Clinical outcomes for men with positive surgical margins after radical prostatectomy—results from the South Australian Prostate Cancer Clinical Outcomes Collaborative community-based registry

Objective Positive surgical margins(PSMs)after radical prostatectomy(RP)indicate failure of surgery to completely clear cancer.PSMs confer an increased risk of biochemical recurrence(BCR),but how more robust outcomes are affected is unclear.This study investigated factors associated with PSMs following RP and determined their impact on clinical outcomes(BCR,second treatment[radiotherapy and/or androgen deprivation therapy],and prostate cancer-specific mortality[PCSM]).Methods The study cohort included men diagnosed with prostate cancer(pT2-3b/N0/M0)between January 1998 and June 2016 who underwent RP from the South Australian Prostate Cancer Clinical Outcomes Collaborative database.Factors associated with risk of PSMs were identified using Poisson regression.The impact of PSMs on clinical outcomes(BCR,second treatment,and PCSM)was assessed using competing risk regression.Results Of the 2827 eligible participants,28%had PSMs—10%apical,6%bladder neck,17%posterolateral,and 5%at multiple locations.Median follow-up was 9.6 years with 81 deaths from prostate cancer recorded.Likelihood of PSM increased with higher pathological grade and pathological tumor stage,and greater tumour volume,but decreased with increasing surgeon volume(odds ratio[OR]:0.93;95%confidence interval[CI]:0.88-0.98,per 100 previous prostatectomies).PSMs were associated with increased risk of BCR(adjusted sub-distribution hazard ratio[sHR]2.5;95%CI 2.1-3.1)and second treatment(sHR 2.9;95%CI 2.4-3.5).Risk of BCR was increased similarly for each PSM location,but was higher for multiple margin sites.We found no association between PSMs and PCSM.Conclusion Our findings support previous research suggesting that PSMs are not independently associated with PCSM despite strong association with BCR.Reducing PSM rates remains an important objective,given the higher likelihood of secondary treatment with associated comorbidities.

Positive Surgical Margins (PSM) after Open Retropubic Radical Prostatectomy: Evaluation of Patient Survival

Background: Many patients who have had radical prostatectomy for prostate cancer may present with microscopic extraprostatic extension of the disease. Positive surgical margins are a common pathological finding in this subgroup of patients. To report the epidemiological, clinical and therapeutic aspects of PSM after radical prostatectomy (RP) and to evaluate the follow-up of patients. Patients and methods: A single-center retrospective descriptive study of patients who underwent radical prostatectomy between June 1, 2004 and December 31, 2019 was conducted. Patients who had radical prostatectomy with PSM on pathology report were included. The parameters studied were age, initial prostate specific antigen (PSA), Gleason and International Society of Uropathology (ISUP) scores, cTNM and pTNM stages, operative technique, PSA levels after surgery, adjuvant treatment and patient survival. Results: Eighty-six (86) radical prostatectomies were performed. PSM was found in 23 patients (26.7%). The mean age of the patients was 63.7 ± 6.1 years. The mean preoperative total PSA was 31.5 ng/mL (6.31 - 146 ng/mL). Prostate biopsy showed only prostatic adenocarcinoma. Thoracic-abdominopelvic CT was performed in all patients. Prostate cancers were found at the localized stage in 12 patients and locally advanced in 11 patients. A classification adjustment was obtained after pathological examination of the surgical specimen. The ISUP score 3 and 1 on the surgical specimen were in the majority with 9 and 7 patients respectively. After the recurrence, all patients who consented received hormone therapy, which was either medical with Goserelin and Triptorelin (7 patients) or surgical with testicular pulpectomy (1 patient). PSA was undetectable (<0.1 mg/mL) in 4 patients. The mean overall survival (OS) time was 28.1 months. Biological recurrence-free survival in the series was 25.7 months. Conclusion: RP with PSM is a fairly common condition that varies from less than 10% to more than 40% depending on the stage of the disease and the operators, and for which the main mean of treatment in our practice setting is hormone therapy.

