Positive surgical margins and biochemical recurrence following minimally-invasive radical prostatectomy \u2013 An analysis of outcomes from a UK tertiary referral centre

Ashwin Sachdeva,Katherine Kelly,Rajan Veeratterapillay,Mark I Johnson,Naeem A Soomro,Jonathan Aning,Antonia Voysey

doi:10.1186/s12894-017-0262-y

Abstract

BackgroundPositive surgical margins are a strong prognostic marker of disease outcome following radical prostatectomy, though prior evidence is largely from a PSA-screened population. We therefore aim to evaluate the biochemical recurrence in men with positive surgical margins (PSM) after minimally-invasive radical prostatectomy (MIRP) in a UK tertiary centre.MethodsRetrospective study of men undergoing laparoscopic or robotic-assisted radical prostatectomy between 2002 and 2014. Men with positive surgical margins (PSM) were identified and their biochemical recurrence (BCR) rate compared with men without PSM. The primary outcome measures were BCR rates and time to BCR. Cox regression was used to estimate adjusted hazard ratios for biochemical recurrence rate (BCR), accounting for potential confounders.ResultsFive hundred ninety-two men were included for analysis. Pre-operative D’Amico risk stratification showed 37.5%, 53.3% and 9.3% of patients in the low, intermediate and high-risk groups, respectively. On final pathological analysis, the proportion of patients with local staging pT2, pT3a and pT3b was 68.8%, 25.2% and 6.1% respectively. Overall positive margin rate was 30.6%. On multivariate analysis, the only pre-operative factor associated with PSM was age >65years. Patients with PSM were more likely to have higher tumour volume and more advanced pathological local stage. The BCR rate was 10.7% in margin-positive patients and 5.1% in margin-negative patients, at median 4.4-year follow-up. Upon multivariate analysis, high pre-operative PSA and high Gleason group were the only significant predictors of BCR (P<0.05).ConclusionsIn comparison to patients with negative surgical margins, those with PSM do not translate into worse medium-term oncological outcomes in the majority of cases amongst our cohort. We found that high pre-operative PSA and high Gleason group were the only significant predictors of BCR.

Highlights

Positive surgical margins are a strong prognostic marker of disease outcome following radical prostatectomy, though prior evidence is largely from a Prostate specific antigen (PSA)-screened population
Surgical margin status at pathological analysis after radical prostatectomy for prostate cancer is a key metric to define the oncological adequacy of prostate resection [1]
positive surgical margins (PSM) has been highlighted as a risk factor for disease progression after surgery and, as such, margin status has been incorporated as a component of multiple prostate cancer outcome prediction models [4,5,6]

Summary

Introduction

Positive surgical margins are a strong prognostic marker of disease outcome following radical prostatectomy, though prior evidence is largely from a PSA-screened population. PSM has been highlighted as a risk factor for disease progression after surgery and, as such, margin status has been incorporated as a component of multiple prostate cancer outcome prediction models [4,5,6]. Patients with the finding of PSM alone at RP can be managed with PSA surveillance, adjuvant or salvage radiotherapy [7] or entered into clinical trials (for example RADICALS) [1, 4]. For patients with biochemical relapse (BCR) following RP, the European Association of Urology advises the use of salvage radiotherapy with at least 66Gy at a PSA level of < 0.5ng/ml [8]

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Results

Conclusion