It is unclear whether preoperative staging using Magnetic Resonance Imaging (MRI) reduces the risk of positive margins in prostate cancer. We aimed to assess the effect on surgical margins and degree of nerve sparing of a pelvic MRI presented at a preoperative MRI conference.
Single institution, observational cohort study including 1037 men that underwent robot assisted radical prostatectomy between October 2013 and June 2015. Of these, 557 underwent a preoperative MRI combined with a preoperative MRI conference and 410 did not. With whole-mount prostate specimen histopathology as gold standard we assessed the ability of MRI in finding the index tumor and the sensitivity and specificity for extra prostatic extension. We calculated relative risks for positive surgical margins and non-nerve sparing procedure, adjusting for preoperative risk factors using stabilized inverse-probability weighting.
MRI detected the index tumor in 80% of the cases. Non-organ confined disease (pT3) at histology was present in the MRI and the non-MRI group in 42% and 24%, respectively. Rate of positive surgical margins comparing the MRI and non-MRI groups was 26.7% and 33.7%, respectively, relative risk 0.79 [95% CI 0.65–0.96], weighted relative risk (wRR) 0.69 [95% CI 0.55–0.86]. The wRR of extensive positive surgical margins was 0.45 [95% CI 0.31–0.67]. Undergoing MRI was also associated with an increased risk of being operated with a non-nerve sparing technique (wRR, 1.84 [95% CI 1.11–3.03]).
Our study suggests that preoperative prostate MRI in combination with a preoperative MRI conference affects the degree of nerve-sparing surgery and reduces positive surgical margins.
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Walsh PC, Donker PJ. Impotence following radical prostatectomy: insight into etiology and prevention. J Urol. 1982;128:492–7.
Reeves F, Preece P, Kapoor J, Everaerts W, Murphy DG, Corcoran NM, et al. Preservation of the neurovascular bundles is associated with improved time to continence after radical prostatectomy but not long-term continence rates: results of a systematic review and meta-analysis. Eur Urol. 2015;68:692–704.
de Rooij M, Hamoen EH, Witjes JA, Barentsz JO, Rovers MM. Accuracy of magnetic resonance imaging for local staging of prostate cancer: a diagnostic meta-analysis. Eur Urol. 2016;70:233–45.
Kasivisvanathan V, Rannikko AS, Borghi M, Panebianco V, Mynderse LA, Vaarala MH, et al. MRI-targeted or standard biopsy for prostate-cancer diagnosis. N Engl J Med. 2018;378:1767–77.
Park BH, Jeon HG, Jeong BC, Seo SI, Lee HM, Choi HY, et al. Influence of magnetic resonance imaging in the decision to preserve or resect neurovascular bundles at robotic assisted laparoscopic radical prostatectomy. J Urol. 2014;192:82–8.
Rud E, Baco E, Klotz D, Rennesund K, Svindland A, Berge V, et al. Does preoperative magnetic resonance imaging reduce the rate of positive surgical margins at radical prostatectomy in a randomised clinical trial? Eur Urol. 2015;68:487–96.
Barentsz JO, Richenberg J, Clements R, Choyke P, Verma S, Villeirs G, et al. ESUR prostate MR guidelines 2012. Eur Radiol. 2012;22:746–57.
Barentsz JO, Weinreb JC, Verma S, Thoeny HC, Tempany CM, Shtern F, et al. Synopsis of the PI-RADS v2 guidelines for multiparametric prostate magnetic resonance imaging and recommendations for use. Eur Urol. 2016;69:41–9.
Outwater EK, Petersen RO, Siegelman ES, Gomella LG, Chernesky CE, Mitchell DG. Prostate carcinoma: assessment of diagnostic criteria for capsular penetration on endorectal coil MR images. Radiology. 1994;193:333–9.
Roethke MC, Lichy MP, Kniess M, Werner MK, Claussen CD, Stenzl A, et al. Accuracy of preoperative endorectal MRI in predicting extracapsular extension and influence on neurovascular bundle sparing in radical prostatectomy. World J Urol. 2013;31:1111–6.
Futterer JJ, Heijmink SW, Scheenen TW, Jager GJ, Hulsbergen-Van de Kaa CA, Witjes JA, et al. Prostate cancer: local staging at 3-T endorectal MR imaging--early experience. Radiology. 2006;238:184–91.
Cornud F, Rouanne M, Beuvon F, Eiss D, Flam T, Liberatore M, et al. Endorectal 3D T2-weighted 1mm-slice thickness MRI for prostate cancer staging at 1.5Tesla: Should we reconsider the indirects signs of extracapsular extension according to the D’Amico tumor risk criteria? Eur J Radiol. 2011;81:e591–7.
