Elsevier

European Urology

Volume 55, Issue 1, January 2009, Pages 87-99
European Urology

Collaborative Review – Prostate Cancer
Positive Surgical Margins in Radical Prostatectomy: Outlining the Problem and Its Long-Term Consequences

https://doi.org/10.1016/j.eururo.2008.09.051Get rights and content

Abstract

Context

This review focuses on positive surgical margins (PSM) in radical prostatectomy (RP).

Objective

To address the etiology, incidence, and oncologic impact of PSM and discuss technical points to help surgeons minimize their positive margin rate. An evidence-based approach to assist clinicians in counseling patients with a PSM is provided.

Evidence acquisition

A literature search in English was performed using the National Library of Medicine database and the following key words: prostate cancer, surgical margins, and radical prostatectomy. Seven hundred sixty-eight references were scrutinized, and 73 were selected for rigorous review based on their pertinence, study size, and overall contribution to the field.

Evidence synthesis

In contemporary series, PSM are reported in 11–38% of patients undergoing RP. Although variability exists in the pathologic interpretation of surgical margins, PSM are associated with an increased hazard of biochemical recurrence (BCR) and local disease recurrence as well as the need for secondary cancer treatment. A posterolateral PSM appears to confer the greatest risk of recurrence, whereas the prognostic significance of positive apical margins remains controversial. The role of preoperative imaging and intraoperative frozen section analysis are being investigated to reduce margin positivity rates. Level-1 evidence indicates that adjuvant radiotherapy (RT) in men with PSM reduces BCR rates and clinical progression and possibly improves overall survival (OS).

Conclusions

PSM in RP specimens are uniformly considered an adverse outcome. Regardless of approach (open or laparoscopic), attention to surgical detail is essential to minimize rates. For patients with a PSM destined to experience a cancer recurrence, RT is the only established treatment with curative potential. A randomized trial in patients with PSM comparing immediate postoperative RT to salvage RT is critically needed before definitive recommendations can be made.

Introduction

The ultimate success of any cancer operation with curative intent relies on complete surgical extirpation of the tumor. Cancer cells at the inked surgical resection margin may suggest an incomplete local resection and suboptimal patient outcome [1]. The importance of achieving negative surgical margins to reducing the risk of recurrence is paramount and has been recognized in all solid malignancies, including prostate cancer (PCa). However, despite the evolution of surgical technique and the introduction of novel surgical approaches, positive surgical margins (PSM) in radical prostatectomy (RP) specimens are not uncommon, leading to an increased risk of biochemical, local, and possibly systemic disease progression. Unfortunately, the optimal treatment strategy for men with PSM remains open to disagreement.

In this review, we focus on the issue of PSM in PCa, addressing the pathologic pitfalls confounding surgical margins interpretation and the impact of PSM on long-term oncologic outcomes, providing technical recommendations to help surgeons minimize their positive margin rate, and discussing available data to assist clinicians in counseling patients with PSM after RP.

Section snippets

Evidence acquisition

A literature search in English was performed using the National Library of Medicine database and the following key words: prostate cancer, surgical margins, and radical prostatectomy. A free-text strategy was applied without limiting the year of publication. Seven hundred sixty-eight references were initially scrutinized, and 115 pertinent publications were identified and rigorously reviewed. Reference lists of retrieved articles were scrutinized for additional relevant articles. Seventy-three

Surgical recommendations and lessons learned

The goals of RP are to remove the cancer completely with negative surgical margins, minimize perioperative complications, and optimize recovery of potency and urinary continence. No surgeon uniformly achieves these results [27]. RP is one of the most complex operations urologists perform, and outcomes are highly sensitive to technique. The success of surgery and the incidence of PSM vary greatly among surgeons [28], [29]. Even among highly experienced surgeons, intraoperative video

Conclusions

PSM in RP specimens are uniformly acknowledged as an adverse outcome indicator associated with an increased hazard of BCR and local disease recurrence as well as the need for secondary cancer treatment. Tumor biology (volume, distribution, and aggressiveness) and surgical factors (type of procedure, technique, and experience) are the primary determinants of margin status. Although a PSM at the posterolateral location appears to confer the greatest probability of relapse, the prognostic

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