Predicting progression in men with positive surgical margins

A new analysis of data from over 7,000 radical prostatectomy patients treated at major academic medical centers suggests that the prognostic value of the number, size, and placement of positive surgical margins is very limited.

It is well known that the presence of positive surgical margins after a radical prostatectomy increases the probability of biochemical recurrence by two- to four times. Stephenson et al. have now analyzed the predictive usefulness of several subclassifications of positive surgical margins, including things like their number, anatomical location, and extent, based on data from 7,160 patients treated by radical prostatectomy alone at one of three academic centers between 1995 and 2006.

The presence of positive surgical margins was subclassified as solitary vs multiple, focal vs extensive, and apical location vs other. Then the value of these subclassifications was assessed by the improvement in predictive accuracy of nomograms containing these parameters compared to a nomogram in which the surgical margin was modeled simply as positive vs negative.

The results of this analysis showed that:

  • The probability of 7-year progression-free survival was 60 percent in patients with positive surgical margins.
  • A positive surgical margin was significantly associated with biochemical recurrence after adjusting for the patient’s age, PSA level, pathological Gleason score, pathological stage, and year of surgery.
  • An increased risk of biochemical recurrence was associated with multiple vs solitary positive surgical margins and extensive vs focal positive surgical margins.
  • Neither of these two subclassifications (multiple vs solitary or extensive vs focal) improved the accuracy of a prognostic nomogram compared to a nomogram in which surgical margin status was modeled as just positive vs negative..

Based on this, relatively simple, subclassification of surgical margin status after radical prostatectomy, there appears to be no good prognostic value compared to just the presence or absence of surgical margins alone.

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