Focal Positive Surgical Margins Research Articles

Alternative use of endocavitary probe to guide minimally invasive partial nephrectomy: is it reasonable?

ABSTRACTPurpose:To describe the use of endocavitary ultrasound probe as an auxiliary tool when performing partial nephrectomy in cases of endophytic renal tumors, to standardize the method, and to report the preliminary results achieved with this technique.Methods:Fifteen patients diagnosed with completely endophytic underwent partial nephrectomy with the use of an endocavitary ultrasound probe. This article describes the technique involved in partial nephrectomy and details the preparation of the endocavitary ultrasound probe to ensure its safe use.Results:All the patients had a RENAL score between 8 and 11. The median time of warm ischemia was 26 and 18 minutes for laparoscopic or robot-assisted surgery, respectively. The median duration of surgery was 150 minutes, and the median console time was 145 minutes for the laparoscopic and robot-assisted surgery groups, respectively. The median estimate of blood loss was 200 mL. Only three patients in the laparoscopic group had focal positive surgical margins. There were no cases of infection at the site of probe entry.Conclusions:Intraoperative use of an endocavitary ultrasound probe for partial nephrectomy is possible and a safe alternative to the excision of endophytic tumors when neither robotic probes nor laparoscopic probes are available.

Linear extent of positive surgical margin impacts biochemical recurrence after robot-assisted radical prostatectomy in a high-volume center

The objective of this study is to evaluate if surgeon volume and stratifying positive surgical margins (PSM) into focal and non-focal may differentially impact the risk of biochemical recurrence (BCR) after robot-assisted radical prostatectomy (RARP). Between January 2013 and December 2017, 732 consecutive patients were evaluated. The population included negative cases (control group) and PSM subjects (study group). PSMs were stratified as focal (≤ 1mm) or non-focal (> 1mm). A logistic regression model assessed the independent association of factors with the risk of PSM. The risk of BCR of PSM and other factors was assessed by Cox's multivariate proportional hazards. Overall, 192 (26.3%) patients had PSM focal in 133 patients; non-focal in 59 cases. Focal PSM was associated with the percentage of biopsy positive cores (BPC; OR 1.011; p = 0.015), extra-capsular extension (pT3a stage; OR 2.064; p = 0.016), seminal vesicle invasion (pT3b; OR 2.150; p = 0.010), body mass index (odds ratio, OR 0.914; p = 0.006), and high surgeon volume (OR 0.574; p = 0.006). BPC (OR 1.013; p = 0.044), pT3a (OR 4.832; p < 0.0001) and pT3b stage (OR 5.153; p = 0.001) were independent predictors of the risk of non-focal PSM. Surgeon volume was not a predictor of non-focal PSM (p = 0.224). Independent factors associated with the risk of BCR were baseline PSA (hazard ratio, HR 1.064; p = 0.004), BPC (HR 1.015; p = 0.027), ISUP biopsy grade group (BGG) 2/3 (HR 2.966; p 0.003) and BGG 4/5 (HR 3.122; p = 0.022) pathologic grade group 4/5 (HR 3.257; p = 0.001), pT3b (HR 2.900; p = 0.003), and non-focal PSM (HR 2.287; p = 0.012). Surgeon volume was not a predictor of BCR (p = 0.253). High surgeon volume is an independent factor that lowers the risk of focal PSM. Surgeon volume does not affect non-focal PSM and BCR. Negative as well as focal PSM are not associated with BCR.

Surgeon volume and body mass index influence positive surgical margin risk after robot-assisted radical prostatectomy: Results in 732 cases

