of tumor volume and location in prostate cancer patients who received radical prostatectomy (RP). (2) Methods: The prognostic significance of tumor volume and location, together with other clinical factors, was studied using 557 patients who received RP. (3) Results: The receiver operating characteristic (ROC) curve identified the optimal cutoff value of tumor volume as 2.8 cc for predicting biochemical recurrence (BCR). Cox regression analysis revealed that a tumor in the posterior area (p = 0.031), peripheral zone (p = 0.0472), and tumor volume ≥ 2.8 cc (p < 0.0001) were predictive factors in univariate analysis. After multivariate analysis, tumor volume ≥ 2.8 cc (p = 0.0225) was an independent predictive factor for BCR. Among them, a novel risk model was established using tumor volume and location in the posterior area and peripheral zone. The progression-free survival (PFS) of patients who met the three criteria (unfavorable group) was significantly worse than other groups (p ≤ 0.001). Furthermore, multivariate analysis showed that the unfavorable risk was an independent prognostic factor for BCR. The prognostic significance of our risk model was observed in low- to intermediate-risk patients, although it was not observed in high-risk patients. (4) Conclusion: Tumor volume (≥2.8 cc) and localization (posterior/peripheral zone) may be a novel prognostic factor in patients undergoing RP.

Radical or Not-So-Radical Prostatectomy: Do Surgical Margins Matter?

Simple Summary

Prostate cancer is the second most common noncutaneous malignancy in men. Prostatectomy is a commonly used treatment modality for selected patients. The prostate’s ill-defined borders and its vicinity with vital structures complicate the wide excision of the organ, resulting in positive margins of resection. Neoplastic infiltration of margins of resection in prostatectomy specimens affects patients’ prognosis. The surgical technique and surgeons’ expertise affect the incidence of margin positivity. The location and the extent of positive margins diversify the risk of recurrence, with basal infiltration and multifocal foci of positive margins behaving more aggressively. Pathologists are encouraged to thoroughly report the status of margins of resection, as they provide important information for patients’ prognosis and enable the clinician to decide upon the most appropriate subsequent therapeutic steps.

Abstract

Prostate cancer is the second most common malignancy in men, and prostatectomy is the treatment of choice for most patients with at least low risk of progression. The presence of positive margins in the radical prostatectomy specimen is considered an adverse pathologic feature, and may prompt additional therapeutic intervention in the patients. The absence of a distinct capsule around the prostate and intraoperative manipulations that aim to minimize postoperative adverse effects, complicate its wide removal. Proper handling of the specimen during the gross processing is essential for accurate determination of the status of margins or resection. Positive margins, defined as the presence of neoplastic glands in the highlighted-with-ink margin of resection, range from 6–38%. The surgical technique, surgeon’s expertise and tumor (i.e., grade and stage) and patients’ (i.e., BMI) characteristics affect the rate of margin positivity. Extensive or multifocal and nonanterior/nonapical positive margins are linked with higher recurrence rates, especially in organ-confined disease, underscoring the need for treating these patients more aggressively. In summary, detailed description of the status of the margins should be performed in every pathology report to determine patients’ prognosis and the most appropriate therapeutic plan.

Preoperative MRI-based estimation of risk for positive resection margin after radical prostatectomy in patients with prostate cancer: development and validation of a simple scoring system

OBJECTIVES

To develop a simplified MRI-based model to predict the risk for positive surgical margins (PSMs) after radical prostatectomy (RP) in patients with prostate cancer (PCa).

METHODS

Consecutive patients who underwent RP for PCa were retrospectively identified from a tertiary referral hospital. Patients who underwent RP between January 2014 and June 2014 were assigned as derivation cohort (n = 330) and those between January 2018 and February 2018 were assigned as validation cohort (n = 100). MRI-based predictors associated with PSM were assessed: tumor size, tumor-capsule contact length, the Prostate Imaging Reporting and Data System (PI-RADS) category, tumor location (tumor contact to the apex or posterolateral side near the neurovascular bundle), apical depth, and prostate volume. A prediction model was developed by using multivariable logistic regression, and then it was transformed into a scoring system. The prediction and calibration performance of this scoring system was evaluated using the C statistics and Hosmer-Lemeshow goodness-of-fit test.

RESULTS

A total of 121 (36.7%) and 32 (32.0%) of patients in the derivation and validation cohorts had PSMs after RP. The scoring system consisted of the following variables: tumor-capsule contact length, PI-RADS category, tumor located at the apex and/or posterolateral side. This scoring system provided good prediction performance for PSM in the derivation (C statistics, 0.80 [95% CI: 0.76, 0.85]) and validation (C statistics, 0.77 [95% CI: 0.68, 0.87]) cohorts, and also showed good calibration in both cohorts (p = 0.83 and 0.86, respectively).

CONCLUSIONS

An MRI-based scoring system can help estimate the risk of PSM after RP.

KEY POINTS

• An MRI-based scoring system served as a tool to estimate the risk of positive surgical margin (C statistics, 0.80 and 0.77 in the derivation and validation cohorts, respectively) after radical prostatectomy. • Tumor with contact to the apex or posterolateral aspect, the tumor contact length to capsule, and higher PI-RADS category were independent predictors for the presence of positive resection margins after radical prostatectomy in men with prostate cancer. • High-risk patients as determined by the scoring system demonstrated adverse post-surgical outcomes compared with low- or intermediate-risk patients, in regard to longer length (mean length, 13.0 mm versus 3.9 mm in low risk or 6.2 mm in intermediate risk; p ≤ 0.001) and higher Gleason grade at the margin (grades 4 and 5 in 69.4% and 20.4% versus 16.7% and 16.7% in low risk or 46.7% and 5.4% in intermediate risk; p < 0.001).

Prostate MRI prior to radical prostatectomy: effects on nerve sparing and pathological margin status

OBJECTIVES

The aim of this study was to assess the positive surgical margin (PSM) and nerve sparing (NS) rates in patients who underwent prostate MRI (pMRI) prior to radical prostatectomy (RP) and compare them with matched, nonimaged control RP patients.

METHODS

We identified 204 men who underwent preoperative pelvic MRI (pelMRI), of whom 176 (86.3%) underwent pMRIs, within 60 days of RP, and compared them (1:1) with a nonim-aged control group matched by surgeon, age, race, body mass index (BMI), prostate-specific antigen (PSA), pathological Gleason score, prostate specimen weight, and RP year.

RESULTS

The rates of nonfocal extracapsular extension (nfECE) on RP pathology in the MRI and control groups were similar. PSM rates were lower in the MRI group (13.7% vs 19.3%; P=0.14), but the difference did not meet statistical significance; this was also the case in patients with nfECE on RP pathology (27.7% vs 39.5%; P=0.3). NS rates were similar between groups. In the MRI group, 54 (26.5%) patients had an MRI suspicious for nfECE; their PSM rate (20.4%) was higher than that of patients with an MRI not suspicious for nfECE (11.3%; P=0.11), but the difference lacked statistical significance; the former group had significantly lower rates of NS. Limitations of the study include sample power and nonuniform heeding of MRI results by each surgeon.

CONCLUSION

MRI did not significantly decrease the rates of PSM, including in the subset of patients with nfECE on final pathology. Even wider resection may be necessary in patients with MRIs suggesting locally-advanced disease. Studies with greater power are needed.