Predictive Factors for Positive Surgical Margins in Patients With Prostate Cancer After Radical Prostatectomy: A Systematic Review and Meta-Analysis

Abstract

Background and ObjectivesPrevious studies have demonstrated that positive surgical margins (PSMs) were independent predictive factors for biochemical and oncologic outcomes in patients with prostate cancer (PCa). This study aimed to conduct a meta-analysis to identify the predictive factors for PSMs after radical prostatectomy (RP).MethodsWe selected eligible studies via the electronic databases, such as PubMed, Web of Science, and EMBASE, from inception to December 2020. The risk factors for PSMs following RP were identified. The pooled estimates of standardized mean differences (SMDs)/odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. A fixed effect or random effect was used to pool the estimates. Subgroup analyses were performed to explore the reasons for heterogeneity.ResultsTwenty-seven studies including 50,014 patients with PCa were eligible for further analysis. The results showed that PSMs were significantly associated with preoperative prostate-specific antigen (PSA) (pooled SMD = 0.37; 95% CI: 0.31–0.43; P < 0.001), biopsy Gleason Score (<6/≥7) (pooled OR = 1.53; 95% CI:1.31–1.79; P < 0.001), pathological Gleason Score (<6/≥7) (pooled OR = 2.49; 95% CI: 2.19–2.83; P < 0.001), pathological stage (<T2/≥T3) (pooled OR = 3.90; 95% CI: 3.18–4.79; P < 0.001), positive lymph node (PLN) (pooled OR = 3.12; 95% CI: 2.28–4.27; P < 0.001), extraprostatic extension (EPE) (pooled OR = 4.44; 95% CI: 3.25–6.09; P < 0.001), and seminal vesicle invasion (SVI) (pooled OR = 4.19; 95% CI: 2,87–6.13; P < 0.001). However, we found that age (pooled SMD = 0.01; 95% CI: −0.07–0.10; P = 0.735), body mass index (BMI) (pooled SMD = 0.12; 95% CI: −0.05–0.30; P = 0.162), prostate volume (pooled SMD = −0.28; 95% CI: −0.62–0.05; P = 0.097), and nerve sparing (pooled OR = 0.90; 95% CI: 0.71–1.14; P = 0.388) had no effect on PSMs after RP. Besides, the findings in this study were found to be reliable by our sensitivity and subgroup analyses.ConclusionsPreoperative PSA, biopsy Gleason Score, pathological Gleason Score, pathological stage, positive lymph node, extraprostatic extension, and seminal vesicle invasion are independent predictors of PSMs after RP. These results may helpful for risk stratification and individualized therapy in PCa patients.

Multiparametric MRI-based nomograms in predicting positive surgical margins of prostate cancer after laparoscopic radical prostatectomy

“…For high-risk patients, who can choose to retain one side or not to retain the neurovascular bundle during surgery, or to combine ADT before surgery to reduce the rate of PSMs. Previous studies have shown that several clinical and pathologic factors have the potential of predicting PSMs ( 4 , 8 , 23 ). Zhang et al.…”

“…Zhang et al. ( 8 ) conducted a comprehensive meta-analysis and systematic review with a sample of 50,014 patients, and showed that TPSA, biopsy-based Gleason score, postoperative Gleason score, pTNM, positive lymph nodes, extra-prostatic extension, and seminal vesicle invasion are independent prognostic factors for PSMs. None of the studies, however, have systematically predicted the post-LRP margin status based on mpMRI.…”

“…In previous studies it was reported that there are some preoperative parameters correlate with PSMs after prostatectomy, including age, clinical stage, free prostate specific antigen (FPSA)/total PSA (TPSA), Gleason score, percent of positive cores (PPC), and extra-prostatic extension ( 3 , 8 ). To predict the risk of advanced PCa, clinicians also often use staging nomograms, such as D’AMICO or CAPRA ( 9 , 10 ).…”

A trend to minimize the radicality of surgery

“…By contrast, in a recent publication from the same group, the authors attempted to use the following strategy as a combination of both multi-parametric magnetic resonance imaging and prostate health index to predict the EPE, 18 based on the strong correlation between EPE and PSM (at least a four-fold increase in PSM). 15 However, the current Dr. Yang’s study also failed to investigate this part, and in fact, even though they have studied the aforementioned factor (EPE), many reported important and independent risk factors were not included in both studies, 13,18 contributing to the absence of any response to why partial NS RARP was associated with PSM in their study.…”

Radical or Not-So-Radical Prostatectomy: Do Surgical Margins Matter?

“…Factors that predict non focal positive MOR are the number of positive cores in preoperative biopsy, stage pT3a and pT3b [ 24 ]. In contrast, Zhang et al conducted a comprehensive meta-analysis and systematic review with high diversity and a sample of 50,014 patients, and showed that age, BMI, prostate volume and type of surgical technique are not reliable and independent prognostic factors for margin positivity [ 43 ]. They confirmed, however, that preoperative PSA levels, Gleason score at the initial diagnostic biopsy, Gleason score and stage at the prostatectomy specimen, and presence of positive lymph nodes, extraprostatic extension and seminal vesicle invasion are associated with positive MOR [ 43 ].…”