Putting Positive Surgical Margins into Perspective

Discovery 
November 30, 2017

The words, “positive surgical margins,” are scary to hear – but much of the fear that those words create is unnecessary, says Jonathan Epstein, M.D., the Reinhard Professor of Urologic Pathology.

After radical prostatectomy, when the removed prostate is sent to the pathologist for examination, “it is not uncommon for the margins to be positive – to have tumor at the cut edge, which potentially could indicate that some cancer has been left behind.” However, he adds, “only about half of prostate cancers with positive margins recur after surgery.” This also means that half of men who have positive margins never have a recurrence of cancer. Sfanos: Infection may cause chronic inflammation in the prostate, which could lead to cancer.

“The question is, can we help predict which tumors will come back – and which men will benefit from early post-operative radiation therapy – and which positive margins are less likely to cause trouble?” Because Epstein has looked at tens of thousands of prostate specimens in his distinguished career, he knows that the positive surgical margin itself is not as important as some other factors. “Prostates can have separate tumors with different Gleason grades, or there can even be different grades within the same tumor,” he explains.

Based on several small studies that Epstein has led, Hopkins pathologists have long made note of such factors. Since 2010, “we have routinely documented the Gleason score at the margin and length of the positive surgical margin after prostatectomy.” In a current study of 4,082 consecutive patients undergoing radical prostatectomy between 2010 and 2014 at Johns Hopkins, Epstein and colleagues showed that men who had a lower Gleason score at the margin were less likely to have a return of PSA after surgery, and “we conclude that the Gleason score of the cancer at the positive margin site should routinely be documented. This might spare men who have lower-grade cancer at the margin from post-operative radiation therapy.” This work was published in the Journal of Urology.

 

“In the same prostate, there may be a high-grade cancer not at a margin, and a separate low-grade tumor that does go to a margin. Currently, 85 percent of pathologists would report on the overall tumor, saying that it is high-grade and the overall margin status as positive – giving the false impression that there is highgrade tumor at the margin.” “In the same prostate, there may be a high-grade cancer not at a margin, and a separate lowgrade tumor that does go to a margin.” Many pathologists would report on the overall tumor, “giving the false impression that there is highgrade tumor at the margin.”


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