Positive surgical margins (PSMs) are frequent in patients undergoing radical prostatectomy (RP). The impact of PSMs on cancer-specific (CSM) and overall (OM) mortality has not yet been proved definitively.
To evaluate whether the presence and the features of PSMs were associated with CSM and OM in patients who underwent robotic-assisted RP.
A cohort of 8141 patients underwent robotic-assisted RP with >10 yr of follow-up.
Cox multivariable analyses assessed the impact of margin status (positive vs negative) and PSM features (negative vs <3 mm vs >3 mm vs multifocal) on the risk of CSM, OM, and biochemical recurrence (BCR) after adjusting for potential confounders. We repeated our analyses after stratifying patients according to clinical (Cancer of the Prostate Risk Assessment [CAPRA] categories) and pathological characteristics (adverse: pT 3-4 and/or grade group [GG] 4-5 and/or pN1 and/or prostate-specific antigen [PSA] persistence).
PSMs were found in 1348 patients (16%). Among these, 48 (3.6%) patients had multifocal PSMs. Overall, 1550 men experienced BCR and 898 men died, including 130 for prostate cancer. At Cox multivariable analyses, PSMs were associated with CSM in patients with adverse clinical (Intermediate risk: hazard ratio [HR]: 1.71, p = 0.048; high risk: HR: 2.20, p = 0.009) and pathological (HR: 1.79, p = 0.005) characteristics. Only multifocal PSMs were associated with CSM and OM in the whole population (HR for CSM: 4.68, p < 0.001; HR for OM: 1.82, p = 0.037) and in patients with adverse clinical (intermediate risk: HR for CSM: 7.26, p = 0.006; high risk: HR for CSM: 9.26, p < 0.001; HR for OM: 2.97, p = 0.006) and pathological (HR for CSM: 9.50, p < 0.001; HR for OM: 2.59, p = 0.001) characteristics. Potential limitations include a selection bias and a lack of information on the Gleason score at PSM location.
We did not find an association between unifocal PSMs and mortality. Conversely, our results underscore the importance of avoiding multifocal PSMs in patients with adverse clinical (intermediate- and high-risk CAPRA score) and pathological (GG ≥4, pT ≥3, pN1, or PSA persistence) characteristics, to enhance overall survival and reduce CSM.
In this study, we evaluated whether the presence and the characteristics of positive surgical margins were associated with mortality in patients who underwent robotic-assisted radical prostatectomy. We found that the presence of positive surgical margins, particularly multifocal margins, was associated with mortality only in patients with adverse clinical and pathological characteristics.
European urology oncology. 2023 Dec 27 [Epub ahead of print]
Francesco Pellegrino, Ugo Giovanni Falagario, Sophie Knipper, Alberto Martini, Olof Akre, Lars Egevad, Markus Aly, Marcio Covas Moschovas, Carlo Andrea Bravi, Joshua Tran, Yasmin Heiniger, Antonius von Kempis, Robin Schaffar, Giuseppe Carrieri, Alberto Briganti, Francesco Montorsi, Charles-Henry Rochat, Alexandre Mottrie, Thomas E Ahlering, Hubert John, Vipul Patel, Markus Graefen, Peter Wiklund, ERUS Scientific Working Group on Prostate Cancer of the European Association of Urology
Department of Pelvic Cancer, Karolinska University Hospital, Solna, Sweden; Unit of Urology/Division of Oncology, Soldera Prostate Cancer Lab, Urological Research Institute, IRCCS San Raffaele Hospital, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy., Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Urology, University of Foggia, Foggia, Italy. Electronic address: ., Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany., Department of Urology, MD Anderson Cancer Center, Houston, TX, USA., Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden., Department of Oncology and Pathology, Karolinska institute, Stockholm, Sweden., Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Departments of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden., AdventHealth Global Robotics Institute, Orlando, FL, USA; University of Central Florida (UCF), Orlando, FL, USA., Department of Urology, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium; ORSI Academy, Ghent, Belgium; Department of Urology, The Royal Marsden NHS Foundation Trust, London, UK., Department of Urology, University of California, Irvine Medical Center, Orange, CA, USA., Department of Urology, Kantonsspital Winterthur, Winterthur, Switzerland., Department of Urology, Clinique Générale Beaulieu, Geneva, Switzerland., Department of Urology, University of Foggia, Foggia, Italy., Unit of Urology/Division of Oncology, Soldera Prostate Cancer Lab, Urological Research Institute, IRCCS San Raffaele Hospital, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy., Department of Urology, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium; ORSI Academy, Ghent, Belgium., Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.