Radical or Not-So-Radical Prostatectomy: Do Surgical Margins Matter?

Abstract

Prostate cancer is the second most common malignancy in men, and prostatectomy is the treatment of choice for most patients with at least low risk of progression. The presence of positive margins in the radical prostatectomy specimen is considered an adverse pathologic feature, and may prompt additional therapeutic intervention in the patients. The absence of a distinct capsule around the prostate and intraoperative manipulations that aim to minimize postoperative adverse effects, complicate its wide removal. Proper handling of the specimen during the gross processing is essential for accurate determination of the status of margins or resection. Positive margins, defined as the presence of neoplastic glands in the highlighted-with-ink margin of resection, range from 6-38%. The surgical technique, surgeon's expertise and tumor (i.e., grade and stage) and patients' (i.e., BMI) characteristics affect the rate of margin positivity. Extensive or multifocal and nonanterior/nonapical positive margins are linked with higher recurrence rates, especially in organ-confined disease, underscoring the need for treating these patients more aggressively. In summary, detailed description of the status of the margins should be performed in every pathology report to determine patients' prognosis and the most appropriate therapeutic plan.

Keywords: margins of resection; pathology; prognosis; prostate cancer; radical prostatectomy.

Figure 1

Gross handling of prostatectomy specimens (a) Prostate specimen, colored with different colors in each surface to help orientation. (b) Serial sectioning through the transverse axis from apex to base (margins colored with blank ink). Apex and base will be subsequently sectioned in a parallel (parasagittal) way (not shown).

Figure 2

Definition of margin positivity (a) Neoplastic cells are close but not in contact with the ink. The distance between the inked margin and the neoplastic cells is pointed with a double-sided arrow. (b) Neoplastic cells are in contact with the ink. This is considered a positive margin. Three asterisks indicate the area of margin infiltration. (c) Cautery artifact in neoplastic cells in contact with the ink. An asterisk highlights the area of cautery effect. (400× magnification).

Figure 3

Representative images from low grade carcinomas with positive margins of different extent (a) Focal margin infiltration with neoplasm graded as PGG1. An arrow indicates the area of margin positivity (100× magnification) (b) Nonfocal margin infiltration with neoplasm graded as PGG1. Five asterisks point the area of margin positivity. (40× magnification).