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 clinical evidence of lymph node involvement 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.
Clinical staging may underestimate or overestimate the anatomic extent of disease. Patients with cT1 or cT2 N0 disease may be reclassified as pT3 or N1 based upon these results. Conversely, patients thought to have more extensive (cT3) disease may be reclassified as pT2. If surgical margins are positive for tumor (residual microscopic disease), staging is modified by an "R1" descriptor, while negative margins are designated "R0."
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- 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