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Diamand R, Roche JB, Lacetera V, Simone G, Windisch O, Benamran D, Fourcade A, Fournier G, Fiard G, Ploussard G, Roumeguère T, Peltier A, Albisinni S. Predicting contralateral extraprostatic extension in unilateral high-risk prostate cancer: a multicentric external validation study. World J Urol 2024; 42:247. [PMID: 38647728 DOI: 10.1007/s00345-024-04966-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/25/2024] [Indexed: 04/25/2024] Open
Abstract
PURPOSE Accurate prediction of extraprostatic extension (EPE) is crucial for decision-making in radical prostatectomy (RP), especially in nerve-sparing strategies. Martini et al. introduced a three-tier algorithm for predicting contralateral EPE in unilateral high-risk prostate cancer (PCa). The aim of the study is to externally validate this model in a multicentric European cohort of patients. METHODS The data from 208 unilateral high-risk PCa patients diagnosed through magnetic resonance imaging (MRI)-targeted and systematic biopsies, treated with RP between January 2016 and November 2021 at eight referral centers were collected. The evaluation of model performance involved measures such as discrimination (AUC), calibration, and decision-curve analysis (DCA) following TRIPOD guidelines. In addition, a comparison was made with two established multivariable logistic regression models predicting the risk of side specific EPE for assessment purposes. RESULTS Overall, 38%, 48%, and 14% of patients were categorized as low, intermediate, and high-risk groups according to Martini et al.'s model, respectively. At final pathology, EPE on the contralateral prostatic lobe occurred in 6.3%, 12%, and 34% of patients in the respective risk groups. The algorithm demonstrated acceptable discrimination (AUC 0.68), comparable to other multivariable logistic regression models (p = 0.3), adequate calibration and the highest net benefit in DCA. The limitations include the modest sample size, retrospective design, and lack of central revision. CONCLUSION Our findings endorse the algorithm's commendable performance, supporting its utility in guiding treatment decisions for unilateral high-risk PCa patients.
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Affiliation(s)
- Romain Diamand
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Rue Meylemeersch 90, 1070, Brussels, Belgium.
| | | | - Vito Lacetera
- Department of Urology, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Giuseppe Simone
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - Olivier Windisch
- Department of Urology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Daniel Benamran
- Department of Urology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Alexandre Fourcade
- Department of Urology, Hôpital Cavale Blanche, CHRU Brest, Brest, France
| | - Georges Fournier
- Department of Urology, Hôpital Cavale Blanche, CHRU Brest, Brest, France
| | - Gaelle Fiard
- Department of Urology, Grenoble Alpes University Hospital, Université Grenoble Alpes, CNRS, Grenoble INP, TIMC, Grenoble, France
| | | | - Thierry Roumeguère
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Rue Meylemeersch 90, 1070, Brussels, Belgium
| | - Alexandre Peltier
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Rue Meylemeersch 90, 1070, Brussels, Belgium
| | - Simone Albisinni
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Rue Meylemeersch 90, 1070, Brussels, Belgium
- Urology Unit, Department of Surgical Sciences, Tor Vergata University, Rome, Italy
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Wrona-Lis M, Wrona M, Madej A, Jakóbczyk B, Różanski W, Lipiński M. A comparative evaluation of radical prostatectomy using laparoscopic and open method in view of surgical margins. Cent European J Urol 2023; 76:300-304. [PMID: 38230315 PMCID: PMC10789277 DOI: 10.5173/ceju.2023.77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 09/24/2023] [Accepted: 09/24/2023] [Indexed: 01/18/2024] Open
Abstract
Introduction A positive surgical margin (PSM) in the radical prostatectomy (RP) specimen is associated with biochemical recurrence (BCR) and the need for adjuvant radiation therapy, and is an analysis of surgical procedure quality. We present data describing the identification, anatomy, and management of PSM after RP performed via an open operation and laparoscopically. The aim of the study was to compare assessment of RP (open vs. laparoscopic) in terms of analysis of PSM in postoperative histopathological tissue. Material and methods Patients with pT1 to pT3b prostate cancer with detailed surgical margin parameters and BCR status were analysed. The patients were divided into groups depending on the stage of neoplastic disease and the choice of operative procedure. Results In total, we obtained data from 140 PC patients. Positive surgical margins were confirmed in 11 cases treated with open surgery and in 7 cases treated with laparoscopic procedure. There was no statistically significant (p >0.05) relationship between the frequency of positive margins and the type of procedure. There was no statistically significant (p >0.05) relationship between the frequency of positive margins and the type of procedure in subgroups according to the Gleason score. There was a statistically significant (p <0.05) relationship between the clinical stage of the tumor and the type of margin. This particularly refers to tumours with stage T3b (more numerous in the group of open surgeries) and T2c (more numerous in the laparoscopic group). Conclusions There was no statistically significant correlation between the type of surgery and the incidence of a positive surgical margin.
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Affiliation(s)
- Marta Wrona-Lis
- 2 Clinic of Urology, Medical University of Łódź, Łódź, Poland
| | - Marek Wrona
- 2 Clinic of Urology, Medical University of Łódź, Łódź, Poland
| | - Adam Madej
- 2 Clinic of Urology, Medical University of Łódź, Łódź, Poland
| | | | | | - Marek Lipiński
- 2 Clinic of Urology, Medical University of Łódź, Łódź, Poland
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Panunzio A, Sorce G, Hoeh B, Hohenhorst L, Tappero S, Nimer N, Rajwa P, Tian Z, Terrone C, Chun FKH, Briganti A, Saad F, Shariat SF, Cerruto MA, Antonelli A, Karakiewicz PI. Effect of positive surgical margins at radical prostatectomy on cancer-specific mortality in high/very high-risk prostate cancer patients with Gleason Grade Group 4-5. Prostate 2023; 83:268-276. [PMID: 36336728 DOI: 10.1002/pros.24458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/18/2022] [Accepted: 10/20/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The effect of positive surgical margins (PSM) on cancer specific mortality (CSM) in high/very high-risk (HR/VHR) prostate cancer (PCa) with aggressive Gleason Grade Group (GGG) is unknown. We tested PSM effect on CSM in this setting, in addition to testing of radiotherapy (RT) benefit in PSM patients. METHODS We relied on Surveillance, Epidemiology, and End Results database (2010-2015), focusing on HR/VHR patients with exclusive GGG 4-5 at radical prostatectomy (RP). Kaplan-Meier plots and multivariable Cox regression models tested the relationship between PSM and CSM. Moreover, the effect of RT on CSM was explored in PSM patients. RESULTS Of 3383 HR/VHR patients, 15.1% (n = 511) exhibited PSM. Patients with PSM harbored higher rates of GGG 5 (60.1% vs. 50.9%, p < 0.001), pathologic tumor stage T3a (69.1% vs. 45.2%, p < 0.001) and lymph node involvement (14.1% vs. 9.4%, p < 0.001), relative to patients without PSM. PSM rates decreased over time (2010-2015) from 16.0% to 13.6%. Seven-year CSM-free survival rates were 91.6% versus 95.7% in patients with and without PSM, respectively. In multivariable Cox regression models, PSM was an independent predictor of CSM (hazard ratio = 1.6, p = 0.040) even after adjustment for age, prostate specific antigen, pathologic tumor stage and lymph node status. Finally, in PSM patients, RT delivery did not reduce CSM in either univariable or multivariable Cox regression models. CONCLUSIONS In HR/VHR PCa patients with exclusive GGG 4-5, PSM at RP adversely affect survival. Moreover, RT has no protective effect on CSM. In consequence, lowest possible PSM rates are crucial in such patients.
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Affiliation(s)
- Andrea Panunzio
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Gabriele Sorce
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
- Division of Experimental Oncology, Department of Urology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Benedikt Hoeh
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Lukas Hohenhorst
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Stefano Tappero
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
- Department of Urology, IRCCS Policlinico San Martino, Genova, Italy
| | - Nancy Nimer
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Pawel Rajwa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, Medical University of Silesia, Zabrze, Poland
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Carlo Terrone
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
- Department of Urology, IRCCS Policlinico San Martino, Genova, Italy
| | - Felix K H Chun
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Alberto Briganti
- Division of Experimental Oncology, Department of Urology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fred Saad
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Departments of Urology, Weill Cornell Medical College, New York City, New York, USA
- Department of Urology, University of Texas Southwestern, Dallas, Texas, USA
- Division of Urology, Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan
| | - Maria Angela Cerruto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
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Kim M, Yoo D, Pyo J, Cho W. Clinicopathological Significances of Positive Surgical Resection Margin after Radical Prostatectomy for Prostatic Cancers: A Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58091251. [PMID: 36143928 PMCID: PMC9500731 DOI: 10.3390/medicina58091251] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/12/2022] [Accepted: 08/26/2022] [Indexed: 12/24/2022]
Abstract
Background and Objectives: This study aims to elucidate the positive rate and the clinicopathological significance of surgical margin after radical prostatectomy (RP) through a meta-analysis. Materials and Methods: This meta-analysis finally used 59 studies, including the information about the positive surgical margin (PSM) and those clinicopathological significances after RP. The subgroup analysis for the estimated rates of PSM was evaluated based on types of surgery, grade groups, and pathological tumor (pT) stages. We compared the clinicopathological correlations between positive and negative surgical margins (NSM). Results: The estimated PSM rate was 25.3% after RP (95% confidence interval [CI] 21.9-29.0%). The PSM rates were 26.0% (95% CI 21.5-31.1%) 28.0% (95% CI 20.2-37.5%) in robot-assisted RP and nerve-sparing RP, respectively. The PSM rate was significantly higher in high-grade groups than in low-grade groups. In addition, the higher pT stage subgroup had a high PSM rate compared to the lower pT stage subgroups. Patients with PSM showed significantly high PSA levels, frequent lymphovascular invasion, lymph node metastasis, and extraprostatic extension. Biochemical recurrences (BCRs) were 28.5% (95% CI 21.4-36.9%) and 11.8% (95% CI 8.1-16.9%) in PSM and NSM subgroups, respectively. Patients with PSM showed worse BCR-free survival than those with NSM (hazard ratio 2.368, 95% CI 2.043-2.744%). Conclusions: Our results showed that PSM was significantly correlated with worse clinicopathological characteristics and biochemical recurrence-free survival. Among the results in preoperative evaluations, grade group and tumor stage are useful for the prediction of PSM.
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Affiliation(s)
- Minseok Kim
- Department of Urology, Chosun University Hospital, Chosun University School of Medicine, Gwangju 61453, Korea
| | - Daeseon Yoo
- Department of Urology, Daejeon Eulji University Hospital, Eulji University School of Medicine, Daejeon 35233, Korea
| | - Jungsoo Pyo
- Department of Pathology, Uijeongbu Eulji University Hospital, Eulji University School of Medicine, Uijeongbu 11759, Korea
| | - Wonjin Cho
- Department of Urology, Chosun University Hospital, Chosun University School of Medicine, Gwangju 61453, Korea
- Correspondence: ; Tel.: +82-62-220-3210
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The Effect of Adverse Surgical Margins on the Risk of Biochemical Recurrence after Robotic-Assisted Radical Prostatectomy. Biomedicines 2022; 10:biomedicines10081911. [PMID: 36009458 PMCID: PMC9405399 DOI: 10.3390/biomedicines10081911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 11/25/2022] Open
Abstract
Positive surgical margins (PSM) after radical prostatectomy are associated with a greater risk of biochemical recurrence (BCR). However, not all PSM harbour the same prognosis for recurrence. We aim to determine the impact of different PSM characteristics and their coexistence on the risk of BCR. This retrospective study included 333 patients that underwent robotic-assisted radical prostatectomy for prostate cancer between 2015−2020 at a single institution. The effect of PSM and their adverse characteristics on the risk of BCR was assessed using Cox proportional hazard models. Kaplan−Meier was used to represent BCR-free survival stratified by margin status. With a median follow-up of 34.5 months, patients with PSM had a higher incidence of BCR, higher risk of relapse and lower BCR-free survival than negative margins (p < 0.001). We established as adverse characteristics: PSM length ≥ 3 mm, multifocality and Gleason at margin > 3. PSM ≥ 3 mm or multifocal PSM were associated with an increased risk for BCR compared to favourable margins (HR 3.50; 95% CI 2.05−5.95, p < 0.001 and HR 2.18; 95% CI 1.09−4.37, p = 0.028, respectively). The coexistence of these two adverse features in the PSM also conferred a higher risk for biochemical relapse and lower BCR-free survival. Adverse Gleason in the margin did not confer a higher risk for BCR than non-adverse margins in our models. We concluded that PSM are an independent predictor for BCR and that the presence of adverse characteristics, such as length and focality, and their coexistence in the PSM are associated with a greater risk of recurrence. Nevertheless, subclassifying PSM with adverse features did not enhance the model’s predictive performance in our cohort.
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Ryu JH, Kim YB, Jung TY, Ko WJ, Kim SI, Kwon D, Kim DY, Oh TH, Yoo TK. Practice Patterns of Korean Urologists Regarding Positive Surgical Margins after Radical Prostatectomy: a Survey and Narrative Review. J Korean Med Sci 2021; 36:e256. [PMID: 34697927 PMCID: PMC8546307 DOI: 10.3346/jkms.2021.36.e256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/23/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND There is no clear consensus on the optimal treatment with curative intent for patients with positive surgical margins (PSMs) following radical prostatectomy (RP). The aim of this study was to investigate the perceptions and treatment patterns of Korean urologists regarding the resection margin after RP. METHODS A preliminary questionnaire was prepared by analyzing various studies on resection margins after RP. Eight experienced urologists finalized the 10-item questionnaire. In July 2019, the final questionnaire was delivered via e-mail to 105 urologists in Korea who specialize in urinary cancers. RESULTS We received replies from 91 of the 105 urologists (86.7%) in our sample population. Among them, 41 respondents (45.1%) had performed more than 300 RPs and 22 (24.2%) had completed 500 or more RPs. In the question about whether they usually performed an additional biopsy beyond the main specimen, to get information about surgical margin invasion during surgery, the main opinion was that if no residual cancer was suspected, it was not performed (74.7%). For PSMs, the Gleason score of the positive site (49.5%) was judged to be a more important prognostic factor than the margin location (18.7%), multifocality (14.3%), or margin length (17.6%). In cases with PSMs after surgery, the prevailing opinion on follow-up was to measure and monitor prostate-specific antigen (PSA) levels rather than to begin immediate treatment (68.1%). Many respondents said that they considered postoperative radiologic examinations when PSA was elevated (72.2%), rather than regularly (24.4%). When patients had PSMs without extracapsular extension (pT2R1) or a negative surgical margin with extracapsular extension (pT3aR0), the response 'does not make a difference in treatment policy' prevailed at 65.9%. Even in patients at high risk of PSMs on preoperative radiologic screening, 84.6% of the respondents said that they did not perform neoadjuvant androgen deprivation therapy. Most respondents (75.8%) indicated that they avoided nerve-sparing RP in cases with a high risk of PSMs, but 25.7% said that they had tried nerve-sparing surgery. Additional analyses showed that urologists who had performed 300 or more prostatectomies tended to attempt more nerve-sparing procedures in patients with a high risk of PSMs than less experienced surgeons (36.6% vs. 14.0%; P = 0.012). CONCLUSION The most common response was to monitor PSA levels without recommending any additional treatment when PSMs were found after RP. Through this questionnaire, we found that the perceptions and treatment patterns of Korean urologists differed considerably according to RP resection margin status. Refined research and standard practice guidelines are needed.
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Affiliation(s)
- Jae Hyun Ryu
- Department of Urology, Veterans Health Service Medical Center, Seoul, Korea
| | - Yun Beom Kim
- Department of Urology, Veterans Health Service Medical Center, Seoul, Korea
| | - Tae Young Jung
- Department of Urology, Veterans Health Service Medical Center, Seoul, Korea
| | - Woo Jin Ko
- Department of Urology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sun Il Kim
- Department of Urology, Ajou University School of Medicine, Suwon, Korea
| | - Dongdeuk Kwon
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Duk Yoon Kim
- Department of Urology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Tae Hee Oh
- Department of Urology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Tag Keun Yoo
- Department of Urology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea.
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Zhang B, Zhou J, Wu S, Guo M, Zhang Y, Liu R. The impact of surgical margin status on prostate cancer-specific mortality after radical prostatectomy: a systematic review and meta-analysis. Clin Transl Oncol 2020; 22:2087-2096. [DOI: 10.1007/s12094-020-02358-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 04/28/2020] [Indexed: 12/21/2022]
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Witthaus MW, Bloom JB. Financial Impact of Positive Surgical Margins During Radical Prostatectomy and the Odds of Receiving Adjuvant Radiation Therapy. JAMA Netw Open 2020; 3:e201894. [PMID: 32232446 DOI: 10.1001/jamanetworkopen.2020.1894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Jonathan B Bloom
- Department of Urology, University of Rochester, Rochester, New York
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Kvåle R, Myklebust TÅ, Fosså SD, Aas K, Ekanger C, Helle SI, Honoré A, Møller B. Impact of positive surgical margins on secondary treatment, palliative radiotherapy and prostate cancer-specific mortality. A population-based study of 13 198 patients. Prostate 2019; 79:1852-1860. [PMID: 31566779 DOI: 10.1002/pros.23911] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 09/12/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND The results of studies evaluating the impact of positive surgical margins on prostate cancer-specific mortality have been inconsistent. We, therefore, evaluated the impact of surgical margin status on subsequent secondary treatment, palliative radiotherapy, and prostate cancer-specific mortality. METHODS A total of 14 837 men treated with radical prostatectomy (RP) during the period 2001 to 2015 were identified from the Cancer Registry of Norway. Of those, 13 198 (89%) patients had complete data on the preoperative prostate-specific antigen level, pathological T-category, Gleason score in the prostatectomy specimen, and margin status. Multivariable Cox proportional hazards models were used to evaluate the risk, and flexible parametric models for the cumulative incidence were fitted to predict the probabilities of secondary treatment (salvage radiotherapy or prophylactic breast radiation), palliative radiotherapy, and prostate cancer-specific mortality. RESULTS After a median follow-up time of 5.2 years (3591 patients with ≥8 years of follow-up), positive surgical margins (PSMs) were independently predictive of secondary treatment (hazard ratio [HR] = 2.43, 95% confidence interval [CI] = 2.21-2.66) and palliative radiotherapy (HR = 1.45, 95% CI = 1.03-2.05). After 10 years, the absolute increased risk for palliative radiotherapy in patients with PSMs after RP varied between 0.1% in pT2 tumors with a Gleason score of 6, to 12% for pT3b tumors with a Gleason score of 9 to 10. PSMs were not independently associated with prostate cancer-specific mortality (HR = 1.14, 95% CI = 0.82-1.59). CONCLUSION PSMs were associated with increased application of secondary treatment and palliative radiotherapy but were not predictive of prostate cancer-specific mortality. As the use of palliative radiotherapy was only marginally increased in patients with PSMs and the lowest-risk disease characteristics, avoiding PSMs may be of greatest prognostic relevance in patients with higher-risk disease characteristics.
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Affiliation(s)
- Rune Kvåle
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
- Department of Health Registry Research and Development, Norwegian Institute of Public Health, Bergen, Norway
- Cancer Registry of Norway, Institute of Population-based Cancer Research, Oslo, Norway
| | - Tor Å Myklebust
- Cancer Registry of Norway, Institute of Population-based Cancer Research, Oslo, Norway
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Sophie D Fosså
- Cancer Registry of Norway, Institute of Population-based Cancer Research, Oslo, Norway
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kirsti Aas
- Department of Surgery, Vestre Viken Hospital Trust, Drammen, Norway
| | - Christian Ekanger
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - Svein I Helle
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - Alfred Honoré
- Department of Urology, Haukeland University Hospital, Bergen, Norway
| | - Bjørn Møller
- Cancer Registry of Norway, Institute of Population-based Cancer Research, Oslo, Norway
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Shangguan X, Qian H, Jiang Z, Xin Z, Pan J, Dong B, Xue W. Cell cycle progression score improves risk stratification in prostate cancer patients with adverse pathology after radical prostatectomy. J Cancer Res Clin Oncol 2019; 146:687-694. [PMID: 31745702 DOI: 10.1007/s00432-019-03089-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 11/15/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess the use of the cell cycle progression (CCP) score versus actual risk stratification practice in making treatment decisions for prostate cancer patients with locally adverse pathology after radical prostatectomy (RP). PATIENTS AND METHODS Men with adverse pathologic features, pT3 or positive surgical margins who underwent RP in 2010-2014 at Renji hospital were retrospectively analyzed. The primary outcome was biochemical recurrence (BCR) after RP. RNA was quantified from paraffin-embedded RP specimens. The CCP score was calculated as average expression of 31 CCP genes, normalized to 15 housekeeper genes. The prognostic utility of the CCP score was assessed using Kaplan-Meier analysis and multivariable Cox proportional hazards model. RESULTS Among the 100 men identified, 5-year BCR-free survival for the low- (< 0), intermediate- (0-1) and high- (> 1) CCP score groups was 89.3%, 38.8%, and 12.9%, respectively. In multivariable models adjusting for clinical and pathological variables with the cancer of the prostate risk assessment post-surgical (CAPRA-S) score, both continuous CCP score [hazard ratio (HR) 1.373 per unit score, 95% confidence interval (CI) 1.006-1.874; p = 0.046) and the categorized CCP score (p < 0.001)were independent predictors of BCR. CONCLUSIONS The present study provides insights into the role the CCP score plays in risk stratification of this cohort and in determining candidacy for deferred secondary treatment. From our perspective, the CCP score allows better stratification and can help identifying patients at lower risk of disease recurrence who could benefit from a wait-and-see policy.
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Affiliation(s)
- Xun Shangguan
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, 1630 Dong Fang Road, 200127, Shanghai, China
| | - Hongyang Qian
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, 1630 Dong Fang Road, 200127, Shanghai, China
| | - Zhou Jiang
- Department of Pathology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, 1630 Dong Fang Road, 200127, Shanghai, China
| | - Zhixiang Xin
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, 1630 Dong Fang Road, 200127, Shanghai, China
| | - Jiahua Pan
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, 1630 Dong Fang Road, 200127, Shanghai, China
| | - Baijun Dong
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, 1630 Dong Fang Road, 200127, Shanghai, China.
| | - Wei Xue
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, 1630 Dong Fang Road, 200127, Shanghai, China.
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Martini A, Gandaglia G, Fossati N, Scuderi S, Bravi CA, Mazzone E, Stabile A, Scarcella S, Robesti D, Barletta F, Cucchiara V, Mirone V, Montorsi F, Briganti A. Defining Clinically Meaningful Positive Surgical Margins in Patients Undergoing Radical Prostatectomy for Localised Prostate Cancer. Eur Urol Oncol 2019; 4:42-48. [PMID: 31411971 DOI: 10.1016/j.euo.2019.03.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 02/27/2019] [Accepted: 03/12/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND The impact of positive surgical margins (PSMs) on the risk of metastases in prostate cancer (PCa) patients treated with radical prostatectomy (RP) is still debated. OBJECTIVE To identify PSM features associated with recurrence in a stage-by-stage analysis. DESIGN, SETTING, AND PARTICIPANTS A total of 1757 PCa patients treated with RP without neoadjuvant or adjuvant treatments between 2011 and 2017 were identified. Patients were stratified according to the presence of PSM and to margins characteristics in three groups: no versus favourable (single margin <3mm) versus unfavourable (≥3mm or multifocal margin) PSMs. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Predictors of biochemical recurrence (BCR) and clinical recurrence (CR) were assessed using semiparametric Cox proportional hazard models. RESULTS AND LIMITATIONS Overall, 285 (16%) patients had PSMs; 146 (51%) had a unifocal PSM, while 139 (49%) had a multifocal PSM. The median length of a PSM was 1mm. Overall, 120 (42%) versus 165 (58%) patients had favourable versus unfavourable PSMs. In patients with ≤pT3a and pathologic grade group ≤3 disease (n=1351), favourable (hazard ratio [HR]: 2.24; 95% confidence interval [CI]: 1.19-4.22) and unfavourable (HR: 2.68; 95% CI: 1.49-4.84) PSMs significantly increased the risk of BCR (p<0.01). However, they were not associated with CR (all p>0.05). Conversely, in patients with pT3b/4 and/or pathologic grade group 4-5 and/or pN1 (n=406), only an unfavourable PSM was associated with both BCR (HR: 2.96; 95% CI: 1.19-4.22) and CR (HR: 2.60; 95% CI: 1.07-6.30; all p≤0.04). CONCLUSIONS Although the presence of PSMs was associated with an increased risk of BCR in all stages, only men with adverse pathologic characteristics and an unfavourable PSM were at an increased risk of experiencing metastases as compared with their counterparts with no or a single margin shorter than 3mm. PATIENT SUMMARY In this study, we defined a new category of unfavourable positive surgical margins (namely, ≥3mm and/or multifocal), which confers a higher risk of developing metastasis in men with more aggressive pathologic features.
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Affiliation(s)
- Alberto Martini
- Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| | - Giorgio Gandaglia
- Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.
| | - Nicola Fossati
- Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Simone Scuderi
- Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Carlo Andrea Bravi
- Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Elio Mazzone
- Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Armando Stabile
- Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Simone Scarcella
- Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Daniele Robesti
- Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Barletta
- Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Vito Cucchiara
- Department of Urology, Università Federico II, Naples, Italy
| | - Vincenzo Mirone
- Department of Urology, Università Federico II, Naples, Italy
| | - Francesco Montorsi
- Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Briganti
- Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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Zhang L, Wu B, Zha Z, Zhao H, Yuan J, Jiang Y, Yang W. Surgical margin status and its impact on prostate cancer prognosis after radical prostatectomy: a meta-analysis. World J Urol 2018; 36:1803-1815. [PMID: 29766319 PMCID: PMC6208659 DOI: 10.1007/s00345-018-2333-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/08/2018] [Indexed: 12/18/2022] Open
Abstract
Background and purpose Positive surgical margins (PSMs) correlate with adverse outcomes in numerous solid tumours. However, the prognostic value of PSMs in prostate cancer (PCa) patients who underwent radical prostatectomy remains unclear. Herein, we performed a meta-analysis to evaluate the association between PSMs and the prognostic value for biochemical recurrence-free survival (BRFS), cancer-specific survival (CSS), overall survival (OS), cancer-specific mortality (CSM) and overall mortality (OM) in PCa patients. Materials and methods According to the PRISMA statement, online databases PubMed, EMBASE and Web of Science were searched to identify relevant studies published prior to February 2018. The hazard ratios (HRs) and 95% confidence intervals (95% CIs) were calculated to evaluate the relationship between PSMs and PCa. Results Ultimately, 32 cohort studies that met the eligibility criteria and involved 141,222 patients (51–65,633 per study) were included in this meta-analysis. The results showed that PSMs were significantly predictive of poorer BRFS (HR = 1.35, 95% CI 1.28–1.48, p < 0.001), CSS (HR = 1.49, 95% CI 1.16–1.90, p = 0.001) and OS (HR = 1.11, 95% CI 1.02–1.20, p = 0.014). In addition, PSMs were significantly associated with higher risk of CSM (HR = 1.23, 95% CI 1.16–1.30, p < 0.001) and OM (HR = 1.09, 95% CI 1.02–1.16, p = 0.009) in patients with PCa. Conclusions Our study suggests that the presence of a histopathologic PSM is associated with the clinical outcomes BRFS, CSS, OS, CSM and OM in patients with PCa, and PSMs could serve as a poor prognostic factor for patients with PCa. Electronic supplementary material The online version of this article (10.1007/s00345-018-2333-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lijin Zhang
- Department of Urology, Affiliated Jiang-yin Hospital of the Southeast University Medical College, 163 Shou-shan Road, Jiangyin, 214400, Jiangsu, People's Republic of China
| | - Bin Wu
- Department of Urology, Affiliated Jiang-yin Hospital of the Southeast University Medical College, 163 Shou-shan Road, Jiangyin, 214400, Jiangsu, People's Republic of China.