ABSTRACTObjectives: To evaluate clinicopathological and perioperative factors associated with the risk of focal and non-focal positive surgical margins (PSMs) after robot-assisted radical prostatectomy (RARP).Patients and methods: The study was retrospective and excluded patients who were under androgen-deprivation therapy or had prior treatments. The population included: negative SM cases (control group), focal and non-focal PSM cases (study groups). PSMs were classified as focal when the linear extent of cancer invasion was ≤1 mm and non-focal when >1 mm. The independent association of factors with the risk of focal and non-focal PSMs was assessed by multinomial logistic regression.Results: In all, 732 patients underwent RARP, from January 2013 to December 2017. An extended pelvic lymph node dissection was performed in 342 cases (46.7%). In all, 192 cases (26.3%) had PSMs, which were focal in 133 (18.2%) and non-focal in 59 (8.1%). Independent factors associated with the risk of focal PSMs were body mass index (odds ratio [OR] 0.914; P = 0.006), percentage of biopsy positive cores (BPC; OR 1.011; P = 0.015), pathological extracapsular extension (pathological tumour stage [pT]3a; OR 2.064; P = 0.016), and seminal vesicle invasion (pT3b; OR 2.150; P = 0.010). High surgeon volume was a protective factor in having focal PSM (OR 0.574; P = 0.006). Independent predictors of non-focal PSMs were BPC (OR 1,013; P = 0,044), pT3a (OR 4,832; P < 0.001), and pT3b (OR 5,153; P = 0.001).Conclusions: In high-volume centres features related to host, tumour and surgeon volume are factors that predict the risk of focal and non-focal PSMs after RARP.Abbreviations: AJCC: American joint committee on cancer; AS: active surveillance; ASA: American society of anesthesiologists; BCR: biochemical recurrence; BMI: body mass index; BPC: percentage of biopsy positive cores; ePLND: extended lymph node dissection; H&E: haematoxylin and eosin; IQR, interquartile range; ISUP: international society of urologic pathology; LNI: lymph node invasion; LOS: length of hospital stay; mpMRI: multiparametric MRI; (c)(p)N: (clinical) (pathological) nodal stage; OR: odds ratio; OT: operating time; PSA-DT: PSA-doubling time; (P)SM: (positive) surgical margin; (NS)(RA)RP: (nerve-sparing) (robot-assisted) radical prostatectomy; RT: radiation therapy; (c)(p)T: (clinical) (pathological) tumour stage

Extent of positive surgical margins following radical prostatectomy: impact on biochemical recurrence with long-term follow-up

BackgroundTo assess the prognostic value of the extent of positive surgical margins (PSM) following radical prostatectomy (RP) on biochemical recurrence (BR) with long-term follow-up.MethodsThis retrospective study analyzed 1275 RPs performed between January 1992 and December 2013 in two university centers in Marseille (France). The inclusion criteria were: follow-up > 24 months, undetectable postoperative prostate-specific antigen (PSA), no seminal vesicle (SV) invasion, no lymph node invasion confirmed by surgery (pN0) or imaging (pNx), and no neoadjuvant or adjuvant treatment. BR was defined by PSA level ≥ 0.2 ng/mL on two successive samples. We included 189 patients, divided into two groups:- Focal PSM (fPSM): single PSM (sPSM) ≤3 mm;- Extensive PSM (ePSM): sPSM with linear length > 3 mm or several margins regardless of the length.ResultsThe median follow-up was 101 months (18–283) and the median age was 63 years (46–76). BR occurred in only 12.1% (14/115) of cases involving fPSM and in 54.1% (40/74) of cases involving ePSM. In the multivariate model, ePSM patients were significantly associated with increased BR compared to fPSM (hazard ratio [HR] = 6.11; 95% confidence interval [CI] = 3.25–11.49). The ePSM significantly decreased BR-free survival (p < 0.001) for every patient and every subgroup (pT2, pT3a, pG ≤6, and pG ≥7). The median BR time following RP was significantly shorter for ePSM patients than fPSM (57.2 vs. 89.2 months p < 0.001).ConclusionWith a median 8-year follow-up, ePSM was strongly associated with BR compared to fPSM. Therefore, it seems legitimate to monitor patients with fPSM. In cases of ePSM, adjuvant treatment appears effective.

Risk factors of positive surgical margins after robot-assisted radical prostatectomy in high-volume center: results in 732 cases.

The aim of the study was to evaluate clinical, pathological and peri-operative factors associated with the risk of positive surgical margins (PSM) after robot-assisted radical prostatectomy (RARP) in a high-volume center. The study is a retrospective analysis of prospectively collected data. We excluded cases who were under androgen deprivation or had prior treatments. The population included negative cases (control group) and PSM subjects (study groups). The logistic regression model assessed the independent association of factors with the risk of PSM. From January 2013 to December 2017, 732 patients underwent RARP. Extended pelvic lymph node dissection was performed in 342 cases (46.7%). Overall, 192 cases (26.3%) had PSM. Independent factors associated with the risk of focal PSM were body mass index (odds ratio, OR = 0.936; p = 0.021), percentage of biopsy-positive cores (BPC; OR = 1.012; p = 0.004), pathological extracapsular extension (OR = 2.702; p < 0.0001), seminal vesicle invasion (OR = 2.889; p < 0.0001) and high-volume surgeon (OR = 0.607; p = 0.006). In high-volume centers, features related to host, tumor biology and surgeon are independent factors associated with the risk of PSM after RARP, which are decreased by the high-volume surgeon. The inverse association between BMI and PSM risk needs further clinical research. These issues should be discussed when counseling patients.

Hypofractionated whole breast radiotherapy with or without hypofractionated boost in early stage breast cancer patients: a mono-institutional analysis of skin and subcutaneous toxicity.

Our study evaluated skin and subcutaneous toxicity analyzing its correlation with patient- and treatment-related factors in a large mono-institutional series of women with early stage breast cancer treated with adjuvant hypofractionated whole breast radiotherapy (WBRT) with or without a sequential hypofractionated boost (HB). Two hundred and nineteen patients, median age 62years, received adjuvant hypofractionated WBRT in 16 fractions to a total dose of 42.4Gy. Patients with negative prognostic factors received a HB of 2.65Gy for 4 or 5 (patients with focal positive surgical margins) fractions. Systemic adjuvant treatments were hormonal therapy (HT) and/or chemotherapy (CHT) and/or Trastuzumab. Toxicities were assessed using the Common Terminology Criteria for Adverse Events (CTCAE 4.03) scale at 5th, 10th, 16th, 20th day from the start of radiotherapy (RT) and 1, 6 and 12months after the end of RT. Univariate and multivariate analysis estimated toxicity predictive factors. No case of treatment interruption and no acute or late G3 toxicities occurred. In the univariate analysis HB administration resulted a risk factor for acute toxicity, while CHT administration and number of excised lymph nodes ≥ 10 resulted a risk factor for late toxicity. In the multivariate analysis none of the evaluated factors emerged a risk factor for acute and/or late toxicity. Our results confirmed that hypofractionated WBRT even followed by a HB resulted safe and well tolerated. Longer follow-up is warranted to estimate late toxicity and treatment outcomes.

Positive Association between Preoperative Total Testosterone Levels and Risk of Positive Surgical Margins by Prostate Cancer: Results in 476 Consecutive Patients Treated Only by Radical Prostatectomy

Objective: To evaluate preoperative total testosterone (TT) as a predictor of positive surgical margins (PSM) in prostate cancer (PCA). Patients and methods: During the period from November 2014 to July 2017, preoperative TT was measured in 476 PCA patients undergoing only radical prostatectomy (RP) and including all risk classes. Surgical margins were stated negative, focal positive (single and less than 1 mL), and multifocal positive (more than 1). The risk of TT and clinical factors associated with the risk of PSM (focal or multifocal versus negative) was evaluated by the multinomial logistic regression model. Results: Overall, PSM were detected in 149 cases (31.3%), which included 99 patients with focal cancer invasion (20.8%) and 50 subjects with multifocal cancer invasion (10.5%). In univariate analysis, PSM associated with higher median levels of TT and prostate-specific antigen than controls. Multifocal PSM associated with higher rates of high-risk PCA (42%) than focal (22.2%) or control cases (18.3%). In multivariate analysis, TT was the only independent factor positively associated with the risk of focal PSM when compared to controls (OR 1.002; p = 0.035). TT (OR 1.003; p = 0.002) and high-risk PCA (OR 1.002; p = 0.047) were independent factors, which positively associated with the risk of multifocal PSM when compared to controls. Risk models were computed. Conclusions: In a large and contemporary cohort of patients elected to primary RP, TT was an ­independent positive factor associated with the risk of focal and multifocal PSM. TT associated with aggressive PCA biology.

Prognostic Value of Focal Positive Surgical Margins After Radical Prostatectomy

BackgroundThe significance of focal positive margins (FPMs) after radical prostatectomy (RP) is unclear. Our objective was to investigate the prognostic value of FPMs in patients undergoing RP. Materials and MethodsThe data were analyzed retrospectively for 1733 patients with clinically localized prostate cancer who had undergone RP at our institution from December 2003 to March 2014 without neoadjuvant or adjuvant therapy. Positive surgical margins were characterized as FPMs (≤ 3 mm long) or non-FPMs (> 3 mm long). Multivariate analysis of the clinicopathologic factors, including FPMs, was performed with respect to biochemical recurrence (BCR)-free survival. ResultsOf the 1733 patients, 1260 (72.7%) had negative margins, 114 (6.6%) had a FPM, 218 (12.6%) had a nonfocal single positive margin (NFSPM), and 141 (8.1%) had nonfocal multiple positive margins (NFMPMs). Of the patients with pathologic T2 prostate cancer, 1065 (84.3%) had negative margins, 62 (4.9%) had 1 FPM, 104 (8.2%) had 1 NFSPM, and 33 (2.6%) had NFMPMs. The 5-year BCR-free survival for patients with negative margins and FPMs was 90% and 83.4%, respectively. On multivariate analysis, the presence of a FPM was not a significant prognostic factor for BCR-free survival in all the patients or in the patients with pathologic T2 disease (P = .458 and P = .512, respectively). ConclusionsFPMs after RP do not significantly affect BCR-free survival in patients with prostate cancer.

V9-01 ROBOTIC PARTIAL NEPHRECTOMY FOR MULTIPLE RENAL TUMORS

You have accessJournal of UrologyRobotics – Renal1 Apr 2015V9-01 ROBOTIC PARTIAL NEPHRECTOMY FOR MULTIPLE RENAL TUMORS Deepansh Dalela, Ravi Barod, and Craig Rogers Deepansh DalelaDeepansh Dalela More articles by this author , Ravi BarodRavi Barod More articles by this author , and Craig RogersCraig Rogers More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2276AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic partial nephrectomy (RPN) in the setting of multiple renal tumors presents unique challenges. While previous reports have documented its feasibility, loner median operative times and length of stay have also been noted. In this video, we present key steps of performing robotic partial nephrectomy in multiple renal tumors. METHODS In this video, we show footage from different cases to highlight the four key areas in RPN for multiple renal tumors. First, we show the use of 4th arm for kidney retraction, allowing two-handed renal hilar dissection, followed by adequate kidney mobilization for providing optimal tumor exposure. Next, intraoperative ultrasound may be used for accurate anatomical identification of margins. Finally, we show techniques of on-demand ischemia, selective clamping, early unclamping, and cooling the kidney using ice to minimize ischemic damage to the kidney. RESULTS From 2008 to 2014, 30 patients underwent RPN for multiple renal tumors at our institution (Table 1). The mean size of the index tumor was 2.8 cm, and the RENAL nephrometry score was 8. Acceptable operating and warm ischemia times and estimated blood loss were achieved. There were two episodes of intraoperative bleeding. Focal positive surgical margins were seen in two patients who underwent tumor enucleation, one for hereditary papillary renal cell carcinoma (RCC) and the other for sporadic RCC. Both the patients were free of recurrence at two years follow-up CONCLUSIONS We present one of the largest single-center case series for multiple renal tumors exclusively undergoing RPN. Judicious use of the 4th arm, greater mobilization of the kidney for tumor exposure, use of the intraoperative ultrasound, and clamping modifications to reduce ischemic damage to the kidney may facilitate RPN in the setting of multiple tumors. Variables (n=30) Result Age; mean (SD) 60.8 (7.2) Index tumor diameter (cm); mean (SD) 2.8 (1) Nephrometry score (index tumor); median (IQR) 8 (7-9) OR time (min); median (IQR) 234 (211-272) Estimated blood loss (ml); median (IQR) 100 (93-212) Warm ischemia time (min); median (IQR) 22 (19-27) Intra-operative complications; n (%) 2 (6.7) Post-operative complications; n (%) 7 (24.1) Length of stay (days); median (IQR) 3 (2-3) Positive surgical margins (focal); n (%) 2 (6.7) © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e775 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Deepansh Dalela More articles by this author Ravi Barod More articles by this author Craig Rogers More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Controversial predictors of biochemical recurrence after radical prostatectomy: a study from a Latin American (Brazilian) Institution

