There are no absolute guidelines as to which patients who have positive surgical margins after a radical prostatectomy (RP) are most appropriate for immediate adjuvant radiation therapy (with or without neoadjuvant and/or adjuvant hormone therapy).
Swanson and Lerner have carried out an exhaustive review of the available literature in an attempt to identify specific risk factors that — in combination with the presence of positive surgical margins — would generally suggest the necessity for immediate adjuvant therapy as compared to later salvage therapy.
They made the assumption that patients with a greater than 70 percent risk for biochemical failure after radical prostatectomy were appropriate candidates for immediate adjuvant therapy. Based on that (reasonable) assumption, and based on their careful review, they suggest that the presence of any one of the following factors places patients with positive surgical margins into the > 70 percent risk for biochemical progression category (i.e., at high risk for relatively short-term biochemical progression):
- Positive lymph nodes
- Positive seminal vesicles
- A pre-surgical PSA level of > 20 ng/ml
- A pathologic Gleason score of > 7
In addition, the authors note the following:
- Many men with positive surgical margins and a Gleason score of 7 fall into the > 70 percent risk category.
- All men with positive surgical margins and one of the above criteria should be carefully considered as candidates for immediate adjuvant therapy.
- There are no “absolutes” regarding who should or shouldn’t be given immediate adjuvant therapy, since clinical experience and judgment (in addition to the patient’s personal wishes) are still critical factors in making such decisions.