Presentation on theme: "Memorial Sloan-Kettering Cancer Center"— Presentation transcript:
1Memorial Sloan-Kettering Cancer Center Significance of and Techniques to Reduce the Frequency of Positive Surgical MarginsJames A. Eastham, MDMemorial Sloan-Kettering Cancer Center353 East 68th StreetNew York, NY 10591NOTE: The following slides are to be used for medical education purposes only. Copyright belongs to Prous Science and Prous Science is not responsible for any modification or change made by the users to these slides.
2Index Definition of a positive surgical margin Significance of a positive surgical marginSurgical techniques to reduce the frequency of a positive surgical marginKey words: prostate, radical prostatectomy, surgical margin
3Definition of a Positive Surgical Margin At the time of specimen processing, the outer surface of the radical prostatectomy is inked to define the margins of resection
4Definition of a Positive Surgical Margin A positive surgical margin is defined as “tumor on ink”, meaning the pathologist sees cancer cells directly in contact with ink at histological examinationCancer cells abut the ink: positive margin
5Significance of a Positive Surgical Margin Multiple series suggest that a positive surgical margin is an independent predictor of biochemical recurrence (BCR) after radical prostatectomy (RP)1-5This risk remains even after controlling for other known risk factors for BCR after RP, including pre-treatment PSA, RP Gleason score, presence or absence of extraprostatic cancer, presence or absence of seminal vesicle invasion and presence or absence of lymph node invasion
7Significance of a Positive Surgical Margin1 Even after controlling for other known risk factors of BCR after RP, a patient with a positive surgical margin is 1.5 times more likely to experience cancer recurrence than a patient with a negative surgical marginOf these clinical and pathological features, only the status of the surgical margins has the potential to be influenced by the surgeon
8Significance of a Positive Surgical Margin Are positive surgical margins inherent in the nature of the cancer, like extracapsular extension, or can margins be influenced by the surgeon/surgical technique?
9Surgeon’s Influence on the Likelihood of a Positive Surgical Margin2 Equal access medical centerAcademic and private practice urologists4629 RP performed by 44 individual surgeonsQuestion: What are the predictors of a positive surgical margin at the time of RP?Analysis included known clinical and histological variables as well as surgical experience (number of RP performed) and individual surgeon
10Multivariable Analysis for Risk of a +SM Based on Clinical and Pathological Parameters2 p-valueSerum PSA level< 0.01Extracapsular extensionSeminal vesicle invasion0.86Lymph node involvement0.56Radical prostatectomy Gleason sumSurgical volume0.01Surgery dateSurgeon0.05
11Individual Surgeon and +SM Study2 The rate of +SM in RP specimens varies widely within and among hospitals and surgeons, whether at an open staffing hospital or a cancer referral center, and cannot be explained by surgical volume aloneWide variations in +SM rates persist even when corrected for all known cancer prognostic factorsDifferences in surgical technique, while hard to define, seem to result in substantial differences in positive margin rates and long-term cancer control rates
12What Can Be Done to Decrease the Risk of a Positive Surgical Margin Exposure and hemostasisAppropriate extent of neurovascular bundle (NVB) preservationWide dissection including Denonvilliers’ fascia, lateral pedicle and bladder neck
13What Can Be Done to Decrease the Risk of a Positive Surgical Margin at Open RP? Exposure and hemostasis8-10 cm lower midline incisionSlight flexion of tableAdequate retraction to expose the deep pelvisAuthor’s choice: Turner-Warwick retractorAppropriate extent of NVB preservationWide dissection including Denonvilliers’ fascia, lateral pedicle and bladder neck
14The patient is positioned supine with the pubis just below the break point in the table. The table is flexed (~150o) and Trendelenburg rotation is applied to level the abdomen. An 8-cm suprapubic midline incision is made 3 fingers breadth above the penis.
15What Can Be Done to Decrease the Risk of a Positive Surgical Margin? Exposure and hemostasisPrior to division of the dorsal venous complex (DVC): suture-ligate the DVC at bladder neck, mid-prostate and pelvic floorIsolate DVC from urethraAuthor’s choice: right-angled clamp and stainless steel wireDivide DVC with knife and oversew cut-edgeAppropriate extent of NVB preservationWide dissection including Denonvilliers’ fascia, lateral pedicle and bladder neck
17Division of the DVC over a guide wire. The DVC has been ligated proximally and distally. A right-angled clamp is passed beneath the DVC and grasps a wire. The DVC must be transected distal to all prostatic tissue.The right angle clamp is used to pass a 22 g guide wire beneath the DVC. The wire serves as a template for precise guillotine transection of the DVC. The DVC is first ligated distally with a figure-of-8 suture before it is divided. By adjusting downward traction on the prostate with a sponge stick and upward traction on the guidewire, the point of transection of the DVC can be adjusted to avoid incision into the prostate. While positive surgical margins are not common in this area, it is difficult to anticipate when cancer is located anteriorly.
18The cut edges of the DVC are oversewn; the last bite beingtaken through the periosteumof the pubis
19What Can Be Done to Decrease the Risk of a Positive Surgical Margin? Exposure and hemostasisAppropriate extent of NVB preservationThorough assessment of risk of cancer in the area of the NVBSelection of appropriate plane of dissectionIntra-, Inter- or Extrafascial dissectionWide dissection including Denonvilliers’ fascia, lateral pedicle and bladder neck
21Endorectal MRI of prostate demonstrating the NVB and possible planes of dissection7, 10
22FeetThe extent of NVBpreservation is a balance between attempts to optimize the recovery of potency while at the same time removing all the cancer (a negative surgical margin). The majority of screen-detected prostate cancers will be candidates for complete NVB preservation (intrafascial dissection).(R) Cavernous nerveProstateHead
23Apical Dissection with Nerve Sparing 1) Incision of lateral pelvic fascia above the nerve 2) Dissection of the NVB from apical third of the prostate 3) Sharp division of post layer of prostatorectal (Denonvilliers’) fasciaThe NVB should be dissected distally away from the apex and the proximal urethra. The posterior layer of Denonvilliers (prostatorectal) fascia also covers the NVB medially. This fascia must be divided, exposing the layer of adipose tissue anterior to the rectum, the correct plane of dissection. The posterior layer of the prostatorectal fascia should be left on the prostate to minimize the risk of a posterior positive margin.
24Click on the link below to start the video. The initial mobilization of the NVB is complete. The scissors sharply incise Denonvilliers’fascia exposing the yellow fat of the anterior rectal wall
25Wide resection of the right NVB in the area of a large, palpable cancer. The dissection is facilitated by starting the dissection laterally such that all periprostatic tissue can be resectedWhen cancer lies over the NVB, some or all of the bundle should be resected to assure a negative margin.
26Transection of the Bladder Neck Wide dissection of the lateral pedicles around the base, and transection of the bladder neck above the prostate, will reduce the risks of positive margins. “Bladder neck preservation” does not improve continence.There should be ample tissue in the angle between the base of the prostate and the seminal vesicles.The bladder neck is transected proximal to the prostatic urethra to reduce the risk of a positive bladder neck margin. Preservation of the bladder neck does not improve long term continence. The specimen should contain abundant tissue in the angle between the base of the prostate and the seminal vesicles.Leave more tissue here
27ConclusionsPositive surgical margins are an adverse prognostic feature at the time of RPOf all prognostic factors, this is the only one modifiable by surgical techniqueMost patients can undergo preservation of the majority of the tissue at the NVB and still have complete resection of their cancer (negative surgical margin)Patient selection, complete resection of Denonvilliers’ fascia and wide resection at the bladder neck have been shown to reduce the incidence of a positive surgical margin
28ReferencesSwindle, P., Eastham, J.A., Ohori, M., Kattan, M.W., Wheeler, T., Maru, N., Slawin, K., Scardino, P.T. Do margins matter? The prognostic significance of positive surgical margins in radical prostatectomy specimens. J Urol 2005, 174:Eastham, J.A., Kattan, M.W., Riedel, E., Begg, C.B., Wheeler, T.M., Gerigk, C., Gonen, M., Reuter, V., Scardino, P.T. Variations among individual surgeons in the rate of positive surgical margins in radical prostatectomy specimens. J Urol 2003, 170:Karakiewicz, P., Eastham, J., Graefen, M., Cagiannos, I., Stricker, P., Klein, E., Cangiano, T., Schröder, F., Scardino, P., Kattan, M. Prognostic impact of positive surgical margins in surgically treated prostate cancer: Multi-institutional assessment of 5831 patients. Urology 2005, 66:Ward, J.F., Zincke, H., Bergstralh, E.J., Slezak, J.M., Myers, R.P,, Blute, M.L. The impact of surgical approach (nerve bundle preservation versus wide local excision) on surgical margins and biochemical recurrence following radical prostatectomy. J Urol 2004, 172:
29ReferencesPalisaar, R-J., Noldus, J., Graefen, M., Erbersdobler, A., Haese, A., Huland, H. Influence of nerve-sparing (NS) procedure during radical prostatectomy (RP) on margin status and biochemical recurrence. Eur Urol 2004, 47:Eastham, J.A., Scardino, P.T. Radical prostatectomy for clinical stage T1 and T2 prostate cancer. In: Comprehensive Textbook of Genitourinary Oncology 2002, (Ed. Vogelzang, N) Philadelphia: Lippincott Williams & Wilkins.Montorsi, F., Salonia, A., Suardi, N. Improving the preservation of the urethral sphincter and neurovascular bundles during open radical retropubic prostatectomy. Eur Urol 2005, 48: 938–945.Walsh, P.C., Partin, A.W., Epstein, J.I. Cancer control and quality of life following anatomical radical retropubic prostatectomy: results at 10 years. J Urol 1994, 152:
30References9. Naya, Y., Slaton, J.W., Troncoso, P., Okihara, K., Babaian, R.J. Tumor length and location of cancer on biopsy predict side specific extraprostatic cancer extension. J Urol 2004, 171:10. Graefen, M., Walz, J., Huland, H. Open retropubic nerve-sparing radical prostatectomy. Eur Urol 2006, 49: 38–48.