CASE 1: A 62-year-old man who presented with a PSA of five ng/mL underwent radical prostatectomy and had a pathologic Stage T2B, Gleason 7 (4 + 3) prostate cancer with 40 to 50 percent involvement of the gland and a focal positive margin at the anterior edge of the apex (from the practice of Alan M Nieder, MD)
| Tracks 1- 4 |
| Track 1 |
Introduction |
| Track 2 |
Case discussion: A 62-year-old
man with Stage T1c, Gleason 7
prostate cancer |
|
| Track 3 |
Management of focal positive
margins |
| Track 4 |
Radiation therapy after prostatectomy
for patients with positive
margins |
|
|
Tracks 2-4
DR MOUL: I would observe this patient and repeat a PSA test every three months for the first year, every six months for the next two years and then annually thereafter. If the PSA stayed undetectable, I would leave him alone.
DR LOVE: Dan, can you review the evolution of clinical trial data evaluating postprostatectomy radiation therapy, particularly the studies reported in the last couple of years?
DR PETRYLAK: The most recent study was performed by the Southwest Oncology Group. Patients were randomly assigned to immediate versus deferred radiation therapy postprostatectomy. An improvement occurred in disease-free survival but not overall survival. The problem with the study is that the event rate in the control arm was a lot lower than originally anticipated.
So with further follow-up, we may see a survival benefit in favor of the postoperative radiation therapy.
DR LOVE: Dr Simon, you published a paper, based on your experience at the University of Miami with Mark Soloway, examining the effect of positive margins on outcome (Simon 2006). What did your study show?
DR SIMON: It included approximately 1,000 patients who underwent radical prostatectomy and an average of five years of follow-up, assessing whether positive margins led to increased recurrence rates (Simon 2006; [1.1]). In
general, a positive margin is an adverse prognostic factor, and it is a significant
variable in increasing risk for recurrence of disease.
However, the recurrence rates were still very low. Among our patients, the
recurrence rate for patients with positive margins during that five-year follow-up was only 19 percent. So 81 percent had no recurrence of cancer; therefore,
if they were all treated with radiation therapy, you’d be radiating 81 percent of
patients for no reason, with all the added side effects.
Positive margins are a significant prognostic factor that you have to discuss
with patients. However, following patients closely is certainly reasonable, and
you may avoid additional costs, treatments and side effects for a majority of the
patients, at least according to our series.
DR MOUL: Dr Simon’s paper is a really good one with 1,000 patients, but it
points out that we’ve seen a stage migration even with positive margins. It’s
so frustrating. We have the SWOG positive-margin trial and the one from
Europe presented by Dr Bolla (Bolla 2005), but they’re probably out of date
because those were “rip-roaring” positive margins. Now we have these “itsy-bitsy” positive margins in many cases, with the recurrence rate at 19 percent.
DR PETRYLAK: The same can be said for the Messing study because of the
issue of positive lymph nodes (Messing 1999). There were probably more
grossly positive lymph nodes than what we’re seeing now, because of the stage
migration from PSA testing. The randomized SWOG-S9921 chemotherapy
study allows patients to receive postoperative radiation therapy. So this patient
would be eligible for that particular study.
DR LOVE: What happened with this patient, Dr Nieder?
DR NIEDER: He recovered very well postoperatively, and we saw him after
six weeks for our first PSA test, which was undetectable. We decided just
to follow him, and we will follow his PSA level every three months. He’s
comfortable with that decision.
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