The Impact of Positive Surgical Margins

The Harvard Medical School is a recognized and authoritative source of correct information about prostate cancer (PCa). Their website has information about anxiety-provoking news after radical prostatectomy, or RP: positive surgical margins (PSMs). No matter how meticulous a surgeon’s technique, there will always be cases in which a tumor has extended beyond where the scalpel cannot cut it all out. Harvard’s site describes the impact of this news on the patients who must hear it:

[With] the radical prostatectomy complete, they head home from the hospital believing they have been cured, only to learn that some cancer may have been left behind. Today, about 10% to 20% of patients …receive this news.[i]

In fact, the number of these disappointed men may be even higher. In a new French study, “Positive Surgical Margins After Radical Prostatectomy: What Should We Care About?” the authors state that PSMs are a “known factor associated with biochemical recurrence” (rising PSA after treatment).[ii] They studied 630 RP cases from 2005-08, and report that 206 of them (32.7% or almost a third) had PSMs.

As I said, this is worrisome news but it’s not necessarily catastrophic. A patient with PSMs will be reassured that this doesn’t inevitably mean that in the future his cancer will begin to grow. He will be carefully monitored. If his PSA begins to rise, it will likely trigger a biopsy; if positive for PCa, he may be a candidate for a salvage treatment such as radiation or ablation—both of which are potentially curative. If his pre-RP risk factors (Gleason score, stage, PSA) indicate a higher level of tumor aggression, he may immediately be offered what is called post-surgical adjuvant radiation. This means having a course of radiation to the pelvic bed beginning around 6 weeks after his surgery, with the intent of killing any cancer cells there before they can spread further. While there is a risk of side effects that affect his healing after surgery, adjuvant radiation can save lives.

The French team chose 110 of the PSM patients who had no surgical evidence of lymph node involvement, whose post-surgical PSA was undetectable, and who did not receive adjuvant radiation therapy. The team analyzed their pre-surgery risk factors and their surgical pathology reports, and followed them for an average of 6 years. The biochemical recurrence rate (BCR) was 30%. “The factors significantly associated with BCR were preoperative PSA, predominance and percentage of Gleason 4, tumor volume, PSA length and predominance of Gleason 4 at the margin.

One thing that struck me about this study was a concluding sentence that reads, “Over a 5-year follow-up, only one-third of patients experienced BCR.” I found myself thinking, ONLY one-third? I did some quick mental math by imagining a huge auditorium where 1,000 prostate cancer patients who are scheduled for prostatectomy are attending a pre-op class. After their operations, 327 of them (32.7%) learn that they had PSMs. Within 72 months, just over 100 men (roughly a third of the 327) now have biochemical recurrence, and many will go on hormones since they can’t have a salvage therapy. It will be no consolation for any of them to know that he was part of “only one-third” of his fellow patients.

The other thing that got my attention was the title question: What Should We Care About? My answer is, we should care about better diagnosis before a man is sent for surgery. We should care about knowing in advance if his tumor has penetrated the prostate capsule, and 3T multiparametric MRI can show us that. We should care about the cell line, because with new tests like the 4K score and other genomic analysis, we can have advance knowledge about how dangerous those cells actually are. We should care about NOT putting a man through surgery if he is either a) a candidate for focal therapy or b) his disease has already begun to spread where a scalpel can’t get it so he needs to consider other options such as radiation.

Reading this article had a big impact on me. My heart goes out to PCa patients who have gone through surgery only to learn they may still have a time bomb ticking in their bodies. The article makes me more determined than ever to raise awareness about the value of multiparametric MRI and the latest ways to assess the true nature of an individual’s prostate cancer. I hope the day comes soon when no man has to hear that after all he went through from diagnosis to decision to treatment—he has positive surgical margins.

 


[i] http://www.harvardprostateknowledge.org/positive-surgical-margins-following-radical-prostatectomy

[ii] Pettenati CNeuzillet YRadulescu C et al. Positive surgical margins after radical prostatectomy: What should we care about? World J Urol. 2015 May 5. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/?term=pettenati+Neuzillet+positive+surgical+margins

 

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