Introduction: The individual clinical significance of a positive surgical margin (PSM) after radical prostatectomy (RP) remains controversial. Despite adequate surgery, up to 40% of patients experience eventually biochemical recurrence (BCR). Various biomarkers have been assessed to better identify the patients who are likely to experience BCR and, therefore, could benefit from multimodal therapy such as adjuvant radiotherapy (XRT). Positive surgical margin (PSM) is an adverse prognostic factor, as it is associated with early biochemical recurrence in 10-40% of patients treated with RP with curative intent. The objective of the current analysis was to summarize the available data to test the hypothesis that GG of PSM affects the risk of early BCR and, therefore, can help of counselling patients tailor individual treatment decision.
Methods: A systematic review was conducted by searching MEDLINE/PubMed for studies published by June 2019 according to the Preferred Reporting Items for Systematic Review (PRISMA) statement. Keywords used included prostate cancer, radical prostatectomy, positive surgical margin, Gleason score, and/or Gleason grade.
Results: A total 1,676 papers were identified using MEDLINE/PubMed database. All 1,676 records were screened according to the inclusion criteria. After reviewing abstracts and removal of duplicates, 10 papers comprising 14,108 patients conducted between 2010 and 2019 were considered for systematic review. Rate of BCR ranged from 13.9% to 48.9% with median follow-up ranging from 18 to 156 months. For meta-analysis, we included all articles that analyzed the association between GG at PSM and BCR. Three studies compared Gleason 3+4 and three studies compared Gleason 3+3 to a higher GG at the PSM. Six studies, including 1,863 patients, were eligible for the meta-analysis, aimed at assessing the prognostic value of different levels of GG at PSM. The forest plot showed that GG at PSM was significantly associated with BCR (pooled HR, 1.87; 95% CI, 1.53-2.28; z=5.87). The Cochrane Q test (chi2 = 5.94; P = 0.312) and I2 test (I2 = 15.8%) revealed no significant heterogeneity. The funnel plot did not identified any studies over the pseudo 95% CI.
Conclusions: GG at PSM should be recorded and commented. A lower grade PSM is associated with a decreased risk of early BCR by almost half. This study provides systematically gathered evidence of value of GG at a PSM, which is a feature of biological and clinical aggressiveness, predicting BCR. However, it remains unclear how to stratify patients with different levels of GS at a PSM. Further studies are needed to assess weather patients with GG3 at the PSM could be could be spared an unnecessary adjuvant treatment. Source of
Funding: Ivan Lysenko was awarded a European Urological Scholarship Program grant (EUSP/Scholarship S-04-2018).