Positive Surgical Margins In Patients Research Articles

Presence of positive surgical margin in patients with organ-confined prostate cancer equals to extracapsular extension negative surgical margin. A plea for TNM staging system reclassification

BackgroundTo test the hypothesis that patients with pT2 and positive surgical margins (SM) have a similar biochemical-recurrence (BCR) risk to patients with pT3a, and negative SM. Moreover, we examined the effect of incorporating positive SM as a higher stage on the discrimination accuracy of the current TNM staging system. Materials and methodsWe evaluated 1,503 prostate cancer patients treated with radical prostatectomy, between 1998 and 2010. Only individuals with pT2N0 or pT3aN0, without neoadjuvant and/or adjuvant therapy, were included. Cox regression analyses tested the relationship between SM status (negative [R0] vs. positive [R1]) and BCR rate, after stratification according to T stage. Predictive accuracy of the current T stage and of a novel T stage, which consider positive SM as a higher stage, was quantified with Harrell's concordance index. ResultsPositive SM rate was 20.3%. The 5-year BCR rates were 96%, 82%, 78%, and 62% for patients with, respectively, pT2R0, pT2R1, pT3aR0, and pT3a1 (all P ≤ 0.03). In multivariable analyses, the BCR rate was 3.6-, 2.5-, and 6.0-fold higher (all P < 0.001) in patients with, respectively, pT2R1, pT3aR0, and pT3aR1 stage relative to patients with pT2R0 stage. The maximum univariable (14.1%) and multivariable (6.9%) discrimination accuracy gains were observed, when tumor stage was stratified into pT2R0 vs. pT2R1/pT3R0 vs. pT3R1. ConclusionsThe presence of positive SM at radical prostatectomy (RP) specimen substantially increases the BCR risk. Patients with pT2R1 have similar BCR risk to patients with pT3aR0. Considering these patients as 1 category substantially improves the discrimination accuracy of the current TNM staging system.

Dosimetric and motion analysis of margin-intensive therapy by stereotactic ablative radiotherapy for resectable pancreatic cancer

BackgroundThe retroperitoneal margin is a common site of positive surgical margins in patients with resectable pancreatic cancer. Preoperative margin-intensive therapy (MIT) involves delivery of a single high dose of ablative radiotherapy (30 Gy) focused on this surgically inaccessible margin, utilizing stereotactic techniques in an effort to reduce local failure following surgery. In this study, we investigated the motion of regional organs at risk (OAR) utilizing 4DCT, evaluated the dosimetric effects of abdominal compression (AC) to reduce regional motion, and compared various planning techniques to optimize MIT.Methods10 patients were evaluated with 4DCT scans. All 10 patients had scans using AC and seven of the 10 patients had scans both with and without AC. The peak respiratory abdominal organ and major vessel centroid excursion was measured. A "sub-GTV" region was defined by a radiation oncologist and surgical oncologist encompassing the retroperitoneal margin typically lateral and posterior to the superior mesenteric artery (SMA), and a 3-5 mm margin was added to constitute the PTV. Identical 3D non-coplanar SABR (3DSABR) plans were designed for the average compression and non-compression scans. Compression scans were planned with 3DSABR, coplanar IMRT (IMRT), and Cyberknife (CK) planning techniques. Dose volume analysis was undertaken for various endpoints, comparing OAR doses with and without AC and for different planning methods.ResultsThe mean PTV size was 20.2 cm3. Regional vessel motion of the SMA, celiac trunk, and renal vessels was small (< 5 mm) and not significantly impacted by AC. Mean pancreatic motion was > 5 mm, so AC has been used in all patients enrolled thus far. AC did not significantly increase OAR dose including the stomach and traverse colon. There were several statistically significant differences in the doses to OARs as a function of the type of planning modality used.ConclusionsAC does not significantly reduce the limited motion of structures in close proximity to the MIT target and does not significantly increase the dose to OARs that can be displaced by the compression plate. The treatment planning techniques evaluated in this study have different advantages with no clearly superior method in our analysis. Dose to adjacent vessels may be reduced with 3DSABR or IMRT techniques, while conformality is increased with IMRT or CK.

