Blute M L, Bostwick D G, Bergstralh E J, Slezak J M, Martin S K, Amling C L, Zincke H
Department of Urology, Mayo Clinic, Rochester, MN 55905, USA.
Urology. 1997 Nov;50(5):733-9. doi: 10.1016/S0090-4295(97)00450-0.
The impact of a positive surgical margin in otherwise confined prostate cancer after radical prostatectomy remains unclear. We analyzed the outcome of a large number of patients with organ-confined prostate cancer according to the presence and anatomic site of margin positivity.
We evaluated 2712 prostatectomy patients with Stage pT2N0 cancer (ie, no evidence of extra-prostatic disease, seminal vesicle or regional node involvement) and no prior therapy who were treated by radical prostatectomy between 1987 and 1995 at Mayo Clinic. A total of 697 patients (26%) had positive margins. To assess the effect of margin status in the absence of treatment, 378 patients with postoperative adjuvant therapy were not considered for the study group: the final group consisted of 2334 patients.
Overall, 253 (58%) tumors were positive at the apex and/or urethra, 85 (19%) at the prostate base, 11 (2.5%) at the anterior prostate, and 174 (40%) at the posterior prostate; 89 (20%) had at least two margins involved and 21 (8.3%) had more than two involved. The apex/urethra was the only positive anatomic site in 183 (42%). Five-year survival free of clinical recurrence or prostate-specific antigen (PSA) biochemical failure (postoperative serum PSA of 0.2 ng/mL or more) for patients with a single positive margin was 79% for apex or urethra, 78% for anterior/posterior, and 56% for prostate base. Five-year survival free of clinical recurrence or PSA (biochemical) failure was slightly higher for those with one versus two margin-positive regions (77% versus 68%, respectively). Multivariate analysis revealed that positive surgical margins were a significant predictor of clinical recurrence and PSA (biochemical) failure (relative risk [95% confidence interval]: 1.65 [1.24, 2.18]) after controlling for Gleason grade, preoperative PSA, and deoxyribonucleic acid (DNA) ploidy. The effect of margin positivity on recurrence at a specific anatomic site (versus negative margins or positive at a different anatomic site) revealed the prostate base to be the only significant anatomic site when adjusted for grade, PSA, and ploidy. Five-year survival free of the combined clinical or PSA failure end point for those with versus those without positive margins at the prostate base was 56% versus 85%, respectively (P < 0.0001).
Positive surgical margins are a significant predictor of recurrence in Stage pT2N0 cancer, which is independent of grade, PSA, and DNA ploidy. The impact of positive margin status on recurrence-free survival appears to be anatomic and site-specific, with prostate base positivity significantly associated with poor outcome. The benefit of adjuvant therapy based on anatomic site-specific margin positivity remains to be tested in order to optimize recurrence-free survival.
在根治性前列腺切除术后，切缘阳性对原本局限的前列腺癌的影响仍不明确。我们根据切缘阳性的存在情况及解剖部位，分析了大量局限于器官内的前列腺癌患者的预后。
我们评估了1987年至1995年在梅奥诊所接受根治性前列腺切除术的2712例pT2N0期癌症（即无前列腺外疾病、精囊或区域淋巴结受累证据）且未接受过先前治疗的前列腺切除术患者。共有697例患者（26%）切缘阳性。为评估在未进行治疗情况下切缘状态的影响，研究组未纳入378例接受术后辅助治疗的患者：最终研究组由2334例患者组成。
总体而言，253例（58%）肿瘤在尖部和/或尿道呈阳性，85例（19%）在前列腺底部呈阳性，11例（2.5%）在前部前列腺呈阳性，174例（40%）在后部前列腺呈阳性；89例（20%）至少有两个切缘受累，21例（8.3%）有两个以上切缘受累。尖部/尿道是183例（42%）患者唯一的阳性解剖部位。单个切缘阳性的患者5年无临床复发或前列腺特异性抗原（PSA）生化失败（术后血清PSA≥0.2 ng/mL）生存率，尖部或尿道为79%，前部/后部为78%，前列腺底部为56%。有一个与两个切缘阳性区域的患者5年无临床复发或PSA（生化）失败生存率略高（分别为77%和68%）。多因素分析显示，在控制了Gleason分级、术前PSA和脱氧核糖核酸（DNA）倍体后，手术切缘阳性是临床复发和PSA（生化）失败的显著预测因素（相对风险[95%置信区间]：1.65[1.24, 2.18]）。切缘阳性对特定解剖部位复发的影响（与切缘阴性或不同解剖部位阳性相比）显示，在调整分级、PSA和倍体后，前列腺底部是唯一显著的解剖部位。前列腺底部有切缘阳性与无切缘阳性的患者5年无临床或PSA联合失败终点生存率分别为56%和85%（P<0.0001）。
手术切缘阳性是pT2N0期癌症复发的显著预测因素，与分级、PSA和DNA倍体无关。切缘阳性状态对无复发生存的影响似乎具有解剖学和部位特异性，前列腺底部阳性与不良预后显著相关。基于解剖部位特异性切缘阳性的辅助治疗的益处仍有待验证，以优化无复发生存率。
