Positive surgical margins, systemic disease, and prostate cancer-specific mortality

Researchers at the Mayo Clinic have queried their large, nearly 20-year-long database of men who have undergone radical prostatectomy in an attempt to assess the correlation between positive surgical margins at the time of surgery and subsequent occurence of systemic disease or prostate cancer-specific mortality.

Boorjian et al. carried out a careful retrospective analysis of the Mayo Clinic’s institutional registry of 16,749 patients who underwent a radical retropubic prostatectomy between 1990 and 2008. Within those 16,000+ patients they were able to identify 2,895 patients (17.3 percent) who had a positive surgical margin identified on post-surgical pathology.

Here are key results from their analysis of data from these 2,895 patients:

  • The average (median) follow-up was 10.6 years.
  • The actuarial 15-year survival free from systemic progression for these patients (i.e., no evidence of metastatic disease) was 90 percent.
  • The actuarial 15-year prostate cancer-specific survival was 93 percent.
  • On multivariate analysis, only three factors were associated with significantly increased likelihood of systemic progression and prostate cancer-specific mortality.
    • High tumor volume
    • High pathological Gleason score
    • Advanced pathological tumor stage
  • The number and location of positive surgical margins did not predict prostate cancer-specific  or overall mortality.

The authors conclude that — in this specific series of patients — the risks of systemic progression and prostate cancer-specific mortality are low on long-term follow-up for men with positive surgical margins at the time of surgery.

Now it is important, in understanding this report, to recognize that biochemical progression (a rising PSA level) may have been evident in many of these 2,895 patients, and so many of these patients may have received some type of follow-up therapy (radiation, androgen deprivation therapy) — whether it was actually necessary or not (which is impossible to determine). In other words, Boorjian and his colleagues are not stating that all these 2,895 men with positive surgical margins were followed for a median of 10.6 years and showed a low level of systemic progression and prostate cancer-specific mortality with no further therapy. Rather, what Boorjian et al. are reporting is simply that only 10 percent of these men ever showed clear, post-surgical evidence of metastatic disease and that only 7 percent of these men actually died of prostate cancer.

4 Responses

  1. Clarification?
    — Is it correct to assume that a number of the 2,895 men are still alive and still COULD die of prostate cancer?
    — Is there information on the remaining 13,764 men who had no positive margins? How many of these experienced recurrence and possibly died of prostate cancer?

  2. I have no idea. You’d have to ask the authors. The first might be answered within the full text of the paper. The second almost certainly is not.

  3. In my RP in December 1992 my urologist found extension into “fatty tissue” where he could go no further to excise. Removed lymph nodes, seminal vesicles, and vas deferens were clear of prostate cancer. For safety, I then went through a full series of EBRT. Three years later I had a recurrence. Now, nearing 19 years since diagnosis and 15 years on/off/on/off and recently back on ADT/IAD, I continue to survive but my prostate cancer appears to have now become hormone refractory (HRPC), so I will be playing the game of drug use with known and new drugs to hopefully continue managing my cancer. Still asymptomatic.

  4. Chuck,

    I sure do like reading about your journey. Ralph V too. It is very refreshing to read cases similar to mine doing well so far out. I was positive in the seminal vesicles at age 44. I have quite a ways to go to catch up, but reading papers like this and knowing cases first hand gives out a lot of hope for guys like me …

    I hope to see you at PCRI?

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