Impact of Prostate Weight on Probability of Positive Surgical Margins in Patients With Low-risk Prostate Cancer After Robotic-assisted Laparoscopic Radical Prostatectomy

To evaluate the impact of prostate weight (PW) on probability of positive surgical margin (PSM) in patients undergoing robotic-assisted radical prostatectomy (RARP) for low-risk prostate cancer. The cohort consisted of 690 men with low-risk prostate cancer (clinical stage T1c, prostate-specific antigen <10 ng/mL, biopsy Gleason score ≤6) who underwent RARP with bilateral nerve-sparing at our institution by 1 of 2 surgeons from 2003 to 2009. PW was obtained from the pathologic specimen. The association between probability of PSM and PW was assessed with univariate and multivariate logistic regression analysis. A PSM was identified in 105 patients (15.2%). Patients with PSM had significant higher prostate-specific antigen (P = .04), smaller prostates (P = .0001), higher Gleason score (P = .004), and higher pathologic stage (P < .0001). After logistic regression, we found a significant inverse relation between PSM and PW (OR 0.97%; 95% confidence interval [CI] 0.96, 0.99; P = .0003) in univariate analysis. This remained significant in the multivariate model (OR 0.98%; 95% CI 0.96, 0.99; P = .006) adjusting for age, body mass index, surgeon experience, pathologic Gleason score, and pathologic stage. In this multivariate model, the predicted probability of PSM for 25-, 50-, 100-, and 150-g prostates were 22% (95% CI 16%, 30%), 13% (95% CI 11%, 16%), 5% (95% CI 1%, 8%), and 1% (95% CI 0%, 3%), respectively. Lower PW is independently associated with higher probability of PSM in low-risk patients undergoing RARP with bilateral nerve-sparing.

Surgical Margin Status After Robot Assisted Radical Cystectomy: Results From the International Robotic Cystectomy Consortium

Positive surgical margins at radical cystectomy confer a poor prognosis. We evaluated the incidence and predictors of positive surgical margins in patients who underwent robot assisted radical cystectomy for bladder cancer. Using the International Robotic Cystectomy Consortium database we identified 513 patients who underwent robot assisted radical cystectomy, as done by a total of 22 surgeons at 15 institutions from 2003 to 2009. After stratification by age group, gender, pathological T stage, nodal status, sequential case number and institutional volume logistic regression was used to correlate variables with the likelihood of a positive surgical margin. Of the 513 patients 35 (6.8%) had a positive surgical margin. Increasing 10-year age group, lymph node positivity and higher pathological T stage were significantly associated with an increased likelihood of a positive margin (p = 0.010, <0.001 and p <0.001, respectively). Gender, sequential case number and institutional volume were not significantly associated with margin positivity. The rate of margin positive disease at cystectomy was 1.5% for pT2 or less, 8.8% for pT3 and 39% for pT4 disease. Positive surgical margin rates at robot assisted radical cystectomy for advanced bladder cancer were similar to those in open cystectomy series in a large, multi-institutional, prospective cohort. Sequential case number, a surrogate for the learning curve and institutional volume were not significantly associated with positive margins at robot assisted radical cystectomy.

1557 ROLE OF POSITIVE SURGICAL MARGINS IN PATIENTS WITH ORGAN CONFINED PROSTATE CANCER. IMPLICATIONS FOR ADJUVANT TREATMENTS

