Variations among individual surgeons in the rate of positive surgical margins in radical prostatectomy specimens.
OBJECTIVE
Cancer at the resection margin (a positive surgical margin) after radical prostatectomy is associated with an increased risk of recurrence even after adjusting for other known risk factors, including pretreatment serum prostate specific antigen (PSA), clinical stage, grade and pathological stage (level of extracapsular extension, seminal vesicle invasion and pelvic lymph node status). Of these prognostic factors only surgical margin status can be influenced by surgical technique. We examined variations in the rate of positive surgical margins among surgeons after controlling for the severity of disease and volume of cases per surgeon.


METHODS
A total of 4,629 men were treated with radical prostatectomy by 1 of 44 surgeons at 2 large urban centers between 1983 and 2002 for clinical stage T1-T3NxM0 prostate cancer. Patients were excluded if they had previously received androgen deprivation therapy or radiation therapy to the pelvis. Positive surgical margins were defined as cancer at the inked resection margin. Other risk factors analyzed were serum PSA, grade (Gleason sum), extracapsular extension level (none, invasion into the capsule, present [not otherwise specified], focal extracapsular extension or established extracapsular extension), seminal vesicle invasion, pelvic lymph node metastases, surgery date, surgeon and volume of cases per surgeon.


RESULTS
For the 26 surgeons who each treated more than 10 patients in the study the rate of positive surgical margins was 10% to 48%. On multivariable analysis higher serum PSA, extracapsular extension level, higher radical prostatectomy Gleason sum, surgery date, surgical volume and surgeon were associated with surgical margin status after controlling for all other clinical and pathological variables.


CONCLUSIONS
While the clinical and pathological features of cancer are associated with the risk of a positive margin in radical prostatectomy specimens, the technique used by individual surgeons is also a factor. Lower rates of positive surgical margins for high volume surgeons suggest that experience and careful attention to surgical details, adjusted for the characteristics of the cancer being treated, can decrease positive surgical margin rates and improve cancer control with radical prostatectomy.
Eastham
James A
JA
Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA. easthamj@mskcc.org
Kattan
Michael W
MW
Riedel
Elyn
E
Begg
Colin B
CB
Wheeler
Thomas M
TM
Gerigk
Claudia
C
Gonen
Mithat
M
Reuter
Victor
V
Scardino
Peter T
PT
D002983:Clinical Competence; D006801:Humans; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D009364:Neoplasm Recurrence, Local; D011379:Prognosis; D017430:Prostate-Specific Antigen / Q000097:blood; D011468:Prostatectomy; D011471:Prostatic Neoplasms / Q000175:diagnosis / Q000473:pathology* / Q000601:surgery; D012307:Risk Factors; D013521:Urologic Surgical Procedures, Male / Q000379:methods / Q000706:statistics & numerical data*
D017430:Prostate-Specific Antigen