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Positive Surgical Margins in Radical Prostatectomy: Outlining the Problem and Its Long-Term Consequences

Yossepowitch, Ofer; Bjartell, Anders LU ; Eastham, James A.; Graefen, Markus; Guillonneau, Bertrand D.; Karakiewicz, Pierre I.; Montironi, Rodolfo and Montorsi, Franceso (2009) In European Urology 55(1). p.87-99
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:... (More)
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. (C) 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved. (Less)
Please use this url to cite or link to this publication:
author
organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
Endorectal MRI, section analysis, Frozen, Radiation therapy, Biochemical recurrence, PSA, Nerve sparing, Radical prostatectomy, Prostate cancer, Positive surgical margins
in
European Urology
volume
55
issue
1
pages
87 - 99
publisher
Elsevier
external identifiers
  • wos:000262066700013
  • scopus:56249132433
ISSN
1873-7560
DOI
10.1016/j.eururo.2008.09.051
language
English
LU publication?
yes
id
b8a9ff6b-0664-4c1e-b278-62a420ca21c8 (old id 1313642)
date added to LUP
2009-03-06 15:17:13
date last changed
2017-11-12 03:40:06
@article{b8a9ff6b-0664-4c1e-b278-62a420ca21c8,
  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. (C) 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved.},
  author       = {Yossepowitch, Ofer and Bjartell, Anders and Eastham, James A. and Graefen, Markus and Guillonneau, Bertrand D. and Karakiewicz, Pierre I. and Montironi, Rodolfo and Montorsi, Franceso},
  issn         = {1873-7560},
  keyword      = {Endorectal MRI,section analysis,Frozen,Radiation therapy,Biochemical recurrence,PSA,Nerve sparing,Radical prostatectomy,Prostate cancer,Positive surgical margins},
  language     = {eng},
  number       = {1},
  pages        = {87--99},
  publisher    = {Elsevier},
  series       = {European Urology},
  title        = {Positive Surgical Margins in Radical Prostatectomy: Outlining the Problem and Its Long-Term Consequences},
  url          = {http://dx.doi.org/10.1016/j.eururo.2008.09.051},
  volume       = {55},
  year         = {2009},
}