Turkbey B, Pinto PA, Mani H, Bernardo M, Pang Y, McKinney YL, et al. Prostate cancer: value of multiparametric MR imaging at 3 T for detection--histopathologic correlation. Radiology. 2010;255:89–99.
Rosenkrantz AB, Deng FM, Kim S, Lim RP, Hindman N, Mussi TC, et al. Prostate cancer: multiparametric MRI for index lesion localization--a multiple-reader study. Am J Roentgenol. 2012;199:830–7.
Epstein JI, Allsbrook WC Jr., Amin MB, Egevad LL, Committee IG. The 2005 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma. Am J Surg Pathol. 2005;29:1228–42.
Magi-Galluzzi C, Evans AJ, Delahunt B, Epstein JI, Griffiths DF, van der Kwast TH, et al. International Society of Urological Pathology (ISUP) Consensus Conference on Handling and Staging of Radical Prostatectomy Specimens. Working group 3: extraprostatic extension, lymphovascular invasion and locally advanced disease. Mod Pathol. 2011;24:26–38.
Tan PH, Cheng L, Srigley JR, Griffiths D, Humphrey PA, van der Kwast TH, et al. International Society of Urological Pathology (ISUP) Consensus Conference on Handling and Staging of Radical Prostatectomy Specimens. Working group 5: surgical margins. Mod Pathol. 2011;24:48–57.
Sooriakumaran P, Ploumidis A, Nyberg T, Olsson M, Akre O, Haendler L, et al. The impact of length and location of positive margins in predicting biochemical recurrence after robot-assisted radical prostatectomy with a minimum follow-up of 5 years. BJU Int. 2015;115:106–13.
Servoll E, Vlatkovic L, Saeter T, Nesland JM, Axcrona U, Waaler G, et al. The length of a positive surgical margin is of prognostic significance in patients with clinically localized prostate cancer treated with radical prostatectomy. Urol Int. 2014;93:289–95.
Dev HS, Wiklund P, Patel V, Parashar D, Palmer K, Nyberg T, et al. Surgical margin length and location affect recurrence rates after robotic prostatectomy. Urol Oncol. 2015;33:109 e107–13.
Yossepowitch O, Briganti A, Eastham JA, Epstein J, Graefen M, Montironi R, et al. Positive surgical margins after radical prostatectomy: a systematic review and contemporary update. Eur Urol. 2014;65:303–13.
Wadhwa H, Terris MK, Aronson WJ, Kane CJ, Amling CL, Cooperberg MR, et al. Long-term oncological outcomes of apical positive surgical margins at radical prostatectomy in the Shared Equal Access Regional Cancer Hospital cohort. Prostate Cancer Prostatic Dis. 2016;19:423–8.
Suardi N, Dell’Oglio P, Gallina A, Gandaglia G, Buffi N, Moschini M, et al. Evaluation of positive surgical margins in patients undergoing robot-assisted and open radical prostatectomy according to preoperative risk groups. Urol Oncol. 2016;34:57 e51–7.
Evans AJ, Henry PC, Van der Kwast TH, Tkachuk DC, Watson K, Lockwood GA, et al. Interobserver variability between expert urologic pathologists for extraprostatic extension and surgical margin status in radical prostatectomy specimens. Am J Surg Pathol. 2008;32:1503–12.
van der Kwast TH, Collette L, Van Poppel H, Van Cangh P, Vekemans K, DaPozzo L, et al. Impact of pathology review of stage and margin status of radical prostatectomy specimens (EORTC trial 22911). Virchows Arch. 2006;449:428–34.
Ahmed HU, El-Shater Bosaily A, Brown LC, Gabe R, Kaplan R, Parmar MK, et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. Lancet. 2017;389:815–22.
Schlomm T, Tennstedt P, Huxhold C, Steuber T, Salomon G, Michl U, et al. Neurovascular structure-adjacent frozen-section examination (NeuroSAFE) increases nerve-sparing frequency and reduces positive surgical margins in open and robot-assisted laparoscopic radical prostatectomy: experience after 11,069 consecutive patients. Eur Urol. 2012;62:333–40.
The study was funded by financial support provided through the regional agreement on medical training and clinical research (ALF) between the Stockholm county council and Karolinska Insititutet. Our great gratitude to Jonas Höijer biostatistician at Institute of Environmental Medicine, Karolinska Institutet for invaluable help during the final statistical calculations for this study.
Statistical code for STATA for the stabilized inverse probability weighting and multivariable regression analysis available in Suppl. 3
Conflict of interest
The authors declare that they have no conflict of interest.
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Jäderling, F., Akre, O., Aly, M. et al. Preoperative staging using magnetic resonance imaging and risk of positive surgical margins after prostate-cancer surgery. Prostate Cancer Prostatic Dis 22, 391–398 (2019) doi:10.1038/s41391-018-0116-z