Follow-up and treatment of patients following radical prostatectomy with positive surgical margins

Czech version

Authors: Ladislav Jarolím; Štěpán Veselý; Marek Schmidt; Kateřina Dušková; Joana Do Carmo; Vojtěch Novák; Marek Babjuk
Authors‘ workplace: Urologická klinika 2. LF UK a FN Motol, Praha
Published in: Ces Urol 2017; 21(2): 139-146
Category: Original Articles

Overview

Major statement:
The positive margins of the radical prostatectomy specimen is an unfavorable prognostic sign which is the indication of adjuvant treatment. Nearly a third of patients with such a finding, however, are alive with no evidence of disease and do not need further treatment.

Aim:
The finding of positive surgical margins obtained in radical prostatectomy is an adverse prognostic factor that is usually an indication for adjuvant therapy. The study focused on long-term results of follow-up and treatment in patients after radical prostatectomy with positive surgical margins. The aim of the study was to evaluate what proportion of such patients can be spared subsequent treatment with known adverse effects.

Patient cohort:
Of the 92 patients who underwent radical prostatectomy and had a finding of positive surgical margins, 72 were followed in the long term and evaluated. An adverse histological finding, high level of PSA nadir, and PSA growth were indications for further treatment – adjuvant radiotherapy, androgen deprivation therapy, or salvage radiotherapy. By contrast, a low PSA level in the long term allowed for watchful waiting and a mere surveillance of the patients. The results were evaluated statistically by using a nonparametric Mann-Whitney test.

Results:
The patient cohort was divided into four groups according to treatment strategy: adjuvant androgen deprivation therapy (ADT), adjuvant radiotherapy (ART), salvage radiotherapy (SRT), and watchful waiting (WW). The efficacy of delayed treatment with salvage radiotherapy was similar when compared with adjuvant therapy; with a follow-up with a median of 86 months in the ART group and 59.7 months in the SRT group, the median of the last PSA level was 0.008 and 0.010 ng/ml, respectively (p = 0.7434). Failure of radiotherapy occurred in 13.6% and 10% of patients in the ART and SRT groups, respectively. The safety of the watchful waiting strategy in the WW group is demonstrated by the median of the last PSA level of 0.029 ng/ml (p = 0.1703) with a median follow-up of 58.5 months.

Conclusion:
The presence of positive surgical margins after radical prostatectomy may not always indicate the need for further treatment. If administered in all the patients in the cohort, adjuvant therapy would have been unnecessary in 34.4%.

KEY WORDS:
Prostate cancer, radical prostatectomy, adjuvant radiotherapy, salvage radiotherapy.

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