UroToday - A positive surgical margin (PSM) after radical prostatectomy (RP) for prostate cancer (CaP) is a known risk factor for disease progression. A PSM is reported to occur in 19%-50% of patients undergoing RP. In most studies, biochemical recurrence (BCR) is the primary endpoint used to assess the impact of margin status. A report from the Mayo Clinic that appears in the online edition of the Journal of Urology evaluates the incidence and clinicopathologic features associated with a PSM during the PSA era. The impact of margin status on the risks of local recurrence, systemic progression, cancer death and overall mortality following RP was determined.

Between 1990 and 2006, 11,729 men who underwent RP at the Mayo clinic were identified for analysis. A PSM was defined as tumor extension to the inked surface of the resected prostate. Adjuvant therapy was treatment received within 90 days of RP and salvage treatment was defined as secondary therapy initiated more than 90 days after RP. BCR was defined as a PSA >0.4ng/ml. Patients were analyzed by era of RP; early (1990-1995), mid (1996-2000), and late PSA era (2001-2006). A PSM was identified in 3,651 of 11,729 men (31.1%). A single PSM was identified in 2,615 men (72%), and 1,036 (28%) had 2 or more PSM sites. The PSM rate was 23.4% for men with organ confined tumors and 55.1% for men with non-organ confined tumors. The most common PSM site was the apex (58%). Patients who underwent RP in the late PSA era were younger, with a lower preoperative PSA, smaller tumor volume and increased rate of organ confined disease. The rate of PSM significantly decreased over time from 41.1% in the early PSA era to 19.6% in the most recent PSA era. For organ confined tumors the PSM rates were 29%, 27% and 16% in the early, mid and late PSA eras, respectively. For non-organ confined disease the respective PSM rates were 59.9%, 54.4%, and 41.5%.

A PSM was associated with multiple adverse pathological features. A total of 454 men (12%), 1,075 men (29%), 634 men (17%), and 700 men (19%) who had a PSM received adjuvant RT, adjuvant ADT, salvage RT and salvage ADT, respectively. With a median followup of 8.2 years, 3,002 patients had a BCR, 678 had a local recurrence, 479 had systemic recurrence, and 1,731 died with 274 dying of CaP. A PSM was adversely associated with each outcome measure. A PSM decreased 10-year BCR-free (56% vs. 77%) and local recurrence-free survival (89% vs. 95%). A PSM resulted in a 10-year systemic progression-free survival rate of 93% compared with 97% for men with a negative surgical margin. On multivariate analysis controlling for clinicopathological variables and receipt of adjuvant therapy, the presence of a PSM was associated with increased risks of BCR, local recurrence and receipt of salvage treatment, but was not a significant predictor of systemic progression, cancer specific death, or overall mortality. When salvage RT and salvage ADT were added to the multivariate analysis as time dependent covariates, margin status remained associated with BCR and local recurrence but did not predict systemic progression, death from CaP or overall mortality.

Boorjian SA, Karnes RJ, Crispen PL, Carlson RE, Rangel LJ, Bergstralh EJ, Blute ML

J Urol. 2010 Mar;183(3):1003-1009

doi:10.1016/j.juro.2009.11.039

UroToday Contributing Editor Christopher P. Evans, MD, FACS

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