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Wrong to be Right: Margin Laterality is an Independent Predictor of Biochemical Failure After Radical Prostatectomy

Kang, Jung, J., MD, PhD*; Reiter, Robert, E., MD; Kummer, Nicolas, MD, PhD*; DeKernion, Jean, MD; Steinberg, Michael, L., MD*; King, Christopher, R., PhD, MD*

American Journal of Clinical Oncology: January 2018 - Volume 41 - Issue 1 - p 1–5
doi: 10.1097/COC.0000000000000216
Original Articles: Genitourinary

Objectives: To examine the impact of positive surgical margin (PSM) laterality on failure after radical prostatectomy (RP). A PSM can influence local recurrence and outcomes after salvage radiation. Unlike intrinsic risk factors, a PSM is caused by intervention and thus iatrogenic failures may be elucidated by analyzing margin laterality as surgical approach is itself lateralized.

Patients and Methods: We reviewed 226 RP patients between 1991 and 2013 with PSM. Data includes operation type, pre/postoperative PSA, surgical pathology, and margin type (location, focality, laterality). The median follow-up was 47 months. Biochemical recurrence after RP was defined as PSA≥0.1 ng/mL or 2 consecutive rises above nadir. Ninety-two patients received salvage radiation therapy (SRT). Failure after SRT was defined as any PSA≥0.2 ng/mL or greater than presalvage. Kaplan-Meier and Cox multivariate analyses compared relapse rates.

Results: The majority of PSM were iatrogenic (58%). Laterality was associated with differences in median relapse: right 20 versus left 51 versus bilateral 14 months (P<0.01). Preoperative PSA, T-stage, Gleason grade, and laterality were associated with biochemical progression on univariate and multivariate analyses. Right-sided margins were more likely to progress than left (hazard ratio, 1.67; P=0.04). More right-sided margins were referred for SRT (55% right vs. 23% left vs. 22% bilateral), but were equally salvaged. Only T-stage and pre-SRT PSA independently influenced SRT success.

Conclusions: Most PSM are iatrogenic, with right-sided more likely to progress (and sooner) than left sided. Margin laterality is a heretofore unrecognized independent predictor of biochemical relapse and hints at the need to modify the traditional unilateral surgical technique.

Departments of *Radiation Oncology

Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA

The authors declare no conflicts of interest.

Reprints: Jung J. Kang, MD, PhD, Department of Radiation Oncology, David Geffen School of Medicine at UCLA, 200 UCLA Medical Plaza, Suite B265, Los Angeles, CA 90095. E-mail:

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