Prostate cancer: Pathologic stage T3 disease or positive surgical margins following radical prostatectomy
- John F Ward, MD, FACS
John F Ward, MD, FACS
- Associate Professor of Surgery
- University of Texas MD Anderson Cancer Center
- Nicholas Vogelzang, MD
Nicholas Vogelzang, MD
- Section Editor — Prostate Cancer
- Professor of Medicine
- University of Nevada School of Medicine
- US Oncology Research
- Brian Davis, MD, PhD
Brian Davis, MD, PhD
- Professor of Radiation Oncology
- Mayo Clinic and Foundation
- Section Editors
- Jerome P Richie, MD, FACS
Jerome P Richie, MD, FACS
- Section Editor — Cancer of the Urethra, Penis, and Ureter; Urologic Surgery; Prostate Cancer
- Elliott Carr Cutler Professor of Surgery
- Harvard Medical School
- W Robert Lee, MD, MS, MEd
W Robert Lee, MD, MS, MEd
- Section Editor — Prostate Cancer
- Professor of Radiation Oncology
- Duke University Medical Center
Prostate cancer is increasingly diagnosed in younger men and at an earlier disease stage when the tumor is confined to the prostate [1,2]. Men who are managed with radical prostatectomy are staged pathologically based upon pathologic examination of the resection specimen; some will have histopathologic extension beyond the prostate (pT3), positive margins upon examination of the surgical specimen (R1), or microscopic lymph node involvement (table 1 and table 2).
The management of patients with pathologic T3 disease, positive surgical margins, or microscopic lymph node involvement following radical prostatectomy will be reviewed here.
The management of patients with lymph node involvement identified at radical prostatectomy is discussed elsewhere. (See "Initial management of regionally localized intermediate-, high-, and very high-risk prostate cancer", section on 'Lymph node involvement'.)
PATHOLOGIC VERSUS CLINICAL STAGING
The American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) system is used to stage newly diagnosed prostate cancer (table 1 and table 2). This system incorporates the anatomic extent of disease, including the primary tumor (T), regional lymph nodes (N), distant metastases (M), and margin status (R). In addition, the baseline serum prostate-specific antigen (PSA) and histologic grade group (based upon the Gleason score) are incorporated to divide patients into prognostic stage groupings (table 3) . Imaging findings are not incorporated into pathologic staging. (See "Initial staging and evaluation of men with newly diagnosed prostate cancer", section on 'Clinical versus pathologic staging'.)
The pretreatment evaluation provides the information for the clinical ("c") stage, which forms the basis for the initial treatment decisions, along with patient age, overall medical condition, and the presence or absence of symptoms. For patients whose initial treatment includes radical prostatectomy, additional information is obtained from the histopathologic examination of the prostatectomy specimen, and this forms the basis for the pathologic ("p") stage.
Subscribers log in hereLiterature review current through: Oct 2017. | This topic last updated: May 04, 2017.References
- Roach M 3rd, Weinberg V, Sandler H, Thompson I. Staging for prostate cancer: time to incorporate pretreatment prostate-specific antigen and Gleason score? Cancer 2007; 109:213.
- Gallina A, Chun FK, Suardi N, et al. Comparison of stage migration patterns between Europe and the USA: an analysis of 11 350 men treated with radical prostatectomy for prostate cancer. BJU Int 2008; 101:1513.
- National Comprehensive Cancer Network (NCCN) guidelines. Available at: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on September 14, 2011).
- Pound CR, Partin AW, Epstein JI, Walsh PC. Prostate-specific antigen after anatomic radical retropubic prostatectomy. Patterns of recurrence and cancer control. Urol Clin North Am 1997; 24:395.
- Eggener SE, Roehl KA, Smith ND, et al. Contemporary survival results and the role of radiation therapy in patients with node negative seminal vesicle invasion following radical prostatectomy. J Urol 2005; 173:1150.
- Salomon L, Anastasiadis AG, Johnson CW, et al. Seminal vesicle involvement after radical prostatectomy: predicting risk factors for progression. Urology 2003; 62:304.
- Kasibhatla M, Peterson B, Anscher MS. What is the best postoperative treatment for patients with pT3bN0M0 adenocarcinoma of the prostate? Prostate Cancer Prostatic Dis 2005; 8:167.
- Alkhateeb S, Alibhai S, Fleshner N, et al. Impact of positive surgical margins after radical prostatectomy differs by disease risk group. J Urol 2010; 183:145.
- Simon MA, Kim S, Soloway MS. Prostate specific antigen recurrence rates are low after radical retropubic prostatectomy and positive margins. J Urol 2006; 175:140.
- Swanson GP, Lerner SP. Positive margins after radical prostatectomy: implications for failure and role of adjuvant treatment. Urol Oncol 2013; 31:531.
- Mauermann J, Fradet V, Lacombe L, et al. The impact of solitary and multiple positive surgical margins on hard clinical end points in 1712 adjuvant treatment-naive pT2-4 N0 radical prostatectomy patients. Eur Urol 2013; 64:19.
