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Thread: Variation in Positive Surgical Margin Status After RP for pT2 PCa

  1. #1

    Variation in Positive Surgical Margin Status After RP for pT2 PCa

    Variation in Positive Surgical Margin Status After Radical Prostatectomy for pT2 Prostate Cancer [2019]

    Abstract

    INTRODUCTION:
    We evaluated patient, hospital, and cancer-specific factors associated with positive surgical margin (PSM) variability after radical prostatectomy in pT2 prostate cancer in the United States.

    PATIENTS AND METHODS:
    A total of 45,426 men from 1152 hospitals with pT2 prostate cancer and known margin status after radical prostatectomy were identified using the National Cancer Database (2010-2015). Data on patient, cancer, hospital factors, and surgical approach were extracted. A mixed effects logistic regression model was computed to examine factors associated with PSM and partial R2 values to assess the relative contributions of patient, cancer, and hospital variables to PSM status.

    RESULTS:
    Median PSM rate of 8.5% (interquartile range, 5.2%-13.0%). Robotic (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.83-0.99) and laparoscopic (OR, 0.74; 95% CI, 0.64-0.90) surgical approach, academic institution (OR, 0.87; 95% CI, 0.76-1.00) and high hospital surgical volume (>297 cases [OR], 0.83; 95% CI, 0.70-0.99) were independently associated with a lower PSM. Black men (OR, 1.13; 95% CI, 1.01-1.26) and adverse cancer-specific features (prostate-specific antigen [PSA], 10-20; PSA >20; cT3 stage; Gleason 7, 8, 9-10; all P > .01) were independently associated with a higher PSM. Patient-specific, hospital-specific, and cancer-specific factors had a contribution of 2.3%, 3.9%, and 15.2%, respectively, to the variation in PSM. Facility had a contribution of 23.7% to the variation in PSM.

    CONCLUSION:
    Cancer-specific factors account for 15.2% of PSM variation with the remaining 84.8% of PSM variation due to patient, hospital, and other factors not accounted within the model. Noncancer-specific factors represent addressable factors that are important for policy-makers in efforts to improve patient outcome.
    From the Full Text:

    Positive surgical margin after radical prostatectomy for pT2 prostate cancer is considered a metric for surgical quality.3 However, there is significant variation in PSM rates reported in the literature.1,4 Cancer-specific risk factors for PSM after radical prostatectomy are well established. There is a clear stage correlation with risk of PSM for which pT3 cancers show a PSM rate as high as 29% to 50% compared with the 4% to 23% in pT2 cancers.5 Inaccurate clinical staging on the basis of presurgery magnetic resonance imaging leading to the decision for nerve-sparing can be associated with a risk for PSM.6 Surgical technique, surgeon’s preference for a nerve-sparing approach, and attempts to preserve maximal urethral length are factors that affect PSM rates.7,8 Anatomic location of cancer within the prostate can be a risk factor, where apical cancers in particular have a higher risk of PSM because of the lack of a distinct capsule and high anatomical variability of the apex.1
    What remains less clear is noncancer-specific risk factors. Reports have shown an association between higher surgeon operating volume and lower PSM rates.7 However, PSM rates between open and robotic techniques are comparable.9 Cancer-specific factors and surgeon volume alone cannot account for the large variation in PSM. Significant variation in the management of prostate cancer has been widely reported. Variations in active surveillance and treatment outcomes for prostate cancer have been shown.10,11 We hypothesised that other factors such as patient demographic characteristics, socioeconomic, geographic,and surgical approach might have an association with PSM.
    [Emphasis mine]

    Note: An assessment of pT2 with positive surgical margin(s) means the SM+ was the only major adverse path finding, i.e., no EPE+, SVI+, or LNI+.

    As we know, SM+ can be, on one hand, unavoidable when the cancer has spread: you can cut only so wide. On the other, % patients with SM+ is used to evaluate the progress of uro surgeons learning the RP procedure.
    Last edited by DjinTonic; 07-17-2019 at 07:58 PM.

  2. #2
    The above, recent study cites this one:

    Are you now a good surgeon? T2 positive margin status as a quality outcome measure following radical prostatectomy [2017, Full Text]

    Abstract

    Objective
    To assess potential biases, such as the reporting pathologist, that may affect objectivity of T2 positive margin rates as a quality outcome measure following radical prostatectomy.

    Patients and methods
    Prospective data on 183 consecutive LRP patients with pT2 disease, operated on by a single surgeon (2003–2009), were studied. Outcomes were grouped as pre-, peri-, and post-operative and included: age, ethnicity, Gleason score, reporting pathologist, percentage of positive cores, operative time, blood loss, nerve-sparing status, hospital stay and prostate weight. Descriptive analysis and logistic regression analysis were carried out to compare these variables by positive margin status.

    Results
    A total of 30 (16.4 %) positive surgical margins (PSMs) were reported. Surgical stage, earlier date of surgery, and lower prostatic weight showed statistically significant associations with PSM status in both univariate and multivariate analysis. The reporting pathologist was not found to be predictive of PSMs (P = 0.855).

    Conclusion
    We showed that the reporting pathologist does not influence T2 positive margin status, in contrast to tumour characteristics and surgeon experience. T2 positive margin assessment therefore appears to be an objective quality outcome measure.
    Last edited by DjinTonic; 07-17-2019 at 09:12 PM.

  3. #3
    TY Dj! As we all know, RP is a highly technically demanding major surgery. PSMs remain a reality and will remain as long as RP surgeries are performed. We also are well aware that a highly skilled, highly experienced URO Surgeon will always be the best surgical option.

    The statement in your 1st posted abstract: "Noncancer-specific factors represent addressable factors that are important for policy-makers in efforts to improve patient outcome," is one of those: We're not going to state it, but you (the reader) should infer it - type statements.

    The 2nd posted paper comes out and says it!!!

    MF
    Last edited by Michael F; 07-18-2019 at 11:15 AM.
    PSA: Oct '09 = 1.91, Oct '11 = 2.79, Dec '11 = 2.98 (PSA, Free = 0.39ng/ml, % PSA Free = 13%)
    Referred to URO MD
    Jan '12: DRE = Positive: "Left induration"
    Jan '12: Biopsy = 6 of 12 Cores were Positive: 1 = G7 (3+4) and 5 = Gleason 6
    Referred to URO Surgeon
    March '12: Robotic RP: Left: PM + EPE. MD waited in surgery for preliminary Path Report then excised substantial left adjacent tissue(s) down to negative margins and placed 2 Ti clips for SR guidance, if needed in future.
    Pathology: Gleason (3+4) pT3a pNO pMX pRO c tertiary pattern 5 / Prostate Size = 32 grams / Tumor = Bilateral: 20% / PNI: present
    3 month Post Op standard PSA = <0.1 ng/ml
    1st uPSA at 7 months Post Op = 0.018 ng/ml
    uPSA remains "stable" at 91 Months Post Op: Mean = 0.022 (22x uPSAs: Range 0.017 - 0.032) LabCorp: Ultrasensitive PSA: Roche ECLIA
    Continence = Very Good (≥ 99%)
    ED = present

  4. #4
    Quote Originally Posted by Michael F View Post
    TY Dj! As we all know, RP is a highly technically demanding major surgery. PSMs remain a reality and will remain as long as RP surgeries are performed. We also are well aware that a highly skilled, highly experienced URO Surgeon will always be the best surgical option.

    The statement in your 1st posted abstract: "Noncancer-specific factors represent addressable factors that are important for policy-makers in efforts to improve patient outcome." Is one of those: We're not going to state it, but you (the reader) should infer it - type statements.

    The 2nd posted paper comes out and says it!!!

    MF
    There will be certain percentage of PSM because of cancer-related factors (e.g. tumor location). Among take-home messages is that surgeons should aim for that number, and under-performing institutions should improve the parameters than can be improved to bring their percentages in line.

    Djin
    Last edited by DjinTonic; 07-18-2019 at 11:18 AM.

