Length of site‐specific positive surgical margins as a risk factor for biochemical recurrence following radical prostatectomy

Abstract

Objectives: Positive surgical margins (PSM) have been associated with biochemical recurrence (BCR) after radical prostatectomy, but the significance of PSM length and location are debated. We assessed the impact of PSM lengths at specific locations for BCR in an open radical prostatectomy series. Methods: Detailed clinical and pathological data were collected from 117 post-prostatectomy patients with PSM from 1984 to 2004 at our institution. PSM locations were classified as apex, mid-gland , base, bladder neck, and anterior fibromuscular region with lengths measured at each site. Aggregate PSM length was obtained by summing lengths of all PSM areas in contact with the inked surface. BCR was defined as serum prostate specific antigen level 0.2 ng/mL or greater. Cox proportional hazards regression analyses of PSM lengths were conducted either as a continuous or categorical variable relative to location as a predictor of BCR. Results: Multivariate analyses demonstrated that as a continuous variable, PSM length at the anterior fibromuscular region (Hazard ratio [HR] = 1.17; P = 0.027) and bladder neck (HR = 1.29; P = 0.046) were significant predictors for BCR. As a categorical variable, PSM length Ն 2 mm at the anterior fibromuscular area was significant for BCR (HR = 3.02; P = 0.036). Increasing Gleason grade and positive lymph node status were also found to be significant independent predictors for BCR. Conclusion: PSM length at the anterior fibromuscular region (continuous and categorical) and the bladder neck (continuous) was significantly associated with BCR. Site-specific PSM length, along with Gleason grade and lymph node status, can be predictive of BCR and assist in risk stratification of patients with PSM following radical prostatectomy.

Editorial Comment from Drs Brookman‐May, May and Burger to Length of site‐specific positive surgical margins as a risk factor for biochemical recurrence following radical prostatectomy

“…A multivariable Cox model will not level out these differences and will be unable to render these prognosticators of BCR comparable. In the study by Hsu et al ., apical PSM was not independently significant as compared with other localisations, and multifocal PSM was significantly related to reduced BCR (57%; HR = 0.43, P = 0.002) as compared with solitary PSM in univariate analysis 1 . In accordance with the aforementioned illustrated findings, our results did not show significant differences in BCR rate of apical versus non‐apical PSM in univariate analysis; however, we did note a significant difference in BCR of apical PSM versus absent PSM 2 .…”

“…Hsu et al . refer their main message of a high impact of anterior PSM to 15 patients (7 with solitary anterior PSM) assessed within 21 years at Stanford University Medical Center 1 . In contrast, our series does not contain patients with anterior PSM.…”

“…In such patients, systemic progression per se is considerably less likely and, accordingly, PSM will have a greater impact. In contrast, roughly one‐third of patients were staged pT3b, 10% pT4 and 20% pN1 1 . A multivariable Cox model will not level out these differences and will be unable to render these prognosticators of BCR comparable.…”

“…Despite multiple justified rationales for assessment of these additional parameters, which can be easily obtained in routine histopathology, we are far from seeing them established in a standardized way. Presently, the Stanford group, which successfully promoted standardizations in histopathological processing in the past, suggests a well‐structured protocol, including the aspect of PSM 1 . From their well and concisely designed study, the authors draw two conclusions: first, the extent of PSM is decisive for prognosis (increase in BCR rate by 14% per mm PSM, P = 0.049); and second, the extent of PSM in the anterior segment is highly relevant for prognosis (increase in BCR rate by 17% per mm PSM, P = 0.027).…”

Editorial Comment from Dr Tsurumaki Sato to Length of site‐specific positive surgical margins as a risk factor for biochemical recurrence following radical prostatectomy

“…The authors reported the prognostic significance of surgical margin status in 117 prostate specimens derived from open radical retropubic prostatectomy 1 …”