You have accessJournal of UrologyProstate Cancer: Localized VI1 Apr 20101557 ROLE OF POSITIVE SURGICAL MARGINS IN PATIENTS WITH ORGAN CONFINED PROSTATE CANCER. IMPLICATIONS FOR ADJUVANT TREATMENTS Alberto Briganti, Nazareno Suardi, Umberto Capitanio, Umberto Capitanio, Andrea Salonia, Andrea Russo, Lorenzo Rocchini, Claudio Doglioni, Cesare Cozzarini, Giorgio Guazzoni, Patrizio Rigatti, and Francesco Montorsi Alberto BrigantiAlberto Briganti More articles by this author , Nazareno SuardiNazareno Suardi More articles by this author , Umberto CapitanioUmberto Capitanio More articles by this author , Umberto CapitanioUmberto Capitanio More articles by this author , Andrea SaloniaAndrea Salonia More articles by this author , Andrea RussoAndrea Russo More articles by this author , Lorenzo RocchiniLorenzo Rocchini More articles by this author , Claudio DoglioniClaudio Doglioni More articles by this author , Cesare CozzariniCesare Cozzarini More articles by this author , Giorgio GuazzoniGiorgio Guazzoni More articles by this author , Patrizio RigattiPatrizio Rigatti More articles by this author , and Francesco MontorsiFrancesco Montorsi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1322AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Recent prospective, randomized trials have shown a positive impact of adjuvant radiation therapy (RT) in patients (pts) with Gleason 6-10 and positive surgical margins (SM+). However, despite a trend toward significance even in pts with organ confined (pT2) disease, these studies enrolled only few patients with pT2 SM+. We hypothesized that the outcome of patients with pT2 and SM+ have heterogeneous outcome which differ according to other cancer characteristics. METHODS The study included 1637 ps with node-negative, pT2 disease treated with radical prostatectomy (RP) and pelvic lymph node dissection (PLND) for clinically localized prostate cancer between 1986 and 2007 at a single European tertiary referral center. All pts had complete clinical and pathological data. Pts were divided into 4 groups according to pathological characteristics: pT2 Gleason 6 and negative SM (SM-; group 1; n=861, 52.6%), pT2 Gleason 6 and SM+ (n=123, 7.5%; group 2), pT2 Gleason 7-10 SM- (n=429; 30.1%; group 3), pT2 Gleason 7-10 SM+ (n=161;9.8%; group 4). No pts received any adjuvant treatment after surgery. The Kaplan Meier method assessed the rate of biochemical recurrence (BCR) defined as two consecutive PSA values >0.2 ng/ml. Multivariable Cox regression models tested the association between SM+ and BCR in each category after accounting for pre-op PSA and pathological Gleason sum RESULTS Mean PSA at RP was 7.3 ng/ml (median 6.2 ng/ml; range: 0.4-40 ng/ml). RP Gleason sum was ¡Ü6, 7 and 8-10 in 60.1, 37 and 2.9% pts, respectively. Overall, BCR free survival rates at 2,5 and 8 years were 96,91 and 84%, respectively. Overall, pts with SM+ had significantly lower 2,5 and 8 BCR free survival rates compared to pts with SM- (91, 80 and 76 vs 98,93 and 86% vs respectively; p<0.001). However, when stratified according to Gleason sum, pts with SM+ and Gleason 6 (group 2) had similar 2,5 and 8 year BCR free survival rates as compared to pts with Gleason 6 and SM- (group 1; 95,89 and 89 vs 98,94 and 89%; p=0.2). Conversely, pts with SM+ and high Gleason score (7-10; group 4) had significantly lower 2,5 and 8 year BCR free survival rates as compared to pts with high Gleason but SM- (group 3; 87,71 and 60 vs 96,89 and 76%; p<0.001). At multivariable analyses where presence of SM+ was a significant predictor of BCR only in patients with high Gleason score (HR: 2.6; p=0.01) CONCLUSIONS We demonstrated that SM+ in pT2 disease matters only in presence of high Gleason score. Our results seem to indirectly suggest that, even in presence of SM+, pts with lower Gleason might not be considered candidates for adjuvant treatments Milan, Italy© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e601-e602 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alberto Briganti More articles by this author Nazareno Suardi More articles by this author Umberto Capitanio More articles by this author Umberto Capitanio More articles by this author Andrea Salonia More articles by this author Andrea Russo More articles by this author Lorenzo Rocchini More articles by this author Claudio Doglioni More articles by this author Cesare Cozzarini More articles by this author Giorgio Guazzoni More articles by this author Patrizio Rigatti More articles by this author Francesco Montorsi More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

How Do You Tell Whether a Change in Surgical Technique Leads to a Change in Outcome?

Surgeons routinely evaluate and modify their surgical technique to improve patient outcome. It is also common for surgeons to analyze results before and after a change in technique to determine whether the change led to better results. Simple comparison of results before and after surgical modification may be confounded by the surgical learning curve. We developed a statistical method applicable to analyzing before/after surgical studies. We used simulation studies to compare different statistical analyses of before/after studies. We evaluated a simple 2-group comparison of results before and after the modification by the chi-square test and a novel bootstrap method that adjusts for the surgical learning curve. In the presence of the learning curve a simple 2-group comparison almost always showed an ineffective surgical modification to be of benefit. When the surgical modification was harmful, leading to a 10% decrease in the success rate, 2-group comparison nonetheless showed a statistically significant improvement in outcome about 80% of the time. The bootstrap method had only moderate power but did not show that ineffective surgical modifications were beneficial more than would be expected by chance. Simplistic approaches to the analysis of before/after surgical studies may lead to grossly erroneous results under the surgical learning curve. A straightforward alternative statistical method allows investigators to separate the effects of the learning curve from those of the surgical modification.