  5. #5
    Senior User
    Join Date
    Nov 2018
    Posts
    262
    My surgeon is the Chair of Urology at Mayo Clinic in Phoenix Arizona and has done over 2500 surgeries yet I still had surgical margins on the side he took the nerves on. He said while doing the surgery everything looked good. He said margins may or may not mean anything. I think he did all he could and hopefully all is well. Sometimes it's all they can do.
    DOB 1955
    63 at dx
    3/2018 PSA 4.05 DRE normal refer to URO small town
    10/2018 PSA 6.28 DRE normal
    Bx 11/2018 12 cores 3 pos 1 - 5% left mid 2 - 50% left base
    GS 3+4=7 T1c
    Appt Mayo Clinic Phoenix Az 1/4/2019
    Dr. Paul Andrews recommend
    MRI 2/27/2019 Mayo AZ
    RALP 2/28/2019 Mayo AZ Dr. Paul Andrews
    Path: GS 3+4=7, Tertiary Gleason Pattern none, Grade Group 2
    Tumor presents moderate to extensive volume mainly posterior
    portion of prostate. Largest tumor nodule measures 8 mm
    Prostate: 21g 3.5 x 3 x 3 cm
    EPE: Neg
    Bladder Neck Invasion: Neg
    Seminal Vesicle Invasion: Pos (left seminal vesicle)
    Margins: Pos left lateral base & central base 2mm focus each
    Lymph Nodes involved: 0
    Lymph Nodes Ex: 16
    Nerves spared right side only
    Path Staging (AJCC 8th Edition)
    Primary Tumor pT3b
    Regional lymph nodes: pNO
    Distant Metastasis: Mx
    Continence 99% 9 wks
    ED Present
    PSA 4/17/2019 <.10
    PSA 5/2/2019 <.007
    PSA 6/10/2019 <.10
    PSA 8/1/2019 <.007
    PSA 9/16/2019 <.10

  6. #6
    Quote Originally Posted by nmguy View Post
    My surgeon is the Chair of Urology at Mayo Clinic in Phoenix Arizona and has done over 2500 surgeries yet I still had surgical margins on the side he took the nerves on. He said while doing the surgery everything looked good. He said margins may or may not mean anything. I think he did all he could and hopefully all is well. Sometimes it's all they can do.
    No doubt, nmguy. However your situation was more serious, being pT3 (with SVI+ and nerve-bundle involvement). One purpose of the recent study was to remind individuals and institutions to try to match the low percentages of the best surgeons, who have SM+ in pT2 patients only for cancer-related reasons.

    Djin
    Last edited by DjinTonic; 07-18-2019 at 04:57 PM.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg., then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%, 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 wk) PSA <0.1
    LabCorp uPSA, Roche ECLIA:
    11-28-17 (3 m ) 0.010
    02-26-18 (6 m ) 0.009
    05-30-18 (9 m ) 0.007
    08-27-18 (1 yr.) 0.018 (?)
    09-26-18 (13 m) 0.013 (30-day retest)
    11-26-18 (15 m) 0.012
    02-25-19 (18 m) 0.015
    05-22-19 (21 m) 0.015
    08-28-19 (2 yr. ) 0.016
    Avg. = 0.013

  7. #7
    Top User
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    Aug 2016
    Posts
    1,926
    It begs the question, do surgeons give preference to nerve sparing procedures over postive margins? Is there a bias that SRT will clean up after and preserve erectile function? Is it now a false premise based on studies showing little difference in treatment choice on ED?

    My surgeon confessed recently his positive margin numbers are going up. Is it an increase in testosterone use and continued low rates of screening? Is new awareness bringing more advanced cases into screening and treatment?

    My brother's surgeon said lets use surgery and we will mop up with radiation.

    My oldest brother was spurred onto treatment after my experience. If he had led the way he probably would have avoided his +SMV.

    It's difficult to judge the source of these outcomes with treament when the inlet valve has no controls.
    Born 1953
    family w/PCa; grandfather, 3 brothers
    07-12-04 PSA 1.90
    07-10-06 PSA 2.02
    08-30-07 PSA 3.20
    12-01-11 PSA 5.69 Internist recommends urologist, I say no
    05-16-12 PSA 4.76 manipulate w/diet & supplements
    12-11-12 PSA 5.20, Health system changes to 3 years on testing
    03-07-16 PSA 7.20 Internist adamant on urologist
    DRE smooth, enlarged
    03-14-16 TRUS biopsy-prostatic adenocarcinoma 1%-60% across 8 of 12 samples, Gleason 3+3=6
    03-31-16 MRI pelvis w/o dye
    05-04-16 DaVinci prostatectomy, nerve sparing, Dr. Kent Adkins - recommend
    Final Path; weight 65g, lymph nodes, seminal vesicles, capsule, margin all negative, Gleason 3+4=7, Tumor volume 35%, +pT2c
    Catheter out - 16 days
    Incontinence at 6mos is minimal – no pad
    Cialis 3x/wk & Viagra on occasion
    Begin self-injection needle therapy for erections, stop after 6 due to onset of Peyronie’s
    Erections 100% - 14 months
    5-21-19 PSA <0.02, Zero Club 3.5 years

  8. #8
    Quote Originally Posted by Another View Post
    It begs the question, do surgeons give preference to nerve sparing procedures over postive margins? Is there a bias that SRT will clean up after and preserve erectile function? Is it now a false premise based on studies showing little difference in treatment choice on ED?

    My surgeon confessed recently his positive margin numbers are going up. Is it an increase in testosterone use and continued low rates of screening? Is new awareness bringing more advanced cases into screening and treatment?

    My brother's surgeon said lets use surgery and we will mop up with radiation.

    My oldest brother was spurred onto treatment after my experience. If he had led the way he probably would have avoided his +SMV.

    It's difficult to judge the source of these outcomes with treament when the inlet valve has no controls.
    After I decided for surgery, based on my biopsy on imaging, my uro/surgeon said he was fairly sure he would be able to save the nerve on one side, but was unsure about the other and wouldn't know until the surgery. I said cancer control came first. The morning of the surgery he stopped by to check on me. He repeated those remarks about the nerve bundles, and wanted to make sure he remembered our conversation correctly: he would try to save both nerves, but would give priority to removing all the cancer -- he asked me directly if I agreed with this, which I did. I gathered there are some men for whom sex is more important (?). I'll make a note to ask him about this issue at my next visit.

    With regard to surgical margins in general, again I think we have to distinguish basically prostate-contained cases (pT2) with pT3, where the cancer is locally advanced.
    Last edited by DjinTonic; 07-18-2019 at 08:08 PM.

  9. #9
    Top User
    Join Date
    Aug 2016
    Posts
    1,926
    Mine never asked.

  10. #10
    Senior User
    Join Date
    May 2017
    Posts
    222
    Quote Originally Posted by DjinTonic View Post
    After I decided for surgery, based on my biopsy on imaging, my uro/surgeon said he was fairly sure he would be able to save the nerve on one side, but was unsure about the other and wouldn't know until the surgery. I said cancer control came first. The morning of the surgery he stopped by to check on me. He repeated those remarks about the nerve bundles, and wanted to make sure he remembered our conversation correctly: he would try to save both nerves, but would give priority to removing all the cancer -- he asked me directly if I agreed with this, which I did. I gathered there are some men for whom sex is more important (?). I'll make a note to ask him about this issue at my next visit.

    With regard to surgical margins in general, again I think we have to distinguish basically prostate-contained cases (pT2) with pT3, where the cancer is locally advanced.
    Djin;
    This is a really interesting topic that comes up from time to time and it continues to make me question the skill of my surgeon. I have read atleast one study that stated how PSM are the direct result of surgeon skill. However, I am reading stories on this Forum how men whose surgeons seemed to have expert skill still end up with PSMs. I thought my surgeon was pretty skillful at the major teaching hospital, Cleveland Clinic and I was left with a 1mm PSM and that was with PT2. I read his full surgical report (3 typewritten pages) which stated that when he took my prostate out and examined it, he said that it looked clean. He told me after surgery that he thought he got it all. His report specifically makes mention of PSMs and how he did things to avoid them.

    So I think there's more to it than just surgical skill despite what at least one report says.

    Tim
    Age at diagnosis: 57
    8/15/14 PSA 2.9
    3/01/17 PSA 5.9
    5/1/17 Biopsy Results
    6 cores positive out of 12
    1. G 6 - 45%, 2. G7 (3+4) - 70%, 3. G6 - <5%, 4. G7 (3+4) - 40% Perineural Invasion Identified
    5. G6 - 15%, 6. G6 - 15%
    CT and bone scan negative
    Biopsy second opinion by the Cleveland Clinic: Still G3+4 (% of pattern 4 in each of two cores = 5% of tumor)
    Pre Surgery PSA = 6.11, Free PSA = 13%
    Davinci performed August 1, 2017 at Cleveland Clinic
    Catheter out August 9, 2017
    Pathology: Pathologic Stage - pT2: Organ confined, Gleason Score 3+4=7: Grade Group 2.
    % of pattern 4: 1-10%, % of pattern 3: 91-100%
    SV -, BN -, LN -
    Margin of resection is focally positive for tumor, Length of positive margin: 1mm
    Gleason pattern at positive margin: Pattern 3.
    Post-Op PSA History: 9/14/17 <.03, 11/10/17 <.03, 5/10/18 <.03, 7/19/18 <.03, 9/15/18 <.03, 11/14/18 .03, 02/18/19 .05, 3/12/19 .05, 4/22/19 .06
    SRT begin 5/7/19, 70.2 gy total in 35 fractions.

 

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