Positive surgical margins with radical retropubic prostatectomy: anatomic site-specific pathologic analysis and impact on prognosis

Abstract

Objectives. To correlate the extent and location of positive surgical margins after radical prostatectomy with disease progression. Methods. Data on 495 patients who underwent radical prostatectomy by one surgeon were analyzed. All radical prostatectomy specimens were sectioned entirely using 2 to 3-mm step sections by one pathologist. One hundred fifty-one patients (30.5%) had one or more positive surgical margins and were subjected to further detailed analysis. Recurrence was defined as a serum prostate-specific antigen (PSA) level of 0.2 ng/mL and rising on at least two postoperative measurements. Results. The mean follow-up was 25.3 months (range 3 to 73). The overall recurrence rate was 13.3%. Neoadjuvant hormonal treatment was given to 37 (25%) of those with a positive margin. Patients with positive surgical margins had a significantly higher incidence of recurrence compared with those with negative margins (27.8% versus 6.9%, P = 0.001). The recurrence rate for various locations was 29% apex/urethra, 30% posterior, 33% anterior, 36% lateral, 48% posterolateral, and 57% bladder neck. Time to recurrence was shorter in patients older than 70 years ( P <0.055); with a preoperative PSA greater than 10 ng/mL ( P <0.0001); with a biopsy Gleason score greater than 7 ( P = 0.02); with a prostatectomy Gleason score greater than 7 ( P <0.001); with seminal vesicle invasion ( P = 0.0001); having more than 1 location of a positive margin ( P = 0.002); or having a positive margin at the bladder neck ( P = 0.0003) or the posterolateral surface of the prostate ( P = 0.02) compared with other locations. Multivariate proportional hazards analyses indicated that age older than 70 ( P = 0.005), a prostatectomy Gleason score of 7 ( P = 0.015) or 8 to 10 ( P = 0.003), and positive margin(s) at the bladder neck ( P = 0.003) were independently associated with a shorter time to recurrence among patients with a positive margin. Conclusions. In our study, among patients with positive surgical margins, those with multiple positive margins, or a margin involving the bladder neck or the posterolateral surface of the specimen carried a higher risk of progression. A positive margin at the bladder neck appears to be the most significant adverse prognostic indicator. This information may help in decisions regarding additional therapy.