Editorial Comment

The authors present data regarding the limited effect of a positive parenchymal margin during partial nephrectomy on cancer-specific outcomes. Despite the finding of a positive margin in 17 patients (15%), only 2 of 13 sites assessed pathologically by either repeat resection or nephrectomy were found to contain residual cancer. None of these 17 patients experienced a recurrence or death due to renal cancer. These data agree with several other recent publications indicating that positive margins during partial nephrectomy have limited effect on cancer-specific outcomes. 1 Yossepowitch O. Thompson R.H. Leibovich B.C. et al. Positive surgical margins at partial nephrectomy: predictors and oncological outcomes. J Urol. 2008; 179: 2158-2163 Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar , 2 Kwon E.O. Carver B.S. Snyder M.E. et al. Impact of positive surgical margins in patients undergoing partial nephrectomy for renal cortical tumours. BJU Int. 2007; 99: 286-289 Crossref PubMed Scopus (113) Google Scholar , 3 Permpongkosol S. Colombo J.R. Gill I.S. et al. Positive surgical parenchymal margin after laparoscopic partial nephrectomy for renal cell carcinoma: oncological outcomes. J Urol. 2006; 176: 2401-2404 Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar Although recent data indicate that enucleation (tumor resection without a margin) provides excellent oncologic outcomes, 4 Carini M. Minervini A. Masieri L. et al. Simple enucleation for the treatment of PT1a renal cell carcinoma: our 20-year experience. Eur Urol. 2006; 50 (discussion: 1269-1271): 1263-1268 Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar we believe that the goal of partial nephrectomy is complete tumor resection with a minimal rim of normal parenchyma. 5 Castilla E.A. Liou L.S. Abrahams N.A. et al. Prognostic importance of resection margin width after nephron-sparing surgery for renal cell carcinoma. Urology. 2002; 60: 993-997 Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar We agree with the authors' conclusion that in a majority of cases, a positive margin should not prompt immediate or delayed radical nephrectomy. Positive Surgical Margins With Renal Cell Carcinoma Have a Limited Influence on Long-term Oncological Outcomes of Nephron Sparing SurgeryUrologyVol. 75Issue 2PreviewTo define the rate of positive surgical margins (PSMs) and analyze the outcome of patients with PSMs. The outcome and proper management of patients with positive PSMs during nephron sparing surgery (NSS) are questionable. In this study we define the clinical outcomes of PSMs at NSS and suggest management. Full-Text PDF

Editorial Comment

The authors have confirmed a growing body of evidence showing that positive soft-tissue surgical margins significantly reduces the recurrence-free, disease-specific, and overall survival of patients with invasive bladder cancer after radical cystectomy. A positive margin is a harbinger of local recurrence and eventual death from bladder cancer. Surprisingly, the authors also showed that even patients with positive margins and node-negative disease had better survival if >15 lymph nodes were removed. This suggests that meticulous pelvic lymph node dissection might improve surgical cure of patients with locally advanced bladder cancer. A Thorough Pelvic Lymph Node Dissection in Presence of Positive Margins Associated With Better Clinical Outcomes in Radical Cystectomy PatientsUrologyVol. 74Issue 1PreviewTo evaluate the effect of positive surgical margins in patients with muscle-invasive transitional cell carcinoma of the bladder on survival. Full-Text PDF Editorial CommentUrologyVol. 74Issue 1PreviewThis article is a retrospective survey of radical cystectomy and pelvic lymph node dissection (PLND) for urothelial cancer performed by a single surgeon, at a single institution, during an 18-year period. In the entire cohort of patients, the authors report that positive surgical margins have a decidedly adverse influence on recurrence-free survival, as well as disease-specific and overall survival (OS), an observation already cited in other cystectomy series. This is not surprising in this series, particularly because some of the procedures were performed for palliation rather than cure, ensuring that a number of patients (the authors do not report how many) had advanced disease at surgery. Full-Text PDF

A Thorough Pelvic Lymph Node Dissection in Presence of Positive Margins Associated With Better Clinical Outcomes in Radical Cystectomy Patients

To evaluate the effect of positive surgical margins in patients with muscle-invasive transitional cell carcinoma of the bladder on survival. A retrospective evaluation of a prospectively maintained radical cystectomy database consisting of the data from 344 patients was performed. Cox regression analysis was done, and Kaplan-Meier tables were developed to evaluate the contribution of this finding to clinical outcomes. A total of 304 (88.4%) patients had negative surgical margins in the radical cystectomy specimen, and 40 (11.6%) had positive surgical margins. On univariate analysis, positive surgical margins conferred a significant risk of poorer clinical outcomes. The 5-year overall (OS) and disease-specific survival (DSS) rate was 9% and 18% for patients with positive margins compared with 48% and 65% for patients with negative margins, respectively. The multivariate analysis demonstrated a significant independent risk of decreased recurrence-free survival, DSS, and OS for patients with positive surgical margins. The corresponding hazard ratios were 2.29 (95% confidence interval 1.54-3.41, P < .001), 1.71 (95% confidence interval 1.15-2.56, P < .009), and 1.70 (95% confidence interval 1.23-2.34, P < .001). Despite these findings, patients with positive margins and node-negative disease experienced improved DSS and recurrence-free survival (P = .001 P and = .009, respectively) if >15 lymph nodes were removed during surgery. The presence of positive surgical margins in the pathologic specimen confers a significant independent risk of reduced recurrence-free survival, DSS, and overall survival. Nevertheless, patients with positive surgical margins will still benefit from a meticulous pelvic lymph node dissection.

Impact of positive surgical margins in patients undergoing partial nephrectomy for renal cortical tumours

To evaluate the clinical outcome of patients undergoing partial nephrectomy (PN) for renal cortical tumours who had a positive surgical margin (SM), as recent studies have shown that a minimal SM is required to achieve equivalent disease-free survival (DFS). Between 1989 and 2005, 777 PNs were performed at the authors' institution. Clinical and pathology data were obtained from our prospective surgical database after obtaining institutional review board approval. Variables were analysed in a logistic regression model to determine predictors of positive SMs. The clinical outcome was reported for local recurrence and distant metastasis and analysed using the log-rank test. Of the 777 PNs, the SM status was documented in 770; the SMs were positive in 57 of 770 (7%). Positive SMs occurred in 33 of 423 (8%) patients with tumours of high malignant potential, and in 24 of 347 (7%) patients with tumours of low malignant potential. On multivariate analysis, an imperative indication for a PN was a significant predictor for a positive SM (P = 0.003). With a median follow-up for survivors of 22 months, there was a local recurrence in two of 57 (4%) patients with a positive SM and four of 713 (0.5%) with a negative SM. No patients with a tumour of low malignant potential had a recurrence, despite having a positive SM. Although local recurrence after PN for renal cortical tumours is rare, our data suggest that patients with a tumour of high malignant potential and a positive SM might have a higher incidence of local recurrence.

Laparoscopic Radical Prostatectomy: Impact of Modified Apical and Posterolateral Dissection In Reduction of Positive Surgical Margins in Patients with Clinical Stage T2 Prostate Cancer and High Risk of Extracapsular Extension

To determine whether modifications of extraperitoneal endoscopic radical prostatectomy (EERP) reduce the rate of a positive surgical margin (PSM) in men with clinical stage T(2) prostate cancer and a high risk of extracapsular extension. A consecutive series of 182 men with stage cT(2) tumors and a high risk of extracapsular extension underwent EERP by a single surgeon (VP). The patients were divided into two groups: 71 patients who underwent a standard EERP (group 1) and 111 patients who underwent EERP with the modified technique (group 2). The basic principles of the modified technique are more thorough and wider resection of the posterolateral prostatic pedicles and extensive excision of periprostatic soft tissue at the apex, which results in better mobilization and exposure of the apex before the urethral transection. Differences in PSM rates were analyzed statistically. No significant differences were found between the two groups regarding the clinical and pathologic findings (P > 0.05). The rate of PSM was 28% in group 1 and 10% in group 2 (P < 0.001). Group 2 was less than one third as likely to have PSM as group 2 (odds ratio 2.9; 95% confidence interval 1.6, 3.9). The strongest (P < 0.0001) independent predictors of PSM were the surgical technique, the presence of extracapsular disease, and the volume of the cancer. Preservation of the neurovascular bundles had no impact on margin status (P = 0.93). Functional outcomes and complication rates were not adversely affected by these modifications. The modified dissection in EERP significantly reduces the rate of PSM in patients with stage cT(2) prostate cancer and a high risk of extracapsular extension.

