What happens when the urologist cannot remove all of a prostate tumor, and the surgical margins are positive? In some men, cancer is more likely to recur, and radiation is the recommended next step. But results from a new Hopkins study, published in Urology, suggest that not all men need this extra treatment. “It turns out that the total length of positive margins was a significant predictor of tumor recurrence after prostatectomy,” says Jonathan I. Epstein, M.D., The Rose-Lee and Keith Reinhard Professor of Urological Pathology. The study, conducted by Epstein along with Fadi Brimo and Brady Director Alan W. Partin, M.D., Ph.D., also was the first to prove that the grade of cancer at the site of a positive margin influences the long-term outcome.
“Men with Gleason 7 cancer have a mixture of Gleason pattern 3 tumor, which is favorable, and pattern 4, which is more aggressive,” explains Epstein. “When there is a Gleason 7 cancer with a positive margin, the remaining tumor could be pure pattern 3, pure pattern 4, or a mix of both. We were able to show that men with pure pattern 3, especially if it’s limited, have an 83-percent chance of maintaining an undetectable PSA at two years and a 67-percent likelihood at fi ve years.”
The grade of cancer at the site of a
positive surgical margin has much
to do with the long-term outcome.
Until this study, Epstein says, almost all men with Gleason 7 tumor and a positive margin would have been recommended to receive radiotherapy. “The good news is that now a subset of men with low-grade, low-volume cancer at the margin can be spared extra radiation and the side effects of additional treatment.”