- Stephenson AJ, Eggener SE, Hernandez AV, et al. Do margins matter? The influence of positive surgical margins on prostate cancer-specific mortality. Eur Urol 2014; 65:675.
- Kordan Y, Salem S, Chang SS, et al. Impact of positive apical surgical margins on likelihood of biochemical recurrence after radical prostatectomy. J Urol 2009; 182:2695.
- Viers BR, Sukov WR, Gettman MT, et al. Primary Gleason grade 4 at the positive margin is associated with metastasis and death among patients with Gleason 7 prostate cancer undergoing radical prostatectomy. Eur Urol 2014; 66:1116.
- Thompson IM, Valicenti RK, Albertsen P, et al. Adjuvant and salvage radiotherapy after prostatectomy: AUA/ASTRO Guideline. J Urol 2013; 190:441.
- Valicenti RK, Thompson I Jr, Albertsen P, et al. Adjuvant and salvage radiation therapy after prostatectomy: American Society for Radiation Oncology/American Urological Association guidelines. Int J Radiat Oncol Biol Phys 2013; 86:822.
- Thompson IM Jr, Tangen CM, Paradelo J, et al. Adjuvant radiotherapy for pathologically advanced prostate cancer: a randomized clinical trial. JAMA 2006; 296:2329.
- Morgan SC, Waldron TS, Eapen L, et al. Adjuvant radiotherapy following radical prostatectomy for pathologic T3 or margin-positive prostate cancer: a systematic review and meta-analysis. Radiother Oncol 2008; 88:1.
- Bolla M, van Poppel H, Tombal B, et al. Postoperative radiotherapy after radical prostatectomy for high-risk prostate cancer: long-term results of a randomised controlled trial (EORTC trial 22911). Lancet 2012; 380:2018.
- Suardi N, Gallina A, Lista G, et al. Impact of adjuvant radiation therapy on urinary continence recovery after radical prostatectomy. Eur Urol 2014; 65:546.
- Thompson IM, Tangen CM, Paradelo J, et al. Adjuvant radiotherapy for pathological T3N0M0 prostate cancer significantly reduces risk of metastases and improves survival: long-term followup of a randomized clinical trial. J Urol 2009; 181:956.
- Wiegel T, Bartkowiak D, Bottke D, et al. Adjuvant radiotherapy versus wait-and-see after radical prostatectomy: 10-year follow-up of the ARO 96-02/AUO AP 09/95 trial. Eur Urol 2014; 66:243.
- Bolla M, van Poppel H, Collette L, et al. Postoperative radiotherapy after radical prostatectomy: a randomised controlled trial (EORTC trial 22911). Lancet 2005; 366:572.
- Cozzarini C, Montorsi F, Fiorino C, et al. Need for high radiation dose (>or=70 gy) in early postoperative irradiation after radical prostatectomy: a single-institution analysis of 334 high-risk, node-negative patients. Int J Radiat Oncol Biol Phys 2009; 75:966.
- Shipley WU, Seiferheld W, Lukka HR, et al. Radiation with or without Antiandrogen Therapy in Recurrent Prostate Cancer. N Engl J Med 2017; 376:417.
- http://www.clinicaltrials.gov/ (Accessed on July 06, 2012).
- Eisenberg ML, Davies BJ, Cooperberg MR, et al. Prognostic implications of an undetectable ultrasensitive prostate-specific antigen level after radical prostatectomy. Eur Urol 2010; 57:622.
- https://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on May 04, 2017).
- Heidenreich A, Bastian PJ, Bellmunt J, et al. EAU guidelines on prostate cancer. Part II: Treatment of advanced, relapsing, and castration-resistant prostate cancer. Eur Urol 2014; 65:467.
- Fossati N, Karnes RJ, Boorjian SA, et al. Long-term Impact of Adjuvant Versus Early Salvage Radiation Therapy in pT3N0 Prostate Cancer Patients Treated with Radical Prostatectomy: Results from a Multi-institutional Series. Eur Urol 2017; 71:886.
- Siddiqui SA, Boorjian SA, Inman B, et al. Timing of androgen deprivation therapy and its impact on survival after radical prostatectomy: a matched cohort study. J Urol 2008; 179:1830.
- Iversen P, McLeod DG, See WA, et al. Antiandrogen monotherapy in patients with localized or locally advanced prostate cancer: final results from the bicalutamide Early Prostate Cancer programme at a median follow-up of 9.7 years. BJU Int 2010; 105:1074.
- PATHOLOGIC VERSUS CLINICAL STAGING
- RISK OF RECURRENCE
- T3a versus T3b or T4 disease
- Positive margins
- Adjuvant RT
- - Clinical trials
- - Radiation dose
- - Concurrent ADT
- - Ultrasensitive PSA
- Adjuvant RT versus early salvage RT
- Adjuvant hormone therapy without RT
- Adjuvant chemohormonal therapy
- Persistently elevated PSA
- Lymph node involvement
- SURVEILLANCE AFTER TREATMENT
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS