Re: The Learning Curve for Surgical Margins After Open Radical Prostatectomy: Implications for the Use of Margin Status as an Oncologic Endpoint
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Surgical excision of the whole prostate through a radical prostatectomy procedure is part of the standard of care for prostate cancer. Positive surgical margins (cancer cells having spread into surrounding nonresected tissue) occur in as many as 1 in 5 cases and strongly correlate with disease recurrence and the requirement of adjuvant treatment. Margin assessment is currently only performed by pathologists hours to days following surgery and the integration of a real-time surgical readout would benefit current prostatectomy procedures. Raman spectroscopy is a promising technology to assess surgical margins: its in vivo use during radical prostatectomy could help insure the extent of resected prostate and cancerous tissue is maximized. We thus present the design and development of a dual excitation Raman spectroscopy system (680- and 785-nm excitations) integrated to the robotic da Vinci surgical platform for in vivo use. Following validation in phantoms, spectroscopic data from 20 whole human prostates immediately following radical prostatectomy are obtained using the system. With this dataset, we are able to distinguish prostate from extra prostatic tissue with an accuracy, sensitivity, and specificity of 91%, 90.5%, and 96%, respectively. Finally, the integrated Raman spectroscopy system is used to collect preliminary spectroscopic data at the surgical margin in vivo in four patients.
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(Objective) Neoadjuvant hormonal therapy (NHT) before radical prostatectomy promotes the downstaging of primary lesions. A retrospective analysis was conducted of the relationship between NHT durations and positive surgical margin rates, as well as between positive surgical margin rates and three types of prostatectomy (antegrade radical prostatectomy, retrograde radical prostatectomy, and laparoscopic radical prostatectomy (LRP)). (Materials and Methods) This study was a retrospective analysis of 257 patients treated with radical prostatectomy during the three years between April 2002 and March 2005. Of the 257 patients, 190 were treated by NHT. NHT durations were classified into “not conducted,” “<1 month,” “1-3 month,” “3-6 month” and “>6 month,” and the relationship between positive surgical margin rates and NHT durations was investigated. Seventy-four patients underwent antegrade radical prostatectomy, 131 were treated with retrograde radical prostatectomy, and 52 underwent LRP. Positive surgical margin rates were investigated according to the types of prostatectomy, as well as according to prostate-specific antigen (PSA) levels upon diagnosis. (Results) Positive surgical margin rates were 53.8% in the “not conducted” and “<1 month” groups, 38.8% in the “1-3 month” group, 32.4% in the “3-6 month” group, and 10.7% in the >6 month” group. Positive surgical margin rates after open surgery (antegrade and retrograde) tended to decrease when NHT durations were longer, while those after LRP tended to increase inversely. No correlation was observed between PSA levels upon diagnosis and positive surgical margin rates or between presurgical PSA levels and NHT durations. (Conclusion) Positive surgical margin rates were not significantly different when patients were treated with NHT for 1-3 months, but they tended to decrease when NHT was for >6 months. However, positive surgical margin rates after LRP increased when NHT continued for longer periods of time. This may the result of fibrous adhesion in the vicinity of the prostate due to long-term NHT which made the surgical margins unclear.
