The impact of length and location of positive margins in predicting biochemical recurrence after robot-assisted radical prostatectomy with a minimum follow-up of 5 years

Abstract

Objective• To evaluate the role of positive surgical margin (PSM) size/focality and location in relation to risk of biochemical recurrence (BCR) after robot-assisted radical prostatectomy (RARP). Patients and Methods• Clinicopathological data were collected from 904 patients who underwent RARP at a single European institution from 2002 to 2006. • PSM status after RARP was defined as cancer cells at the inked margin, and was stratified by size/focality and location.• The outcome variable was BCR, defined as a postoperative PSA level of ≥0.2 ng/mL. • We modelled clinicopathological covariates including PSM size/focality and location using Cox proportional hazards regression. In subgroup analyses, we assessed the effect of PSM size and location at different pathological stages and grades of disease. Results• Compared with negative SM, a PSM of >3 mm/multifocal was associated with an increased risk of BCR in the entire cohort (hazard ratio [HR] 2.84, 95% confidence interval 1.76-4.59), while unifocal PSMs of ≤3 mm were not significantly associated with BCR.• In subgroup analyses, the negative impact of >3 mm/multifocal PSM appeared greatest in those with lower postoperative stage and grade of disease.• The prognostic role of PSM location was unconfirmed, although data indicated that posterolateral PSMs may be of lower significance in RARP patients.• The study is limited by lack of central pathology review, and lack of statistical adjustment for tumour volume, lymph node status, and surgeon volume. Conclusion• We found that men with >3 mm/multifocal PSMs have a higher risk of BCR than those with unifocal PSMs of ≤3 mm or negative SMs, especially if they have lower risk disease.• Posterolateral margins may be of little significance in a RARP population.

Postoperative early ultrasensitive prostate-specific antigen identifies patients at risk for biochemical recurrence in margin positive prostate cancers: a single-center study

“…However, over half of the patients with RM1 did not experience BCR at 4 years in this study using the BCR threshold of 0.2 ng/ml. This result was comparable with that of previous reports (4,7,8). Recently, Toussi et al…”

“…Thus, patients with RM1 are candidates for immediate adjuvant radiation therapy (RT) to decrease BCR and provide a survival benefit compared with that of patients undergoing observation (10)(11)(12). However, several reports indicated that BCR did not occur in over half of the patients, even in the presence of RM1, over 5-year follow-up (4,7,8). This raises an issue for the treatment of patients with RM1 in which a number of patients are overtreated by immediate adjuvant RT.…”

Surgical margin length and location affect recurrence rates after robotic prostatectomy

“…Each institution involved in this study have reported their method of RARP, which has been detailed previously [11,16,17]. Subsequent subtle modifications are used by some of the contributing centers but not others (e.g., grades of nerve-sparing dissection, cautery-free technique, local hypothermia, and retrograde dissection) [18][19][20].…”

“…Tissue handling, retraction, and tension applied at each step are all unique from open radical (ORP) and laparoscopic radical prostatectomy procedures; hence, the effect of margin parameters on outcomes after robotic-assisted radical prostatectomy (RARP) cannot be drawn from such studies. Two recent RARP single-institution series have been published; one establishing the effect of PSMs Z3 mm or multifocal margins compared with those o3 mm or unifocal margins (hazard ratio [HR] = 2.84, 95% CI: 1.76-4.59) [10,11]. This effect has not been demonstrated in RARP multiinstitutional cohorts with long-term follow-up.…”

“…An institution reported a trend toward a greater effect of apical margins on progression-free survival [15]; initial trends suggest PSM locations in RARP having different prognostic value when compared with ORP series, where there is more generally accepted importance of posterolateral margins, but still controversy regarding apical margins [11].…”