Time to standardize reporting of surgical margin data after radical prostatectomy?

It’s been a while since we last discussed the reporting of surgical margin status after radical prostatectomy and the prognostic value of positive surgical margins in determination of who would be wise to consider immediate, adjuvant radiation therapy as opposed to waiting until the need for salvage radiation therapy became evident.

One of the problems in knowing how to interpret the presence of positive surgical margins after radical surgery is that there is no consensus across the uropathology community on the best way to report the details of surgical margin status (e.g., location, focality, length, uniformity of specimen, and Gleason score at the margin). Still less is there consensus on how such data may affect risk for biochemical recurrence and how such data should be used to assist urologists, radiation oncologists, and others in clinical decision-making.

Fontenot and Mansour have recently presented a new analysis in which they: (a) assess the consistency of reporting of data on positive surgical margins and associated prognostic variables after radical prostatectomy and (b) propose a standardized methodology for quantifying the characteristics and the prognostic impact of positive surgical margins after surgery.

To do this they looked at available data from 44 studies (all involving ≥ 100 patients and all published after January 1, 2005 to the present). For each of the 44 studies, they analyzed the available data according to six criteria defined in guidelines laid down by the College of American Pathologists and the International Society of Uropathologists.

They found that:

  • The definition of a positive surgical margin was the only criterion that was consistently reported across the 44 studies.
  • There were “major inconsistencies” among the reports regarding the site and length of the positive surgical margins, and the presence of intraprostatic incision.
  • The conflicting reports gave little insight into the true significance of particular positive surgical margin-associated variables on biochemical recurrence.

The authors suggest the implementation of a novel system (using what they refer to as the “FUSE” scoring system) to quantify reporting of the anatomical and pathological variables associated with positive surgical margin data. They claim that this system would allow “a standardized methodology” for future reporting of positive surgical margins

In their conclusion,  Fontenot and Mansour hypothesize that the conflicting results “are partly attributable to a lack of use of a standardized reporting methodology” for positive surgical margins.

It does seem odd to The “New” Prostate Cancer InfoLink that there is no consistent, standardized method as yet for the pathological reporting of surgical margin data. Without such a standardized, consistent methodology, it would appear to be impossible to reach any meaningful conclusions about how to assess the prognostic significance of these data in specific circumstances.

8 Responses

  1. I am one of those that may have cancer in the margins after surgery and I would love to have an absolute standard so that it could be determined if I truly do need further treatment. I hate the idea of having to have radiation when I have already endured a major operation. Radiation to me is like killing an ant with a sledgehammer. It’ll get the job done but the potential for a lot of collateral damage is always present. But having said that, is it at all possible to come up with a standard when every man’s physiology is different and every surgeon’s skill level is different? Are we looking for absolutes when doing so may miss that one cell that lies beyond the agreed upon clinical definition? That’s an even scarier proposition.

  2. Gary:

    Medicine is not an exact science, for precisely the reasons you define, but it should still be possible to give you and your physicians a much better set of prognostic tools regarding the clinical implications of a positive surgical margin than anything we have available today.

  3. Gary,

    I recently had IMRT radiation therapy as salvage therapy when my PSA was 0.12, 5 months after prostatectomy. The treatments were uneventful, as were the side effects. I feel great 5 months after treatment. If this was like ” killing an ant with a sledgehammer”, I am just hoping the damn ant is dead. Fortunately I had no “collateral damage”. I hope you would be as fortunate.

  4. Thanks for the words of encouragement. With my incontinence still pretty bad, and not an erection in sight, it worries me to start radiation therapy and either get stuck at this point of recovery or even regress because of the consequential damage done by the treatment. I am having another PSA test done tomorrow to see if the level has risen from the <0.01 ng/ml it was a month ago. If it is the same, then I am going to entertain postponing the treatment for another month to give me some more time to get things under control. I hope I am not shooting myself in the foot by doing so but I would like to try and get back to where I was functioning before the surgery and not do anything else that might keep me in this less than satisfactory condition.

  5. Gary,

    I had surgery for T3b, Gleason 9, exactly 1 year ago. I still have one pad per day incontinence, though that may be due to the fact I am 76 years old. The radiation did not worsen my incontinence. I also have had no erections in over a year, but I began Firmagon 2 weeks before radiation therapy and I am still on it monthly. Testosterone is 17. Plan is to continue Firmagon for 6 more months. I do have hot flashes and some fatigue but I will continue with the ADT in hopes that longer is better than shorter. I am a firm believer in aggressive treatment, surgery, IMRT, and 1 year of ADT. Fortunately, I have had few side effects. I eat right, use a personal trainer, and try to keep positive. My last PSA level, 2.5 months after radiation, was < 0.1 and the next one is in 3 weeks time. Hate the PSA anxiety. Hope your PSA remains at 0.01.

    Dr. K

  6. Hi Gary,

    I had positive margins after my surgery as well, and my first tests came out < 0.01. Only about 50% of positive margins actually contain viable cells, so you have that 50% chance of never having to get radiation treatment. Only after 7 months did my PSA begin to rise, going first to 0.01, and then to 0.03 about 2 months after that. At that point, with Gleason 9 disease, I had to pull the trigger because, from my reading, radiation is most effective if it is done when the PSA has not risen much beyond 0.05. With luck you'll never have to worry about it.

  7. Gary:

    My situation was similar to yours. I think what you are doing is exactly correct. Act based on knowledge, not fear. Be kind to yourself and take time to recover and adjust. But, if necessary, the radiation effects are much less now than they were several years ago. I would not tell you this if I had not experienced it myself. (But watch out for the possibility of androgen deprivation therapy, the effects of which are in the “fine print”).

  8. My Gleason score was 7 (4 + 3 post-surgery when it was 3 + 4 pre-surgery); my PSA was 8.8 pre-surgery and < 0.1 post-surgery. I was told I am a T2c. I met with another radiation oncologist today who laid out my options better than the two others I met with. As long as the PSA doesn't start to creep up, he believes we can postpone radiation for up to 6 months after surgery. I do feel more comfortable postponing so I can Kegel my brains out and regain as much continence as possible. But you're right about the PSA anxiety. Having to do that once a month and then wait for the results, even 1 day, is annoying at best. I had a PSA today and we'll know by the end of the week. Then we'll see where we are and go from there.

    Thanks for all the words of encouragement and sharing your experiences. Nice to have others to communicate with who can relate.

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