| | - Zhenlei Zha
- Department of Urology, Affiliated Jiang-yin Hospital of the Southeast University Medical College, 163 Shou-shan Road, Jiangyin, 214400, Jiangsu, People's Republic of China
| | - Hu Zhao
- Department of Urology, Affiliated Jiang-yin Hospital of the Southeast University Medical College, 163 Shou-shan Road, Jiangyin, 214400, Jiangsu, People's Republic of China
| | - Jun Yuan
- Department of Urology, Affiliated Jiang-yin Hospital of the Southeast University Medical College, 163 Shou-shan Road, Jiangyin, 214400, Jiangsu, People's Republic of China
| | - Yuefang Jiang
- Department of Urology, Affiliated Jiang-yin Hospital of the Southeast University Medical College, 163 Shou-shan Road, Jiangyin, 214400, Jiangsu, People's Republic of China
| | - Wei Yang
- Department of Urology, Affiliated Jiang-yin Hospital of the Southeast University Medical College, 163 Shou-shan Road, Jiangyin, 214400, Jiangsu, People's Republic of China
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Ki-67 expression predicts biochemical recurrence after radical prostatectomy in the setting of positive surgical margins. BMC Urol 2018; 18:13. [PMID: 29506507 PMCID: PMC5838874 DOI: 10.1186/s12894-018-0330-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 02/28/2018] [Indexed: 01/09/2023] Open
Abstract
Background Positive surgical margin (PSM) is a predictor of biochemical recurrence (BCR) following radical prostatectomy (RP). Attempts to stratify PSM based on linear length, Gleason score, location and number have failed to add to predictive models using margin status alone. We evaluated the prognostic significance of Ki-67 expression in this setting. Methods Immunohistochemical staining for Ki-67 was done on prostatectomy specimens from 117 patients who had a PSM. Ki67 expression was measured at the margin and in the index lesion. Patients were dichotomized based on Ki-67 expression into three groups. Group 1 with no Ki-67 expression, Group 2 with Ki-67 ≤ 2%, and Group 3 with Ki-67 ≥ 3%. To eliminate the impact of the adjuvant treatment (AT) on the outcome, data were analyzed by the Cox proportional hazards in which AT was Considered as a time-dependent covariate. Results The discordance rate of Ki-67 expression between matched index lesion and margin specimens was 44/117 (37.6%). There was a trend for higher risk of BCR (HR:2.06, (0.97–4.43), P = 0.06) in patients expressing high Ki67 at the surgical margin although this was not statistically significant. However High Ki-67 expression in the index lesion was an independent predictive factor for BCR in this subset of patients. (HR:4, (1.64–9.80), P = 0.002). Conclusion High Ki67 expression in the index prostate cancer lesion is an independent predictor of BCR in patients with positive surgical margin following radical prostatectomy. Our findings need to be validated in a larger cohort.
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Tringale KR, Pang J, Nguyen QT. Image-guided surgery in cancer: A strategy to reduce incidence of positive surgical margins. WILEY INTERDISCIPLINARY REVIEWS-SYSTEMS BIOLOGY AND MEDICINE 2018; 10:e1412. [PMID: 29474004 DOI: 10.1002/wsbm.1412] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/13/2017] [Accepted: 11/03/2017] [Indexed: 12/16/2022]
Abstract
Primary treatment for many solid cancers includes surgical excision or radiation therapy, with or without the use of adjuvant therapy. This can include the addition of radiation and chemotherapy after primary surgical therapy, or the addition of chemotherapy and salvage surgery to primary radiation therapy. Both primary therapies, surgery and radiation, require precise anatomic localization of tumor. If tumor is not targeted adequately with initial treatment, disease recurrence may ensue, and if targeting is too broad, unnecessary morbidity may occur to nearby structures or remaining normal tissue. Fluorescence imaging using intraoperative contrast agents is a rapidly growing field for improving visualization in cancer surgery to facilitate resection in order to obtain negative margins. There are multiple strategies for tumor visualization based on antibodies against surface markers or ligands for receptors preferentially expressed in cancer. In this article, we review the incidence and clinical implications of positive surgical margins for some of the most common solid tumors. Within this context, we present the ongoing clinical and preclinical studies focused on the use of intraoperative contrast agents to improve surgical margins. This article is categorized under: Laboratory Methods and Technologies > Imaging.
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Affiliation(s)
- Kathryn R Tringale
- Division of Otolaryngology, Head and Neck Surgery, University of California, San Diego, La Jolla, California
| | - John Pang
- Division of Otolaryngology, Head and Neck Surgery, University of California, San Diego, La Jolla, California
| | - Quyen T Nguyen
- Division of Otolaryngology, Head and Neck Surgery, University of California, San Diego, La Jolla, California.,Department of Pharmacology, University of California, San Diego, La Jolla, California.,Moores Cancer Center, University of California, San Diego, La Jolla, California
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Bellangino M, Verrill C, Leslie T, Bell RW, Hamdy FC, Lamb AD. Systematic Review of Studies Reporting Positive Surgical Margins After Bladder Neck Sparing Radical Prostatectomy. Curr Urol Rep 2017; 18:99. [PMID: 29116405 PMCID: PMC5676800 DOI: 10.1007/s11934-017-0745-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
PURPOSE OF REVIEW Bladder neck preservation (BNP) during radical prostatectomy (RP) has been proposed as a method to improve early recovery of urinary continence after radical prostatectomy. However, there is concern over a possible increase in the risk of positive surgical margins and prostate cancer recurrence rate. A recent systematic review and meta-analysis reported improved early recovery and overall long-term urinary continence without compromising oncologic control. The aim of our study was to perform a critical review of the literature to assess the impact on bladder neck and base margins after bladder neck sparing radical prostatectomy. EVIDENCE ACQUISITION We carried out a systematic review of the literature using Pubmed, Scopus and Cochrane library databases in May 2017 using medical subject headings and free-text protocol according to PRISMA guidelines. We used the following search terms: bladder neck preservation, prostate cancer, radical prostatectomy and surgical margins. Studies focusing on positive surgical margins (PSM) in bladder neck sparing RP pertinent to the objective of this review were included. EVIDENCE SYNTHESIS Overall, we found 15 relevant studies reporting overall and site-specific positive surgical margins rate after bladder neck sparing radical prostatectomy. This included two RCTs, seven prospective comparative studies, two retrospective comparative studies and four case series. All studies were published between 1993 and 2015 with sample sizes ranging between 50 and 1067. Surgical approaches included open, laparoscopic and robot-assisted radical prostatectomy. The overall and base-specific PSM rates ranged between 7-36% and 0-16.3%, respectively. Mean base PSM was 4.9% in those patients where bladder neck sparing was performed, but only 1.85% in those without sparing. Bladder neck preservation during radical prostatectomy may increase base-positive margins. Further studies are needed to better investigate the impact of this technique on oncological outcomes. A future paradigm could include modification of intended approach to bladder neck dissection when anterior base lesions are identified on pre-operative MRI.
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Affiliation(s)
- Mariangela Bellangino
- Department of Urology, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
- Department of Urology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Clare Verrill
- Department of Pathology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Tom Leslie
- Department of Urology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard W. Bell
- Department of Urology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Freddie C. Hamdy
- Department of Urology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Alastair D. Lamb
- Department of Urology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Long-term oncological outcomes of apical positive surgical margins at radical prostatectomy in the Shared Equal Access Regional Cancer Hospital cohort. Prostate Cancer Prostatic Dis 2016; 19:423-428. [DOI: 10.1038/pcan.2016.45] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 06/26/2016] [Accepted: 07/12/2016] [Indexed: 11/08/2022]
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Bessede T, Patard JJ. Words of Wisdom. Re: The Use of Early Postoperative Prostate-specific Antigen to Stratify Risk in Patients with Positive Surgical Margins After Radical Prostatectomy. Eur Urol 2016; 69:372. [PMID: 26758520 DOI: 10.1016/j.eururo.2015.10.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Thomas Bessede
- Department of Urology, Bicetre Hospital, Université Paris-Sud, Le Kremlin-Bicetre, France.
| | - Jean-Jacques Patard
- Department of Urology, Bicetre Hospital, Université Paris-Sud, Le Kremlin-Bicetre, France
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Affiliation(s)
- Stanley A. Yap
- Department of Urology; University of California Davis Medical Center; 4860 Y Street Suite 3500 Sacramento CA 95817 USA
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