Importance of Reporting The Gleason Score at the Positive Surgical Margin Site: An Analysis of 4,082 Consecutive Radical Prostatectomy Cases.

INTRODUCTION - Since 2010, pathologists at our institution have routinely been documenting the Gleason score (GS) at the margin and length of the positive surgical margin (PM) after prostatectomy. Our objective was to evaluate how the GS and length of the PM correlates with the grade and adverse pathologic characteristics of the final specimen, and whether the PM GS affects the risk of early biochemical recurrence (BCR).

METHODS - 4,082 consecutive patients undergoing radical prostatectomy and pelvic lymph node dissection between 2010 and 2014 for localized prostate cancer were included, of which 405 had GS ≥7 of the primary nodule and a PM with the length and GS recorded at the margin. Concordance rates between the GS at the margin and the final pathological specimen were compared using the kappa score of interobserver reliability. Logistic regression models were utilized to predict the risk of having unfavorable pathology. Cox-proportional hazards models controlling for GS, pre-operative PSA, pathologic stage, and adjuvant radiation were used to predict BCR, and Kaplan-Meir estimates of recurrence free survival were calculated by GS.

RESULTS - Among patients with positive margins, BCR was identified in 22% (vs 5.6% without pos margins), metastases in 3% (vs 0.5%) and adjuvant radiation in 30% (vs 4.1%). Mean follow up was 22 months (range 12-48). The GS at the PM was the same as the final pathology specimen in 44% of patients, and a lower GS in 56% of patients. A shorter PM was independently associated with a lower GS at the margin (p=0.02). Kaplan Meir estimates by GS demonstrated improved freedom from BCR. In multivariate Cox models, having a lower grade margin was associated with decreased risk of BCR (HR 0.50; OR 0.25-0.97).

CONCLUSIONS - A lower GS at the PM is independently associated with a shorter margin length and a decreased risk of early biochemical recurrence. The GS at the margin should be documented.

J Urol. 2015 Aug 8. pii: S0022-5347(15)04530-9. doi: 10.1016/j.juro.2015.08.002. [Epub ahead of print]

Kates M1, Sopko NA2, Han M2, Partin AW2, Epstein JI2.

1 James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
2 James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA.