The Use of Early Postoperative Prostate-specific Antigen to Stratify Risk in Patients With Positive Surgical Margins After Radical Prostatectomy

Stepan Vesely; Ladislav Jarolim; Katerina Duskova; Marek Schmidt; Pavel Dusek; Marko Babjuk

Disclosures

BMC Urol. 2014;14(79) 

In This Article

Background

Although radical prostatectomy provides excellent control for localized prostate cancer, pathologic examination of approximately one-third of specimens will reveal positive surgical margins (PSM).[1,2] Numerous studies report that the presence of PSM adversely affects cancer specific outcomes and considerably increases the risk of biochemical recurrence (BCR).[3] However, the optimum management of patients with PSM remains controversial.

Evidence from randomized trials suggests that immediate radiotherapy after the surgery, rather than watchful waiting, is more appropriate for the patient with pathologically advanced disease because it can improve cancer-specific and overall survival.[4–6] Despite the fact that the most contemporary guidelines do not uniformly recommend adjuvant therapy for patients with adverse pathologic characteristics at radical prostatectomy, it has been shown that in daily clinical practice the patients with PSM were significantly more likely to receive immediate adjuvant treatment.[7]

But not all of the patients with PSM develop BCR and the policy of adjuvant radiotherapy could result in considerable over-treatment. Therefore correct identification of those patients most likely to benefit from adjuvant management is of paramount importance. However, attempts to improve early staging after the surgery already hint at several difficulties. The ability of imaging modalities remains limited.[8] The impact of PSM-associated variables (location, focality, length and Gleason score at the margin) on clinical decision making was not clearly established yet.[2] Even routine use of frozen section on all cases has not fulfilled its expectation to provide effective control of surgical margin status.[9,10]

Postoperative PSA measurements are generally performed 3 months after the surgery, although a significant decline in PSA may be detectable much earlier. Results from several studies indicate that intensive monitoring of PSA changes early after radical prostatectomy may provide clinically useful information, which facilitates identification of surgical failure.[11–14] Moreover, recently introduced ultrasensitive PSA detection techniques are offering a new insight into the changes in serum PSA at very low concentration. It has been demonstrated that after a properly performed radical prostatectomy, measurable PSA is most likely attributed to the presence of active prostate cancer cells rather than to retained benign prostatic tissue.[15,16] It is therefore conceivable, that real candidates for immediate adjuvant therapy, who have active prostate cancer cells remaining in the body after the surgery, should present with higher postoperative serum PSA in a comparison to individuals with incorrect diagnosis of PSM.

This hypothesis prompted us to evaluate the ability of early postoperative ultrasensitive PSA levels to reduce the overtreatment rate by further stratification of potential candidates for immediate adjuvant radiotherapy.

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