title: The significance of a positive bladder neck margin after radical prostatectomy: the American Joint Committee on Cancer Pathological Stage T4 designation is not warranted.
abstract: OBJECTIVE
  The American Joint Committee on Cancer currently designates invasion of the bladder neck as a pT4 lesion. However, retrospective analyses have not demonstrated biochemical recurrence-free survival after radical prostatectomy to be consistent with other T4 lesions. We examined biochemical recurrence-free survival and cancer specific survival in men with a positive bladder neck margin.
  
  
  METHODS
  Of nearly 17,000 patients in the Johns Hopkins Institutional radical prostatectomy database (1982 to 2008) 198 (1.2%) were identified with a positive bladder neck margin. Kaplan-Meier analyses were used to evaluate biochemical recurrence-free survival and cancer specific survival. A multivariate proportional hazards model predicting biochemical recurrence-free survival and cancer specific survival was fit with prostate specific antigen, Gleason sum and pathological stage to determine the significance of a positive bladder neck margin.
  
  
  RESULTS
  Of the 198 men with a positive bladder neck margin 79 had an isolated bladder neck margin without seminal vesicle or lymph node involvement. The 12-year biochemical recurrence-free survival of men with organ confined disease, extraprostatic extension, seminal vesicle invasion and lymph node involvement without a positive bladder neck margin was 91.1%, 61.1%, 24.5% and 8.1%, respectively. For men with a positive bladder neck margin and those with an isolated positive bladder neck margin biochemical recurrence-free survival was 16.8% and 37.1%, respectively. The 12-year cancer specific survival for men with organ confined disease, extraprostatic extension, seminal vesicle invasion and lymph node involvement without a positive bladder neck margin was 93.5%, 89.0%, 77.0% and 66.8%, respectively. For men with a positive bladder neck margin and those with an isolated positive bladder neck margin cancer specific survival was 78.2% and 92.5%, respectively. A positive bladder neck margin was not a significant predictor of outcome (p = 0.4) on multivariable analysis.
  
  
  CONCLUSIONS
  The incidence of an isolated positive bladder neck margin is low. Men with an isolated positive bladder neck margin after radical prostatectomy experienced a 12-year biochemical recurrence-free survival of 37% and cancer specific survival of 92%, similar to patients with seminal vesicle invasion (pT3b) and extraprostatic extension (pT3a), respectively. The existing American Joint Committee on Cancer classification for prostate cancer should be reconsidered.
authors.affiliation: James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA. philpierorazio@jhmi.edu
authors.forename: Phillip M
authors.initials: PM
authors.lastname: Pierorazio
authors.forename: Jonathan I
authors.initials: JI
authors.lastname: Epstein
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Humphreys
authors.forename: Misop
authors.initials: M
authors.lastname: Han
authors.forename: Patrick C
authors.initials: PC
authors.lastname: Walsh
authors.forename: Alan W
authors.initials: AW
authors.lastname: Partin
mesh_terms: D000328:Adult; D000368:Aged; D018572:Disease-Free Survival; D006801:Humans; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D011468:Prostatectomy / Q000379:methods; D011471:Prostatic Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D015996:Survival Rate; D001743:Urinary Bladder / Q000473:pathology*