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You have accessJournal of UrologyProstate Cancer: Localized IV1 Apr 2014MP46-04 GLEASON SCORE AT THE SURGICAL MARGIN AND THE RISK OF BIOCHEMICAL RECURRENCE AFTER RADICAL PROSTATECTOMY Viacheslav Iremashvili, Lizet Pelaez, Merce Jorda, Ramgopal Satyanarayana, and Mark Soloway Viacheslav IremashviliViacheslav Iremashvili More articles by this author , Lizet PelaezLizet Pelaez More articles by this author , Merce JordaMerce Jorda More articles by this author , Ramgopal SatyanarayanaRamgopal Satyanarayana More articles by this author , and Mark SolowayMark Soloway More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1437AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives Several pathological parameters are well-known to be associated with the risk of prostate cancer progression after radical prostatectomy. These include Gleason score (GS), which reflects the biological aggressiveness of the cancer, and the presence of tumor at surgical margin, which is associated with the completeness of cancer excision. Gleason score at the surgical margin (GSM) theoretically can represent the aggressiveness of the cancer tissue that was left behind and therefore be associated with the risk of recurrence. However, little is known about this association. The aim of our analysis is to establish if GSM improves our ability to predict biochemical recurrence after radical prostatectomy. Methods In our radical prostatectomy database we indentified 892 men who had both low and high grade cancer (pathological GS 3 + 4/5 or 4/5 + 3). These patients were selected because in them there might be additional information provided by the GSM compared to the final GS of the prostate. The prostate was step-sectioned at 3 to 5-mm intervals in transverse planes into separate blocks that were embedded for analysis. All slides with a positive margin were reviewed and the GSM was recorded for each case. To determine if the GSM has independent predictive value with regards to the biochemical outcome we compared the predictive performance of four multivariate Cox regression models, one composed of traditional pathological and clinical variables (model 1) and others additionally including GSM recorded as Gleason sum (model 2), predominantly high- vs. low-grade cancer (model 3) and GSM being higher or lower compared to the overall GS (model 4). The predictive performance of these models was quantified using the Harrell’s c-index. Results Out of 152 prostatectomy specimens with GS 3+4/5 and positive margin, 25 (16%) had GSM ≥ 4+3, while out of 74 specimens with GS 4/5+3, 38 (51%) had a GSM≤3 + 4. Over a mean follow-up of 3.1 years, 173 (21%) of patients had biochemical recurrence (BCR). The GSM recorded in different ways was significantly associated with the risk of BCR in all multivariate models. The c-index for models 1 through 4 was 0.738, 0.750, 0.748 and 0.746 respectively. Conclusions Our findings suggest that GSM may be an independent predictor of BCR after radical prostatectomy in patients with mixed cancer. Addition of GSM to established factors resulted in a modest improvement in predictive value of the model. Taken together these findings support the idea that information about GSM may improve the accuracy of predictions of the risk of BCR after radical prostatectomy. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e511 Advertisement Copyright & Permissions© 2014Metrics Author Information Viacheslav Iremashvili More articles by this author Lizet Pelaez More articles by this author Merce Jorda More articles by this author Ramgopal Satyanarayana More articles by this author Mark Soloway More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...
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What's known on the subject? and What does the study add? HistoScanning ™ is a novel ultrasonography technique for visualization of prostate cancer. The technology it uses and its encouraging results in prostate cancer foci detection in 29 men with prostate cancer have been described previously. A recent study confirmed these results in 31 patients. The sensitivity and specificity of prostate cancer foci detection were 90% and 72%, respectively. These promising results raised the question of whether HistoScanning ™ technology might also be helpful in therapy planning. Preoperative knowledge of the distribution and size of tumours might be useful for treatment planning of a nerve‐sparing radical prostatectomy. We tested the ability of HistoScanning ™ to predict a negative surgical margin in 80 patients undergoing radical prostatectomy. Objective To assess the accuracy of HistoScanning ™ ( HS ) as a visualization tool for preoperative treatment planning for nerve‐sparing ( NS ) radical prostatectomy ( RP ). Patients and Methods A retrospective study was carried out on 80 patients with prostate cancer undergoing RP from O ctober 2009 to D ecember 2009. All patients underwent a HS procedure 1 day before surgery. Frozen sections ( FSs ) were performed on each latero‐posterior side of the prostate to assess for the presence of cancer. On the HS analysis, the region corresponding to that removed at FS was assessed for suspicious lesions. The size of suspicious lesions within this volume was compared with the FS histopathological analysis. Results HS results corresponded to a 93% probability of having a negative surgical margin in the FSs . The presence of a HS volume ≥0.2 mL in a specific side was associated with a 3.7 times increased risk of a positive surgical margin at FS . Conclusions HS has the potential to assist in the planning of NSRP . Larger, multicentre studies need to be performed for validation of these encouraging results.