1125: Impact of Positive Surgical Margins in Patients Undergoing Partial Nephrectomy for Renal Cortical Tumors

1125: Impact of Positive Surgical Margins in Patients Undergoing Partial Nephrectomy for Renal Cortical Tumors

Real-Time Transrectal Ultrasound Guidance During Laparoscopic Radical Prostatectomy: Impact on Surgical Margins

We evaluated whether intraoperative real-time TRUS navigation during LRP can decrease the incidence of positive surgical margins. Since March 2001, 294 patients with clinically organ confined prostate cancer undergoing LRP have been retrospectively divided into 2 groups, including group 1-217 who underwent LRP without TRUS from March 2001 to February 2003 and group 2-77 who have undergone LRP with TRUS since March 2003. Various baseline parameters were similar between the groups. Before March 2001 the senior surgeon had already performed more than 50 cases of LRP, thus, gaining reasonable familiarity with the technique. Compared to group 1, group 2 had a significantly decreased rate of positive surgical margins in patients with pT3 disease (57% vs 18%, p = 0.002). Positive margin rates also decreased in our overall experience (29% vs 9%, p = 0.0002). Intraoperative TRUS correctly predicted pT2 and pT3 disease in 85% and 86% of patients, respectively. Of the 54 TRUS visualized hypoechoic lesions at sites corresponding to biopsy proven cancer extracapsular extension was suspected in 31, leading to a real-time recommendation of calibrated wider, site specific dissection to achieve negative surgical margins. Intraoperative TRUS monitoring during LRP allows individualized, precise dissection tailored to the specific prostate contour anatomy, thus, compensating for the muted tactile feedback of laparoscopy. In what is to our knowledge the initial experience real-time TRUS guidance significantly decreased the incidence of positive surgical margins during LRP. In the future this concept of rectum based, intraoperative real-time navigation may facilitate a more sophisticated performance of radical prostatectomy.

SALVAGE SURGERY FOR BULKY LOCAL RECURRENCE OF PROSTATE CANCER FOLLOWING RADICAL PROSTATECTOMY

We report our experience with salvage radical surgery as palliative treatment in patients with bulky recurrence of prostate cancer following radical prostatectomy (RP). From files at the department of urology we identified 5 patients who had biopsy confirmed, bulky recurrence of prostate cancer after initial RP and subsequent salvage radiation therapy (4), prior to presentation at our cancer center. Positive surgical margins were present in all 5 patients. All received androgen ablation and 4 also received systemic chemotherapy. Due to persistent bulky tumors in the 5 patients and debilitating unrelenting symptoms, including refractory hematuria, obstructive uropathy and pelvic pain in 4, salvage radical surgery was performed. Total pelvic exenteration was done in 4 patients and wide tumor resection with continent urinary diversion was done in 1. Four patients were permanently relieved of local symptoms following surgery and another had entero-urethral fistula formation. Revision of a continent urinary diversion was necessary in another patient who was otherwise free of cancer and of local pelvic symptoms. Long-term symptom-free survival was achieved in 2 patients following surgery at 26 and 56 months, respectively. One patient died of metastatic disease 3.5 months after surgery but he had been rendered free of local symptoms by surgery. The other 2 patients are currently free of local symptoms 5 and 7 months following surgery, respectively. Wound infection, delirium and prolonged ileus occurred in 1 patient each. Otherwise surgery was well tolerated. Salvage radical surgery is feasible and it provides effective palliation in patients with bulky local recurrence following RP.

THE IMPACT OF SURGICAL APPROACH (NERVE BUNDLE PRESERVATION VERSUS WIDE LOCAL EXCISION) ON SURGICAL MARGINS AND BIOCHEMICAL RECURRENCE FOLLOWING RADICAL PROSTATECTOMY

Surgical margin (SM) status is widely reported as a significant risk factor for prostate cancer recurrence following radical prostatectomy (RP). It has been presupposed that preserving the neurovascular bundle may compromise cancer control due to the limited surgical margin obtained with a resultant increase in treatment failure. We examined whether neurovascular bundle preservation during RP is a risk factor for positive SMs and progression-free survival after adjusting for disease severity. Outcomes following RP in 7,268 men between 1990 and 2000 were examined retrospectively. Median followup in those last known to be alive is 6.4 years. RP was performed by a total of 21 surgeons in the same basic fashion with strict attention to anatomical detail. Overall a positive SM was identified in 38% of patients. The positive SM rate was higher for wide excision than for nerve sparing (NS) (42% vs 34%) (p </= 0.001). The OR for positive SMs in patients undergoing NS-RP was 0.86 (95% CI 0.76 to 0.97, p = 0.012) after incorporating age, clinical stage, biopsy grade, year of surgery and prostate specific antigen. Similarly NS-RP had no significant impact on biochemical progression rates after controlling for these variables (HR 0.98, 95% CI 0.88 to 1.08, p = 0.64). NS-RP is not an independent adverse risk factor for positive SMs or progression-free survival. Tumor biology appears set prior to technically skilled anatomical radical prostatectomy independent of wide excision of the neurovascular bundles. All patients with organ confined prostate cancer should be considered candidates for an NS operation.

Screening with low PSA cutoff values results in low rates of positive surgical margins in radical prostatectomy specimens.

In the literature, positive margins in radical prostatectomy specimens, the rate of which ranges between 7% and 46%, are associated with adverse patient survival. The aim of the present study was to determine the predictive value of preoperative serum prostate specific antigen (PSA) values for the rate of positive margins in radical retropubic prostatectomy. The study included a cohort of 845 patients who underwent radical retropubic prostatectomy between October of 1993 and December of 1999. All patients were stratified in groups on the basis of their preoperative PSA values: PSA group I, 0-1.99 ng/ml; PSA group II, 2-3.99 ng/ml; PSA group III, 4-5.99 ng/ml; PSA group IV, 6-7.99 ng/ml; PSA group V, 8-9.99 ng/ml; and PSA group VI, >10 ng/ml. For each group, the pathologic stage, Gleason score, and the incidence of positive margins were analyzed. For statistical analysis, the Mann Whitney U-test was used. Our data show a significantly higher rate of organ-confined prostate cancers and a significantly lower rate of positive surgical margins in patients with preoperative total PSA values of less than 4 ng/ml compared with patients with higher preoperative total PSA levels. As tumor stage and surgical margin status after radical prostatectomy are important predictors of the likelihood of PSA recurrence, which necessitates additional therapy, these findings support the concept of PSA screening by using low PSA cutoff levels.

Prognostic significance of positive surgical margins in patients with extraprostatic carcinoma after radical prostatectomy.

A significant number of prostate adenocarcinoma patients undergoing radical prostatectomy are found to have microscopic extraprostatic disease extension. A majority of these patients have focal extraprostatic extension limited to one or both sides of the prostate. In addition, positive surgical margins are a common pathologic finding in this patient subgroup. In the current study, the authors evaluated the impact of positive surgical margins as an independent predictive factor for prostate specific antigen (PSA) progression in patients with pT3a/b N0M0 carcinoma. The Mayo Clinic prostate cancer registry list provided 1202 patients with pT3a/b NO prostate carcinoma (no seminal vesicle or regional lymph node involvement) who underwent a radical prostatectomy between 1987-1995. To reduce confounding variables, patients who received preoperative therapy or adjuvant therapy were excluded, resulting in 842 patients who were eligible for analysis. A total of 354 patients (42%) had > or = 1 positive surgical margins whereas 488 patients (58%) demonstrated no margin involvement. The sites of margin positivity were as follows: apex (n = 163), base (n = 47), posterior prostate (n = 227), and anterior prostate (n = 11). A total of 111 patients had > or = 2 positive surgical margins. The 5-year survival free of clinical recurrence and/or biochemical failure (postoperative PSA level > 0.2 ng/mL) for patients with no positive surgical margins was 76% and was 65% for patients with 1 positive surgical margin (P = 0.0001). There was no significant difference in biochemical disease progression between patients with 1 versus those with > or = 2 surgical margins (65% vs. 62%). Multivariate analysis revealed that positive surgical margins were a significant predictor (P = 0.0017) of clinical disease recurrence and biochemical failure (relative risk, 1.55; 95% confidence interval, 1.18-2.04) after controlling for preoperative PSA, Gleason score, and DNA ploidy. In the current study, positive surgical margins were found to be a significant predictor of disease recurrence in patients with pT3a/b NO prostate carcinoma, a finding that is independent of PSA, Gleason score, and DNA ploidy. The benefit of adjuvant therapy in optimizing recurrence-free survival remains to be tested.

THE EXTENT OF BIOPSY INVOLVEMENT AS AN INDEPENDENT PREDICTOR OF EXTRAPROSTATIC EXTENSION AND SURGICAL MARGIN STATUS IN LOW RISK PROSTATE CANCER: : IMPLICATIONS FOR TREATMENT SELECTION

We identify predictors of extraprostatic extension and positive surgical margins in patients with low risk prostate cancer (prostate specific antigen [PSA] 10 ng./ml. or less, biopsy Gleason score 7 or less and clinical stage T1c-2b). From August 1997 to January 1999, 143 previously untreated patients underwent radical retropubic prostatectomy for clinically localized prostate cancer. A total of 62 patients were low risk, with PSA 10 ng./ml. or less, biopsy Gleason score 7 or less and clinical stage T1c-2b, and had sextant biopsy with separate pathological evaluation of each sextant cores. PSA, clinical stage, biopsy Gleason score, average percentage of cancer in the entire biopsy specimen, maximum percentage of cancer on the most involved core, number of cores involved and bilaterality were evaluated for association with extraprostatic extension, seminal vesicle involvement and positive surgical margins. Of the 62 patients 13 (21%) had extraprostatic extension, 6 (10%) seminal vesicle involvement and 20 (32%) positive surgical margins. Average percentage greater than 10% and maximum percentage greater than 25% were associated with extraprostatic extension (p = 0.01 and 0.004, respectively). Average percentage greater than 10%, maximum percentage greater than 25%, more than 2 cores involved and bilaterality were associated with positive surgical margins (p = 0.007, 0.01, 0.002 and 0.03, respectively). On multivariate analysis maximum percentage remained the only independent predictor of extraprostatic extension (p = 0.03), and the number of cores involved remained an independent predictor of positive surgical margins (p = 0.01). Biopsy Gleason score, PSA and clinical stage did not correlate with extraprostatic extension or positive surgical margins in this patient population. In low risk prostate cancer the extent of biopsy involvement significantly correlates with the risk of extraprostatic extension and positive surgical margins. Biopsy information should be considered when selecting and modifying treatment modalities.

NEOADJUVANT HORMONAL ABLATIVE THERAPY BEFORE RADICAL PROSTATECTOMY: A REVIEW. IS IT INDICATED?

Neoadjuvant hormonal ablation therapy has been used to decrease the rate of positive surgical margins in patients treated with radical prostatectomy. We reviewed the available literature to determine whether this therapy is indicated and beneficial. We performed a MEDLINE key word search and assessed randomized prospective articles. Data were analyzed for the rate of positive surgical margins, seminal vesicle invasion and lymph node metastasis as well as surgical characteristics, including operative time, blood loss, hospital stay, rate of complications and difficulty of surgical dissection. In addition, these data were evaluated for prostate specific antigen-free survival. Neoadjuvant hormonal therapy decreased the rate of positive margins in 6 of the 7 randomized prospective studies. In none of 4 randomized prospective series was there an improved rate of seminal vesicle invasion with neoadjuvant hormonal therapy. Of 4 studies 3 showed no improvement in the rate of lymph node metastasis after neoadjuvant hormonal therapy compared with that in controls. Similarly there was no improvement in prostate specific antigen-free survival and no significant difference in operative time, operative blood loss, transfusion or hospital stay in patients treated with neoadjuvant hormonal therapy and controls. In addition, in 2 of 3 studies there was no difference in the complication rate. Analysis of the available literature revealed no significant improvement in outcome to support the routine administration of neoadjuvant hormonal therapy before prostatectomy.

Race is not an independent predictor of positive surgical margins after radical prostatectomy

Objectives. To determine whether race is an independent predictor of positive surgical margins in patients who undergo radical prostatectomy. Methods. Radical prostatectomies were performed on 750 patients at five Veterans Affairs hospitals: Shreveport, Louisiana (n = 451), Houston, Texas (n = 92), Jackson, Mississippi (n = 83), New Orleans, Louisiana (n = 69), and Little Rock, Arkansas (n = 55). All men who did not receive neoadjuvant hormonal therapy and for whom complete follow-up data were available were included in the analysis (of 607, 260 were African-American and 347 were white). Multiple logistic regression analysis was used to determine the significance of race as an independent predictor of surgical margin status after radical prostatectomy for clinically localized prostate cancer. Results. After controlling for clinical stage, Gleason grade, and preoperative prostate-specific antigen (PSA), multivariable logistic regression analysis revealed that race was not an independent predictor of positive surgical margins ( P = 0.9). Of the variables evaluated, both preoperative PSA ( P = 0.0005) and biopsy Gleason grade ( P = 0.047) were significant predictors of an increased risk of a positive surgical margin. Conclusions. Positive surgical margins are a widely accepted surrogate marker of increased biologic potential in patients with prostate cancer. In our study population, race was not an independent predictor of surgical margin status. Coupled with observations that survival is not related to race, this finding suggests that the biology of prostate cancer in African-American and white men is similar and that observed racial differences more likely are due to ethnic factors that influence tumorigenicity.