Current strategies to diagnose and manage positive surgical margins and local recurrence after partial nephrectomy

Objective:No standard strategy for diagnosis and management of positive surgical margin(PSM)and local recurrence after partial nephrectomy(PN)are reported in literature.This review aims to provide an overview of the current strategies and further perspectives on this patient setting.Methods:A non-systematic review of the literature was completed.The research included the most updated articles(about the last 10 years).Results:Techniques for diagnosing PSMs during PN include intraoperative frozen section,imprinting cytology,and other specific tools.No clear evidence is reported about these methods.Regarding PSM management,active surveillance with a combination of imaging and laboratory evaluation is the first option line followed by surgery.Regarding local recurrence management,surgery is the primary curative approach when possible but it may be technically difficult due to anatomy resultant from previous PN.In this scenario,thermal ablation(TA)may have the potential to circumvent these limitations representing a less invasive alternative.Salvage surgery represents a valid option;six studies analyzed the outcomes of nephrectomy on local recurrence after PN with three of these focused on robotic approach.Overall,complication rates of salvage surgery are higher compared to TA but ablation presents a higher recurrence rate up to 25%of cases that can often be managed with repeat ablation.Conclusion:Controversy still exists surrounding the best strategy for management and diagnosis of patients with PSMs or local recurrence after PN.Active surveillance is likely to be the optimal first-line management option for most patients with PSMs.Ablation and salvage surgery both represent valid options in patients with local recurrence after PN.Conversely,salvage PN and radical nephrectomy have fewer recurrences but are associated with a higher complication rate compared to TA.In this scenario,robotic surgery plays an important role in improving salvage PN and radical nephrectomy outcomes.

Does intraoperative frozen section really predict significant positive surgical margins after robot-assisted laparoscopic prostatectomy?A retrospective study

We investigated the relationship between positive surgical margin(PSM)-related factors and biochemical recurrence(BCR)and the ability of intraoperative frozen sections to predict significant PSM in patients with prostate cancer.The study included 271 patients who underwent robot-assisted laparoscopic prostatectomy with bilateral nerve sparing and maximal urethral preservation.Intraoperative frozen sections of the periurethra,dorsal vein,and bladder neck were analyzed.The ability of PSM-related factors to predict BCR and significant PSM was assessed by logistic regression.Of 271 patients,108(39.9%)had PSM and 163(60.1%)had negative margins.Pathologic Gleason score^8(18.9%vs 7.5%,P=0.015)and T stage≥T3a(51.9%vs 24.6%,P<0.001)were significantly more frequent in the PSM group.Multivariate analysis showed that Gleason pattern≥4(vs<4;hazard ratio:4.386;P=0.0004)was the only significant predictor of BCR in the PSM cohort.Periurethral frozen sections had a sensitivity of 83.3%and a specificity of 84.2%in detecting PSM with Gleason pattern≥4.Multivariate analysis showed that membranous urethra length(odds ratio[OR]:0.79,P=0.0376)and extracapsular extension of the apex(OR:4.58,P=0.0226)on magnetic resonance imaging(MRI)and positive periurethral tissue(OR:17.85,P<0.0001)were associated with PSM of the apex.PSM with Gleason pattern≥4 is significantly predictive of BCR.Intraoperative frozen sections of periurethral tissue can independently predict PSM,whereas sections of the bladder neck and dorsal vein could not.Pathologic examination of these samples may help predict significant PSM in patients undergoing robot-assisted laparoscopic prostatectomy with preservation of functional outcomes.

