Positive margins after radical prostatectomy: implications for failure and role of adjuvant treatment.

Surgery is one of the most common curative modalities in prostate cancer. Unfortunately, as with any therapy, patients can suffer recurrence. Postoperative adjuvant therapy has been shown to prevent or delay recurrence. The presence of positive margins puts the patient at a high risk for recurrence. Additional risk factors have been identified that can predict for recurrence, but it is still uncertain as to who warrants immediate treatment. We reviewed the extensive surgical literature for prognostic factors for recurrence in addition to positive margins. We attempted to be exhaustive, first searching PubMed and Medline for all papers for radical prostatectomy and then checking the articles cited in those papers. We sought out papers that reviewed the effect of positive margins and its modifying factors on outcome. With the supposition that patients with >70% risk of failure is enough to consider additional treatment, we were able to identify the factors that appear to consistently place patients at or above that level of recurrence. For patients with positive margins, any one of these factors places the patients at a very high risk of recurrence: positive lymph nodes or seminal vesicles, preoperative PSA > 20 ng/ml, or a Gleason score > 7. Many Gleason 7 patients with positive margins fall into the >70% risk of failure category, especially if they have additional risk factors (i.e., those with extraprostatic extension). While there are no absolutes, all these patients should be strongly considered for adjuvant therapy in addition to radical prostatectomy.