To analyze controversial clinicopathologic predictors of biochemical recurrence after surgery: age, race, tumor extent on surgical specimen, tumor extent on needle biopsy, Gleason score 3 + 4 vs 4 + 3, and amount of extent of extraprostatic extension and positive surgical margins. The needle biopsies and the correspondent surgical specimens were analyzed from 400 patients. Time to recurrence was analyzed with the Kaplan-Meier curves and risk of shorter time to recurrence using Cox univariate and multivariate analysis. Except for age, race, maximum percentage of cancer per core, and number of cores with cancer, all other variables studied were significantly predictive of time to biochemical recurrence using the Kaplan-Meier curves. In univariate analysis, except for focal extraprostatic extension, age, race, focal positive surgical margins, and maximum extent and percentage of cancer per core, all other variables were significantly predictive of shorter time to recurrence. On multivariate analysis, diffuse positive surgical margins and preoperative PSA were independent predictors. Young patients and non-whites were not significantly associated with time to biochemical recurrence. The time consuming tumor extent evaluation in surgical specimens seems not to add additional information to other well established predictive findings. The higher predictive value of Gleason score 4 + 3 = 7 vs 3 + 4 = 7 discloses the importance of grade 4 as the predominant pattern. Extent and not simply presence or absent of extraprostatic extension should be informed. Most tumor extent evaluations on needle biopsies are predictive of time to biochemical recurrence, however, maximum percentage of cancer in all cores was the strongest predictor.

Alternative techniques to reduce warm ischemia time in laparoscopic partial nephrectomy

Demonstrate two alternatives that permit a warm ischemia time reduction during laparoscopic partial nephrectomy. In this video, two cases of intermediate complexity renal tumors according to the RENAL nephrometry renal scoring system illustrating the techniques and our preliminary experience: a 65 year old man with a 4 cm right, posterior renal tumor. This patient underwent an early unclamping and parenchymal suturing using a greek bar continuous suture with hem-o-lock clips attached to the respective extremities of the suture; The second patient is a 49 year old man with a 3 cm renal tumor. The technique utilized was no clamping resection following the ABC Medical School technique: dissection of renal hilum for eventual clamping if necessary, a frontal 360 degrees visualization of tumor limits, pneumoperitoneum pressure elevated to 25mmHg during tumor resection, spiral excavation of normal parenchyma around the tumor and resection with negative margins. We previously performed 15 cases utilizing the early unclamping technique. The mean clamp time was 15 minutes with a mean blood loss of 285 mL. Only 1 patient had focal positive surgical margins, without recurrence demonstrated at 30 months. Fifteen partial nephrectomies were previously performed with on demand clamping. In 3 cases, clamping was necessary with a mean ischemia time of 11 minutes. The mean blood loss was 390 mL and 2 cases required a perioperative blood transfusion. One case presented with a positive focal margin without recurrence demonstrated at 24 months of follow-up. Renal function was preserved in all cases regardless of the technique applied. Warm ischemia time can be reduced and kidney function can be preserved during laparoscopic nephrectomy if either early unclamping or on demand clamping are selectively applied.

The clinical significance of in-depth pathological assessment of extraprostatic extension and margin status in radical prostatectomies for prostate cancer

Despite recent Level 1 evidence on the benefits of adjuvant radiotherapy for locally advanced prostate cancer (PCa), the timing and decision to administer adjuvant radiotherapy post-radical prostatectomy (post-RP) remains debatable, particularly for patients with focal extraprostatic extension (EPE) and/or focal positive surgical margins (PSMs). In this study, we assess the utility of detailed pathological assessment of EPE and PSM, as this may influence the criteria for instituting adjuvant radiotherapy. A total of 148 RP cases (1993-2001) were identified retrospectively as having EPE and/or PSM. All slides were re-reviewed, incorporating recent proposals by the Collage of American Pathologists (CAP) for the reporting of EPE and PSM, and correlated with clinical data. Both EPE and PSM were found to be independent predictors of biochemical failure (BCF); however, only EPE was associated with metastasis and death. BCF was also more likely to be associated with cases that had non-focal EPE than focal EPE. Similarly, non-focal PSM cases had a significantly higher risk of BCF than focal cases. Our study confirms the value of detailed pathological assessment of EPE and PSM post-RP. The results support the concept of selective adjuvant radiotherapy in patients with EPE and PSM, based on focality and extent.

Tumor Volume in Radical Prostatectomy Specimens Assessed by Digital Image Analysis Software Correlates With Other Prognostic Factors

Digital image analysis software to review histopathology specimens is advancing uropathology by objectivity and reproducibility. Subjective pathologist assessed prostate tumor volume calculations correlate with known prognostic factors at radical prostatectomy. We ascertained whether image analysis software calculations of prostate tumor volume correlate with such prognostic factors, particularly positive surgical margins. Prostate tumor volume was calculated using digital image analysis software in 851 sequential radical prostatectomy specimens. Results were correlated with clinicopathological data by logistic regression. Median prostate tumor volume was 2.2 cc (IQR 0.9-3.8). Median peripheral and transition zone tumor volume was 1.9 and 0.6 cc, respectively. Transition zone tumors were noted in 236 specimens (27.8%) and positive surgical margins occurred in 244 (28.7%). Tumors with extensive positive surgical margins had larger image analysis software assessed prostate tumor volume (p = 0.029) and peripheral zone volume (p = 0.007) than those with only focal positive surgical margins. On univariate analysis positive surgical margin tumors were larger and had seminal vesicle invasion, extraprostatic extension, perineural invasion and higher preoperative prostate specific antigen than those without positive surgical margins (each p <0.001). A linear relationship existed between image analysis software determined prostate tumor volume, and increasing tumor stage, Gleason score and prostate specific antigen (p for trend <0.001). On multivariate analysis tumor volume and tumor volume as a percent of prostate volume predicted positive surgical margins. Prostate tumor volume determined objectively by image analysis software correlates with positive surgical margins, as do prognostic variables such as extraprostatic extension, seminal vesicle invasion, perineural invasion, peripheral zone volume and Gleason score greater than 7. Objective digital image analysis software assessment appears to be a valid form to determine prostate tumor volume at radical prostatectomy. It is a useful adjunct to other histopathological analyses.

Focal Positive Surgical Margins Decrease Disease-free Survival After Radical Prostatectomy Even in Organ-confined Disease

To investigate the significance of focal positive margins (FPM) in prostatectomy patients. The significance of FPM after radical prostatectomy is unclear. The implication is that FPM are surgically induced, may not represent true tumor extension beyond the prostate, and thus would not affect disease-free survival (DFS). Data were retrospectively reviewed from 2468 patients undergoing radical prostatectomy between January 1996 and October 2008. The DFS probabilities were compared among different margin statuses (negative [NM], FPM, and extensively positive [EPM]) with the log-rank test. FPM was defined as less than/equal to 3 mm. EPM was greater than 3 mm. A multivariate Cox analysis was performed to evaluate the significance of FPM in patients with prostate cancer. Of all patients, 2022 (82%) had NM, 344 (14%) had FPM, and 99 (4%) had EPM. Of the 1997 patients with pT2 disease, 1716 (86%) had NM, 229 (11.5%) had FPM, and 52 (2.6%) had EPM. The 10-year DFS for all patients was 84%, 64%, 38% for NM, FPM, and EPM, respectively (P < .0001). The 10-year DFS for organ-confined disease was 90%, 76%, and 53% for NM, FPM, and EPM, respectively (P < .0001). The risk of biochemical recurrence for all patients increases with worsening margin status. Margin status affects biochemical recurrence and depends on the Gleason grade on surgical pathology for all patients (P = .0005) and patients with pT2 disease (P = .0233). FPM and EPM after radical prostatectomy confer a decreased DFS even in patients with otherwise organ-confined disease.

Location, Extent and Number of Positive Surgical Margins Do Not Improve Accuracy of Predicting Prostate Cancer Recurrence After Radical Prostatectomy

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. 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. 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). 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.

Focal Positive Surgical Margins Decrease Disease-Free Survival Following Radical Prostatectomy Even in Organ-Confined Disease

Focal Positive Surgical Margins Decrease Disease-Free Survival Following Radical Prostatectomy Even in Organ-Confined Disease