The tissue shrinkage phenomenon on surgical margins in oral and oropharyngeal squamous cell carcinoma

Aim:One of the most important factors associated with recurrence rate and overall survival is the status of surgical margin of resection free of disease.However,sometimes,the margins measured intra-operatively at the time of surgery differ of those measured by the pathologist in the histopathologic analysis.Faced with this dilemma,a literature review of the best available evidence was conducted in an attempt to determine how the phenomenon of tissue shrinkage may influence on the surgical margin of resection in patients undergoing oral and oropharyngeal squamous cell carcinoma(SCC).Methods:An electronic and manual search was conducted by one reviewer.A combination of controlled Medical Subjects Headings and keywords were used as search strategy.Inclusion and exclusion criteria were established.Results:Finally,after an exhaustive selection process,four articles fulfilled the inclusion criteria and were analyzed.All articles reported a decrease of surgical margin after resection.The tumor site and tumor stage seem to influence in degree of margin shrinkage.Conclusion:Tissue shrinkage on surgical margins of resection in oral SCC is a tangible phenomenon.There is a significant discrepancy between margins measured intraoperatively previous to resection and margins measured by pathologist after histologic processing.The highest percentage of retraction occurs at the time of resection.Margin shrinkage based on tumor site and tumor stage should be considered by any oncologic surgeon to ensure adequate margins of resection cleared of tumor.

Role of preoperative magnetic resonance imaging on the surgical outcomes of radical prostatectomy:Does preoperative tumor recognition reduce the positive surgical margin in a specific location?Experience from a Thailand prostate cancer specialized center

Objective Multiparametric magnetic resonance imaging(MRI)has become the standard of care for the diagnosis of prostate cancer patients.This study aimed to evaluate the influence of preoperative MRI on the positive surgical margin(PSM)rates.Methods We retrospectively reviewed 1070 prostate cancer patients treated with radical prostatectomy(RP)at Siriraj Hospital between January 2013 and September 2019.PSM rates were compared between those with and without preoperative MRI.PSM locations were analyzed.Results In total,322(30.1%)patients underwent MRI before RP.PSM most frequently occurred at the apex(33.2%),followed by posterior(13.5%),bladder neck(12.7%),anterior(10.7%),posterolateral(9.9%),and lateral(2.3%)positions.In preoperative MRI,PSM was significantly lowered at the posterior surface(9.0%vs.15.4%,p=0.01)and in the subgroup of urologists with less than 100 RP experiences(32%vs.51%,odds ratio=0.51,p<0.05).Blood loss was also significantly decreased when a preoperative image was obtained(200 mL vs.250 mL,p=0.02).Multivariate analysis revealed that only preoperative MRI status was associated with overall PSM and PSM at the prostatic apex.Neither the surgical approach,the neurovascular bundle sparing technique,nor the perioperative blood loss was associated with PSM.Conclusion MRI is associated with less overall PSM,PSM at apex,and blood loss during RP.Additionally,preoperative MRI has shown promise in lowering the PSM rate among urologists who are in the early stages of performing RP.

The surgical learning curve for robotic-assisted laparoscopic radical prostatectomy： experience of a single surgeon with 500 cases in Taiwan, China

To analyze the learning curve for cancer control from an initial 250 cases （Group I） and subsequent 250 cases （Group II） of robotic-assisted laparoscopic radical prostatectomy （RALP） performed by a single surgeon. Five hundred consecutive patients with clinically localized prostate cancer received RALP and were evaluated. Surgical parameters and perioperative complications were compared between the groups, Positive surgical margin （PSM） and biochemical recurrence （BCR） were assessed as cancer control outcomes. Patients in Group II had significantly more advanced prostate cancer than those in Group I （22.2% vs 14.2%, respectively, with Gleason score 8-10, P = 0.033; 12.8% vs 5.6%, respectively, with clinical stage T3, P = 0.017）. The incidence of PSM in pT3 was decreased significantly from 49% in Group I to 32.6% in Group Ih A meaningful trend was noted for a decreasing PSM rate with each consecutive group of 50 cases, including pT3 and high-risk patients. Neurovascular bundle （NVB） preservation was significantly influenced by the PSM in high-risk patients （84.1% in the preservation group vs 43.9% in the nonpreservation group）. The 3-year, 5-year, and 7-year BCR-free survival rates were 79.2%, 75.3%, and 70.2%, respectively. In conclusion, the incidence of PSM in pT3 was decreased significantly after 250 cases. There was a trend in the surgical learning curve for decreasing PSM with each group of 50 cases. NVB preservation during RALP for the high-risk group is not suggested due to increasing PSM.

Diagnostic value of preoperative examination for evaluating margin status in breast cancer

BACKGROUND A positive resection margin is a major risk factor for local breast cancer recurrence after breast-conserving surgery(BCS).Preoperative imaging examinations are frequently employed to assess the surgical margin.AIM To investigate the role and value of preoperative imaging examinations[magnetic resonance imaging(MRI),molybdenum target,and ultrasound]in evaluating margins for BCS.METHODS A retrospective study was conducted on 323 breast cancer patients who met the criteria for BCS and consented to the procedure from January 2014 to July 2021.The study gathered preoperative imaging data(MRI,ultrasound,and molybdenum target examination)and intraoperative and postoperative pathological information.Based on their BCS outcomes,patients were categorized into positive and negative margin groups.Subsequently,the patients were randomly split into a training set(226 patients,approximately 70%)and a validation set(97 patients,approximately 30%).The imaging and pathological information was analyzed and summarized using R software.Non-conditional logistic regression and LASSO regression were conducted in the validation set to identify factors that might influence the failure of BCS.A column chart was generated and applied to the validation set to examine the relationship between pathological margin range and prognosis.This study aims to identify the risk factors associated with failure in BCS.RESULTS The multivariate non-conditional logistic regression analysis demonstrated that various factors raise the risk of positive margins following BCS.These factors comprise non-mass enhancement(NME)on dynamic contrastenhanced MRI,multiple focal vascular signs around the lesion on MRI,tumor size exceeding 2 cm,type III timesignal intensity curve,indistinct margins on molybdenum target examination,unclear margins on ultrasound examination,and estrogen receptor(ER)positivity in immunohistochemistry.LASSO regression was additionally employed in this study to identify four predictive factors for the model:ER,molybdenum target tumor type(MT Xmd Shape),maximum intensity projection imaging feature,and lesion type on MRI.The model constructed with these predictive factors exhibited strong consistency with the real-world scenario in both the training set and validation set.Particularly,the outcomes of the column chart model accurately predicted the likelihood of positive margins in BCS.CONCLUSION The proposed column chart model effectively predicts the success of BCS for breast cancer.The model utilizes preoperative ultrasound,molybdenum target,MRI,and core needle biopsy pathology evaluation results,all of which align with the real-world scenario.Hence,our model can offer dependable guidance for clinical decisionmaking concerning BCS.

Laparoscopic distal pancreatectomy for adenocarcinoma of the pancreas

Since the first report on laparoscopic distal pancreatectomy (LDP) appeared in the 1990s, the procedure has been performed increasingly frequently to treat both benign and malignant lesions of the pancreas. Many earlier publications have shown LDP to be a good alternative to open distal pancreatectomy for benign lesions, although this has never been studied in a prospective, randomized manner. The evidence for the use of LDP to treat adenocarcinoma of the pancreas is not as well established. The purpose of this review is to evaluate the current evidence for LDP in cases of pancreatic adenocarcinoma. We conducted a review of English language publications reporting LDP results between 1990 and 2013. All studies reporting results in patients with histologically proven pancreatic adenocarcinoma were included. Thirty-nine publications were found and included in the results for a total of 309 cases of pancreatic adenocarcinoma (potential double publications were not eliminated). Most LDP procedures are performed in selected cases and generally involve smaller tumors than open distal pancreatectomy (ODP) procedures. Some of the papers report unselected cases and include procedures on larger tumors. The number of lymph nodes harvested using LDP is comparable to the number obtained with ODP, as is the frequency of R0 resections. Current data suggest that similar short term oncological results can be obtained using LDP as those obtained using ODP.

Influence of bladder neck suspension stitches on early continence after radical prostatectomy： a prospective randomized study of 180 patients

Several techniques have been introduced to improve early postoperative continence. In this study, we evaluated the impact of bladder neck （vesicourethral anastomosis） suspension on the outcome of extraperitoneal endoscopic radical prostatectomy （EERPE）. In this research, a total of 180 patients underwent EERPE. Group 1 included patients who underwent nerve-sparing EERPE （nsEERPE） （n=45）, and Group 2 included patients who underwent nsEERPE with bladder neck suspension （BNS, n=45）. Groups 3 （n=45） and 4 （n=45） included patients who received EERPE and EERPE with BNS, respectively. Patients were randomly assigned to receive BNS with their nsEERPE or EERPE procedure. Perioperative parameters were recorded, and continence was evaluated by determining the number and weight of absorbent pads （pad weighing test） on the second day after catheter removal and by a questionnaire 3 months postoperatively. Two days after catheter removal, 11.1% of Group 1, 11.1% of Group 2, 4.4% of Group 3 and 8.9% of Group 4 were conti nent. The average urine loss was 80.4, 70.1, 325.0 and 291.3 g for the each of these groups, respectively. At 3 months, 76.5% of Group I and 81.3% of Group 2 were continent. The continence figures for Group 3 and 4 were 48.5% and 43.8%, respectively. Similar overall rates were observed in all groups. In conclusion, although there are controversial reports in the literature, early continence was never observed to be significantly higher in the BNS groups when compared with the non-BNS groups, regardless of the EERPE technique performed.

Is Retzius-sparing robot-assisted radical prostatectomy associated with better functional and oncological outcomes? Literature review and meta-analysis

Objective:To evaluate the efficiency,safety and clinical outcomes of Retziussparing robot-assisted radical prostatectomy(RS-RARP)in comparison with the standard RARP.Methods:A systematic search from Web of Science,PubMed,EMBase,Cochrane Library and Google Scholar was performed using the terms“Retzius-sparing”,“Bocciardi approach”and“robot-assisted radical prostatectomy”.Video articles and abstract papers for academic conferences were excluded.Meta-analysis of interested outcomes such as positive surgical margins(PSMs)and continence recovery was undertaken.A comprehensive literature review of all studies regarding Retzius-sparing(RS)approach was conducted and summarized.Results:From 2010 to 2017,11 original articles about RS-RARP approach were retrieved.Of that,only four studies comparing the RS-RARP approach to the conventional RARP were comparable for meta-analysis.Faster overall continence recovery within 1 month after the surgery was noted in the RS group(61%vs.43%;pZ0.004).PSMs of pT2 and pT3 stages were not significantly different between the groups(10.0%vs.7.4%;p Z 0.39 and 13.1%vs.9.5%,p Z 0.56,respectively).Of all the studies,only one reported sexual recovery outcomes after RS treatment in which 40%of the participants achieved sexual intercourse within the first month.Conclusion:Though more technically demanding than the conventional RARP,the RS technique is a safe and feasible approach.This meta-analysis and literature review indicates that RS technique,as opposed to the conventional approach,is associated with a faster continence recovery while PSMs were comparable between the two groups.The limitations of observational studies and the small data in our meta-analysis may prevent an ultimate conclusion.Future well-designed RCTs are needed to validate and confirm our findings.

Anatomic resection improved the long-term outcome of hepatocellular carcinoma patients with microvascular invasion:A prospective cohort study

BACKGROUND The long-term effect of anatomic resection(AR)is better than that of nonanatomic resection(NAR).At present,there is no study on microvascular invasion(MVI)and liver resection types.AIM To explore whether AR improves long-term survival in patients with hepatocellular carcinoma(HCC)by removing the peritumoral MVI.METHODS A total of 217 patients diagnosed with HCC were enrolled in the study.The surgical margin was routinely measured.According to the stratification of different tumor diameters,patients were divided into the following groups:≤2 cm group,2-5 cm group,and>5 cm group.RESULTS In the 2-5 cm diameter group,the overall survival(OS)of MVI positive patients was significantly better than that of MVI negative patients(P=0.031).For the MVI positive patients,there was a statistically significant difference between AR and NAR(P=0.027).AR leads to a wider surgical margin than NAR(2.0±2.3 cm vs 0.7±0.5 cm,P<0.001).In the groups with tumor diameters<2 cm,both AR and NAR can obtain a wide surgical margin,and the surgical margins of AR are wider than that of NAR(3.5±5.8 cm vs 1.6±0.5 cm,P=0.048).In the groups with tumor diameters>5 cm,both AR and NAR fail to obtain wide surgical margin(0.6±1.0 cm vs 0.7±0.4 cm,P=0.491).CONCLUSION For patients with a tumor diameter of 2-5 cm,AR can achieve the removal of peritumoral MVI by obtaining a wide incision margin,reduce postoperative recurrence,and improve prognosis.

Prognostic Impact of Surgical Margin Width in Hepatectomy for Colorectal Liver Metastasis

As for resection for colorectal liver metastasis (CRLM), secur-ing an adequate surgical margin is important for achieving a better prognosis. However, it is often difficult to achieve ade-quate margins for the resection of CRLM. So the current sur-vival impact of sub-centi/millimeter surgical margins in he-patectomy for CRLM should be evaluated. In the current era of multidisciplinary treatment options, this review focused on the prognostic impact of a sub-centi/millimeter surgical margin width in hepatectomy for CRLM. We systematically reviewed retrospective studies that clearly described the sur-gical margin width for hepatectomy for CRLM. We selected studies conducted since 2000 that involved patients diag-nosed as having CRLM. We focused on studies that investi-gated not only surgical margins, but also microscopic surgical curability such as R0 (microscopically complete resection) or R1 (microscopically incomplete resection), which clearly de-scribe their definitions. Based on our literature review, 1, 2, or 5 mm was considered the minimum surgical margin width for hepatectomy for CRLM. Although a surgical margin width of 1 mm is acceptable for hepatectomy for CRLM, submil-limeter margins, which are defined as R1 in many reports, are only acceptable for limited patients such as those who have undergone preoperative chemotherapy. Zero-mm mar-gins are also acceptable in limited patients such as those who show a good response to preoperative chemotherapy. New chemotherapy agents have been reported to reduce the prognostic impact of a narrow surgical margin width. The incidence of margin recurrence, which is a major concern regarding R1 resection of CRLM, is about 20-30% according to the majority of earlier reports. As evaluations of the actual prognostic impact of the surgical margin remain difficult, fur-ther study is warranted.

Perineural invasion status, Gleason score and number of positive cores in biopsy pathology are predictors of positive surgical margin following laparoscopic radical prostatectomy

This study was designed to define possible preoperative predictors of positive surgical margin after laparoscopic radical prostatectomy. We retrospectively analyzed the records of 296 patients with prostate cancer diagnosed by prostate biopsy, and eventually treated with laparoscopic radical prostatectomy. The prognostic impact of age, prostate volume, preoperative prostate-specific antigen, biopsy Gleason score, maximum percentage tumor per core, number of positive cores, biopsy perineurat invasion, capsule invasion on imaging, and tumor laterality on surgical margin was assessed. The overall positive surgical margin rate was 29.1%. Gleason score, number of positive cores, perineural invasion, tumor laterality in the biopsy specimen, and prostate volume significantly correlated with risk of positive surgical margin by univariate analysis （P 〈 0.05）. Gleason score （odds ratio [OR] = 2.286, 95% confidence interval [95% CI] = 1.431-3.653, P= 0.001）, perineural invasion （OR = 4.961, 95% CI = 2.656-9.270, P〈 0.001）, and number of positive cores （OR = 4.403, 95% CI = 1.878-10.325, P = 0.001） were independent predictors of positive surgical margin at the multivariable logistic regression analysis. Patients with perineural invasion, higher biopsy Gleason scores and/or a large number of positive cores in biopsy pathology had more possibility of capsule invasion. The positive surgical margin rate in patients with capsule invasion （49.5%） was much higher than that with localized disease （17.8%）. In contrast, prostate volume showed a protective effect against positive surgical margin （OR = 0.572, 95% CI = 0.346-0.945, P = 0.029）. Gleason score, perineural invasion, and number of positive cores in the biopsy specimen were preoperative independent predictors of positive surgical margin after laparoscopic radical prostatectomy while prostate volume was a protective factor against positive surgical margin.

Risk factors of positive surgical margin and biochemical recurrence of patients treated with radical prostatectomy： a single-center 10-year report

Background Many studies have shown that positive surgical margin and biochemical recurrence could impact the life of patients with prostate cancer treated with radical prostatectomy. With more and more patients with prostate cancer appeared in recent 20 years in China, it is necessary to investigate the risk of positive surgical margin and biochemical recurrence, and their possible impact on the prognosis of patients treated with radical prostatectomy. In this study, we analyzed the characteristics of patients with prostate cancer who had undergone radical prostatectomy in Macao area and tried to find any risk factor of positive surgical margin and biochemical recurrence and their relationship with the proanosis of these oatients.

Treatment of the positive surgical margin following radical prostatectomy

Objective With increased incidence of prostate cancer and an increased number of patients undergoing radical prostatectomy in China, it will be necessary to elaborate the diagnosis, clinical significance and treatment of patients whose tumors have positive surgical margins following radical prostatectomy.Data sources Positive surgical margin, prostate cancer and radical prostatectomy were used as subject words and the medical literature in recent decades was searched using the PubMed database and the results are summarized.Study selection Using positive surgical margin, prostate cancer and radical prostatectomy as subject words the PubMed medical database produced 275 papers of pertinent literature. By further screening 28 papers were selected and they represent relatively large-scale clinical randomized and controlled clinical trials.Results A pertinent literature of 275 papers was identified and 28 papers on large clinical studies were obtained. Analysis of results indicated that the positive rate of surgical margin after radical prostatectomy is 20%-40%, and although most patients with positive surgical margins are stable for a considerable period, the data available now suggested that the presence of a positive surgical margin will have an impact on the patient＇s prognosis. The risk factors of positive surgical margin include preoperative prostate specific antigen level, Gleason＇s score and pelvic lymph node metastasis. The most common site with positive surgical margin is in apical areas of the prostate; therefore surgical technique is also a factor resulting in positive surgical margins. From data available now it appears that as long as the surgical technique is skilled, different surgical modes do not affect the rate of surgical margin. Adjuvant radiotherapy is mainly used to treat patients with positive surgical margin after radical prostatectomy, but combination with androgen deprivation therapy may increase the curative effect.Conclusion The current data indicated that the presence of positive surgical margins can markedly affect the patient＇s prognosis. Therefore we should be aware how we reduce the positive surgical margin, how to diagnose positive surgical margin and how to treat when there are positive surgical margins.

Evaluating the oncologic outcomes in 152 patients undergoing extraperitoneal laparoscopic radical prostatectomy

Background Although many midterm oncologic data have been reported for extraperitoneal laparoscopic radical prostatectomy （ELRP） in western countries, few oncologic data of the extraperitoneal procedure was published in China. The aim of the study was to evaluate the oncologic outcomes of patients treated with ELRP in China.Methods From January 2005 to March 2010, a total of 152 consecutive patients diagnosed with clinically localized prostate cancer were included in this study and treated with ELRP. The patients were staged according to the TNM （tumor, nodes, metastases） system. Median and mean postoperative follow-up were 28.1 months and 27.0 months, respectively. The patients were retrospectively analyzed for progression-free survival.Results One hundred and twelve cases （73.7%） were postoperatively diagnosed as pT2 in, and 40 cases （26.3%） as pT3. Positive lymph nodes were shown in 5 patients （3.3%）. Gleason score was 〈7 in 49 men （32.2%）, 7 in 69 men （45.4%）, and 〉7 in 34 men （22.4%）. Positive surgical margins （PSM） were observed in 15 patients （9.9%）, which included 32.0% of all pT3a cases and 46.7% of all pT3b cases, respectively. The overall prostate-specific antigen recurrence-free survival rate was 86% in all patients. The recurrence-free survival rates were 91.8% and 62.2% in pT2N0 patients and pT3N0 patients, respectively. Preoperative prostate-specific antigen, surgical margins, tumor stage, and lymph nodal status were identified as independent predictors of biochemical recurrence-free survival using multivariate Cox proportional hazard model. Conclusions ELRP is a precise, safe and effective procedure at this particular Chinese institution. The prognostic power of prostate-specific antigen relapse after ELRP is not identical to that described previously with transperitoneal or open retropubic approaches.

Triage for management of cervical high-grade squamous intraepithelial lesion patients with positive margin by conization： a retrospective analysis

The objective of this study is to guide a triage for the management of cervical high-grade squamous intraepithelial lesion （HSIL） patients with positive margin by conization. Clinico-pathological data of HSIL patients with positive margin by conization were retrospectively collected from January 2009 to December 2014. All patients underwent secondary conization or hysterectomy within 6 months. The rate of residual lesion was calculated, and the factors associated with residual lesion were analyzed by univariate and multivariate analyses. Among a total of 119 patients, 56 （47.06%） patients presented residual HSIL in their subsequent surgical specimens, including 4 cases of invasive cervical carcinoma （3 stage IA1 and 1 stage IA2 patients）. Univariate analysis showed that patient age 〉 35 years （P = 0.005）, menopausal period 〉 5 years （P = 0.0035）, and multiple- quadrant involvement （P=0.001） were significantly correlated with residual disease; however, multivariate analysis revealed that multiple-quadrant involvement （P=0.001; OR, 3.701; 95%CI, 1.496-9.154） was an independent risk factor for residua! disease. Nearly half of HSIL patients with positive margin by conization were disease-free in subsequent surgical specimens, and those with multiple positive margins may consider re- conization or re-assessment.

Significance of margin in nephron sparing surgery for renal cell carcinoma of 4 cm or less

Background Current surgical practice for nephron sparing surgery allows at least 1 cm margin of normal tissue around the tumour. However, recent studies show that the width of the margin is not important, even simple enucleation is as effective as partial nephrectomy. We explored whether margin size has significant impacts on clinical outcomes in nephron sparing surgery for renal cell carcinoma of 4 cm or less. Methods Between 1998 and 2006, 115 patients with sporadic, pathologically confirmed, renal cell carcinoma 4 cm or less （Tla） and normal contralateral kidney were treated by nephron sparing surgery using a margin less than 5 mm. The surgical margin status was evaluated from frozen and permanent paraffin sections. Results Mean and median tumour diameter were 3.3 cm and 3.5 cm （range 1.0-4.0）. The mean margin width was 2.2 mm （median 2.0, range 0-6）. In addition, 114 cases had margins 5 mm or less （99.1%）, 97 cases （84.3%） had margin 3 mm or less, and 26 cases had margin zero （22.6%）. None of the patients had positive surgical margins. No patients died during follow-up （mean 65 months）. There were no any major surgical complications and no distant metastasis was detected. Local recurrence was detected in one case （0.9%） at a different site of the kidney. Conclusions For early localized renal cell carcinoma of 4 cm or less, as long as tumour is completely excised, the size of margin in nephron sparing surgery is not important. Nephron sparing surgery with 5 mm margin is enough for tumour control. It provides excellent renal function preservation, favourable long term progression free survival and is not associated with an increased risk of local recurrence.

Parenchymal sparing anatomical liver resections for hepatocellular carcinoma

The rationale of the performance of anatomic resection(AR)of the liver in case of hepatocellular carcinoma(HCC)is the removal of portal pedicle feeding the tumor because of the tumor’s tendency to invade the portal veins(1).This technical approach is expected to be effective from an oncological perspective for a disease such as HCC,which is associated with a high rate of intrahepatic recurrence(2,3).In the eighties,Makuuchi et al.proposed the systematic subsegmentectomy(4)reporting excellent results(5),and later some other authors reported new techniques to identify the portal territory of a given HCC and perform a true AR of the liver(5-7).