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To investigate whether subgroups of prostate cancer patients, stratified by positive surgical margin locations, have different oncological outcomes following robot-assisted radical prostatectomy.A retrospective multicenter cohort study in prostate cancer patients undergoing robot-assisted radical prostatectomy was conducted at 10 institutions in Japan. Pre- and post-operative outcomes were collected from enrolled patients. Biochemical recurrence and clinical and pathological variables were evaluated among subgroups with different positive surgical margin locations.A total of 3195 patients enrolled in this study. Data from 2667 patients (70.1% [N = 1869] with negative surgical margins and 29.9% [N = 798] with positive surgical margins based on robot-assisted radical prostatectomy specimens) were analyzed. The median follow-up period was 25.0 months. The numbers of patients with apex-only, middle-only, bladder-neck-only, seminal-vesicle-only and multifocal positive surgical margins were 401, 175, 159, 31 and 32, respectively. In the multivariate analysis, PSA level at surgery, pathological Gleason score based on robot-assisted radical prostatectomy specimens, pathological T stage, pathological N stage and surgical margin status were independent risk factors significantly associated with biochemical recurrence-free survival. Patients undergoing robot-assisted radical prostatectomy with multifocal positive surgical margins and seminal-vesicle-only positive surgical margins were associated with worse biochemical recurrence-free survival than those with apex-only, middle-only and bladder-neck-only positive surgical margins. Patients undergoing robot-assisted radical prostatectomy with apex-only positive surgical margins, the most frequent positive surgical margin location, were associated with more favorable biochemical recurrence-free survival that those with middle-only and bladder-neck-only positive surgical margins. The study limitations included the lack of central pathological specimen evaluation.Although positive surgical margin at any locations is a biochemical recurrence risk factor after robot-assisted radical prostatectomy, positive surgical margin location status should be considered to accurately stratify the biochemical recurrence risk after robot-assisted radical prostatectomy.
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Objective. The presence of a tertiary Gleason grade (TGG) pattern 4 or 5 in radical prostatectomy (RP) specimens has been reported with adverse pathology and a higher biochemical relapse rate after RP. This study investigated the impact of a TGG pattern 4 or 5 on biochemical and pathological outcome in men operated with RP. Material and methods. The study reviewed 151 consecutive cases treated at the hospital between 1985 and 2006; 148 were included in the study. All prostatectomy specimens were re-examined by a genitourinary pathologist and among others parameters the presence of TGG pattern 4 or 5 was recorded. The hospital files were examined retrospectively for clinical follow-up data. Prostate-specific antigen (PSA) relapse was defined as two subsequent rising measurements above 0.20 ng/ml. The influence of a TGG pattern 4 or 5 on prognosis was assessed in a Cox proportional hazards regression model controlling for pathological stage, surgical margin (SM) status, seminal vesicle invasion (SVI) and extraprostatic extension (EPE). Results. Fifty-six patients (38%) experienced PSA relapse during follow-up. Twenty-one patients (58%) with a TGG pattern 4 or 5 had a biochemical relapse compared with 35 patients (31%) without TGG pattern 4 or 5. In the Cox regression model, TGG pattern 4 or 5 was an independent predictor of biochemical failure (p = 0.020). Conclusions. In patients undergoing RP the presence of a TGG pattern 4 or 5 is an independent predictor for biochemical relapse. Consequently, the RP specimens should routinely be investigated for TGG pattern 4 or 5.
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With increased incidence of prostate cancer and an increased number of patients undergoing radical prostatectomy in China, it will be necessary to elaborate the diagnosis, clinical significance and treatment of patients whose tumors have positive surgical margins following radical prostatectomy.Positive surgical margin, prostate cancer and radical prostatectomy were used as subject words and the medical literature in recent decades was searched using the PubMed database and the results are summarized.Using positive surgical margin, prostate cancer and radical prostatectomy as subject words the PubMed medical database produced 275 papers of pertinent literature. By further screening 28 papers were selected and they represent relatively large-scale clinical randomized and controlled clinical trials.A pertinent literature of 275 papers was identified and 28 papers on large clinical studies were obtained. Analysis of results indicated that the positive rate of surgical margin after radical prostatectomy is 20%-40%, and although most patients with positive surgical margins are stable for a considerable period, the data available now suggested that the presence of a positive surgical margin will have an impact on the patient's prognosis. The risk factors of positive surgical margin include preoperative prostate specific antigen level, Gleason's score and pelvic lymph node metastasis. The most common site with positive surgical margin is in apical areas of the prostate; therefore surgical technique is also a factor resulting in positive surgical margins. From data available now it appears that as long as the surgical technique is skilled, different surgical modes do not affect the rate of surgical margin. Adjuvant radiotherapy is mainly used to treat patients with positive surgical margin after radical prostatectomy, but combination with androgen deprivation therapy may increase the curative effect.The current data indicated that the presence of positive surgical margins can markedly affect the patient's prognosis. Therefore we should be aware how we reduce the positive surgical margin, how to diagnose positive surgical margin and how to treat when there are positive surgical margins.
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No AccessJournal of UrologyAdult Urology1 Jul 2009Length of Positive Surgical Margin After Radical Prostatectomy as a Predictor of Biochemical Recurrenceis accompanied byPhase II Trial of Capecitabine and Weekly Docetaxel for Metastatic Castrate Resistant Prostate Cancer Sergey Shikanov, Jie Song, Cassandra Royce, Hikmat Al-Ahmadie, Kevin Zorn, Gary Steinberg, Gregory Zagaja, Arieh Shalhav, and Scott Eggener Sergey ShikanovSergey Shikanov , Jie SongJie Song , Cassandra RoyceCassandra Royce , Hikmat Al-AhmadieHikmat Al-Ahmadie , Kevin ZornKevin Zorn , Gary SteinbergGary Steinberg , Gregory ZagajaGregory Zagaja , Arieh ShalhavArieh Shalhav , and Scott EggenerScott Eggener View All Author Informationhttps://doi.org/10.1016/j.juro.2009.02.139AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: Length and location of positive surgical margins are independent predictors of biochemical recurrence after open radical prostatectomy. We assessed their impact on biochemical recurrence in a large robotic prostatectomy series. Materials and Methods: Data were collected prospectively from 1,398 men undergoing robotic radical prostatectomy for clinically localized prostate cancer from 2003 to 2008 at a single institution. The associations of preoperative prostate specific antigen, pathological Gleason score, pathological stage and positive surgical margin parameters (location, length and focality) with biochemical recurrence rate were evaluated. Margin status and length were measured by a single uropathologist. Biochemical recurrence was defined as serum prostate specific antigen greater than 0.1 ng/ml on 2 consecutive tests. Cox regression models were constructed to evaluate predictors of biochemical recurrence. Results: Of 1,398 consecutive patients who underwent robotic prostatectomy positive margins were present in 243 (17%) (11% of pathological T2 and 41% of T3). Preoperative prostate specific antigen, pathological stage, Gleason score, margin status, and margin length as a continuous and categorical variable (less than 1, 1 to 3, more than 3 mm) were independent predictors of biochemical recurrence. Patients with negative margins and those with a positive margin less than 1 mm had similar rates of biochemical recurrence (log rank test p = 0.18). Surgical margin location was not independently associated with biochemical recurrence. Conclusions: Margin status and length are independent predictors of biochemical recurrence following robotic radical prostatectomy. Although longer followup and validation studies are necessary for confirmation, patients with a positive margin less than 1 mm appear to have similar recurrence rates as those with negative margins. References 1 : Anatomic site-specific positive margins in organ-confined prostate cancer and its impact on outcome after radical prostatectomy. Urology1997; 50: 733. Crossref, Medline, Google Scholar 2 : Prognostic significance of location of positive margins in radical prostatectomy specimens. Urology2007; 70: 965. Google Scholar 3 : Natural history of biochemical progression after radical prostatectomy based on length of a positive margin. Urology2008; 71: 308. Google Scholar 4 : Do margins matter?: The prognostic significance of positive surgical margins in radical prostatectomy specimens. J Urol2008; 179: S47. Link, Google Scholar 5 : Vattikuti Institute prostatectomy: contemporary technique and analysis of results. Eur Urol2007; 51: 648. Google Scholar 6 : Robotic radical prostatectomy: outcomes of 500 cases. BJU Int2007; 99: 1109. Google Scholar 7 : A comparison of the incidence and location of positive surgical margins in robotic assisted laparoscopic radical prostatectomy and open retropubic radical prostatectomy. J Urol2007; 178: 2385. Link, Google Scholar 8 : Adoption of new technology and healthcare quality: surgical margins after robotic prostatectomy. Urology2007; 70: 96. Google Scholar 9 : Robotic-assisted laparoscopic prostatectomy: functional and pathologic outcomes with interfascial nerve preservation. Eur Urol2007; 51: 755. Google Scholar 10 : Complete histologic serial sectioning of a prostate gland with adenocarcinoma. Am J Surg Pathol1993; 17: 468. Google Scholar 11 : Evidence from robot-assisted laparoscopic radical prostatectomy: a systematic review. Eur Urol2007; 51: 45. Google Scholar 12 : Positive surgical margins in radical prostatectomy: outlining the problem and its long-term consequences. Eur Urol2008; 55: 87. Google Scholar 13 : Positive proximal (bladder neck) margin at radical prostatectomy confers greater risk of biochemical progression. Urology2004; 64: 551. Google Scholar 14 : Positive surgical margins with radical prostatectomy: detailed pathological analysis and prognosis. Urology1996; 48: 80. Google Scholar 15 : Positive surgical margins with radical retropubic prostatectomy: anatomic site-specific pathologic analysis and impact on prognosis. Urology1999; 54: 682. Crossref, Medline, Google Scholar University of Chicago, Chicago, Illinois© 2009 by American Urological AssociationFiguresReferencesRelatedDetailsCited byKates M, Sopko N, Han M, Partin A and Epstein J (2015) Importance of Reporting the Gleason Score at the Positive Surgical Margin Site: Analysis of 4,082 Consecutive Radical Prostatectomy CasesJournal of Urology, VOL. 195, NO. 2, (337-342), Online publication date: 1-Feb-2016.Udo K, Cronin A, Carlino L, Savage C, Maschino A, Al-Ahmadie H, Gopalan A, Tickoo S, Scardino P, Eastham J, Reuter V and Fine S (2012) Prognostic Impact of Subclassification of Radical Prostatectomy Positive Margins by Linear Extent and Gleason GradeJournal of Urology, VOL. 189, NO. 4, (1302-1307), Online publication date: 1-Apr-2013.Spahn M, Briganti A, Capitanio U, Kneitz B, Gontero P, Karnes J, Schubert M, Montorsi F, Scholz C, Bader P, van Poppel H and Joniau S (2012) Outcome Predictors of Radical Prostatectomy Followed by Adjuvant Androgen Deprivation in Patients with Clinical High Risk Prostate Cancer and pT3 Surgical Margin Positive DiseaseJournal of Urology, VOL. 188, NO. 1, (84-90), Online publication date: 1-Jul-2012.Budäus L, Isbarn H, Eichelberg C, Lughezzani G, Sun M, Perrotte P, Chun F, Salomon G, Steuber T, Köllermann J, Sauter G, Ahyai S, Zacharias M, Fisch M, Schlomm T, Haese A, Heinzer H, Huland H, Montorsi F, Graefen M and Karakiewicz P (2010) Biochemical Recurrence After Radical Prostatectomy: Multiplicative Interaction Between Surgical Margin Status and Pathological StageJournal of Urology, VOL. 184, NO. 4, (1341-1346), Online publication date: 1-Oct-2010.Related articlesJournal of Urology18 May 2009Phase II Trial of Capecitabine and Weekly Docetaxel for Metastatic Castrate Resistant Prostate Cancer Volume 182Issue 1July 2009Page: 139-144 Advertisement Copyright & Permissions© 2009 by American Urological AssociationKeywordsrecurrenceprostatectomyMetricsAuthor Information Sergey Shikanov Nothing to disclose. More articles by this author Jie Song Nothing to disclose. More articles by this author Cassandra Royce Nothing to disclose. More articles by this author Hikmat Al-Ahmadie Nothing to disclose. More articles by this author Kevin Zorn Financial interest and/or other relationship with Intuitive Surgical and SurgRx, Inc. More articles by this author Gary Steinberg Financial interest and/or other relationship with Vysis, Bioniche and Spectrum. More articles by this author Gregory Zagaja Financial interest and/or other relationship with Intuitive Surgical. More articles by this author Arieh Shalhav Nothing to disclose. More articles by this author Scott Eggener Nothing to disclose. More articles by this author Expand All Advertisement PDF downloadLoading ...
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