Elsevier

Human Pathology

Volume 44, Issue 8, August 2013, Pages 1556-1562
Human Pathology

Original contribution
Role of frozen section analysis of surgical margins during robot-assisted laparoscopic radical prostatectomy: a 2608-case experience

https://doi.org/10.1016/j.humpath.2012.12.011Get rights and content

Summary

It remains unanswered whether and how intraoperative frozen section analysis contributes to the surgical margin status on radical prostatectomy specimens. We aimed to determine whether frozen section analysis during radical prostatectomy reduces the incidence of positive surgical margins. We retrospectively analyzed a consecutive series of patients undergoing robot-assisted laparoscopic radical prostatectomy performed at our institution between 2004 and 2011. We identified 2608 cases, including 1128 (43.3%) where intraoperative frozen section analysis was performed to assess surgical margins. Of the cases with positive (n = 60; 5.3%)/negative (n = 1029; 91.2%)/atypical or indeterminate (n = 39; 3.5%) frozen section analyses, 22 (36.7%)/83 (8.1%)/4 (10.3%) were found to have positive surgical margins on radical prostatectomy specimens, respectively. Thus, 109 (9.7%) of 1128 cases with frozen section analysis had positive surgical margins, compared with 163 (11.0%) of 1480 cases with no frozen section analysis (P = .264). When the patients were subgrouped by histopathologic characteristics, frozen section analysis led to a considerable reduction in the rate of positive surgical margins in cases with biopsy Gleason score 7 (12.4% → 8.7%; P = .087)/8 (28.6% → 16.3%; P = .048)/≥7 (15.3% → 10.1%; P = .012) tumor or pT3b (36.6% → 23.2%; P = .075)/≥pT3b (38.1% → 25.4%; P = .091) disease. Multivariate analysis further revealed that performing frozen section analysis in biopsy Gleason score 7 or higher tumors was an independent predictor of negative surgical margins (odds ratio, 0.61; P = .018). In addition, frozen section analysis of the distal urethra or apex of the prostate (7.5%, P = .035) as well as multiple negative frozen section analyses (≥2: 6.2%, P = .001; ≥4: 2.2%, P = .007) correlated with significantly lower rates of positive surgical margin, compared with no frozen section analysis. Overall, intraoperative frozen section analysis did not dramatically change surgical margin status of radical prostatectomy. Nonetheless, it could be useful in preventing incomplete tumor resection, especially in men with high-grade (Gleason score ≥7) tumor at the apex.

Introduction

In spite of the considerable progress of surgical technique, positive surgical margins (+SMs) are not uncommonly seen in radical prostatectomy (RP) specimens (eg, 11%-38% [1]), presumably due to such causes as extraprostatic extension of the tumor. Nevertheless, there are no reliable tools, other than meticulous assessment of prostate biopsy in rare cases, to preoperatively determine the presence of extraprostatic extension. Indeed, +SM is considered to be a poor prognostic indicator, which correlates with a high risk of biochemical recurrence (eg, up to 50% at 5 years after RP [2], [3]). Thus, the importance of achieving negative surgical margins (−SMs) to reduce the risk of recurrence has been well recognized.

Intraoperative frozen section analysis (FSA) of surgical margins (SMs) during RP has been used to prevent incomplete tumor resection. When the margin is positive for carcinoma on FSA, additional tissue is often excised until a negative FSA at the site is obtained. However, it remains controversial whether intraoperative FSA really contributes to reducing the rates of +SM on the final resection specimen. Uncertainty also remains regarding the appropriate site/number of specimens to send for FSA and the selection of patients on whom to perform FSA. In this study, we retrospectively reviewed our experience of 2608 RP cases with or without intraoperative FSA in a single institution to assess its role in the final status of SMs.

Section snippets

Patient population

We studied consecutive patients with prostatic adenocarcinoma who had undergone robot-assisted laparoscopic RP at our institution between June 2004 and September 2011. From our institutional review board–approved surgical pathology electronic database, we identified 2608 cases coded as RP specimens, including 1128 (43.3%) in which intraoperative FSA was done to assess the areas suspected of having +SMs. Additional patients (n = 23) who had received therapy with hormonal reagents or radiation

Results

Table 1 summarizes the clinicopathologic features of the patients with (1128 cases; 43.3%) and without (1480 cases; 56.7%) intraoperative FSA of the prostate. Between these 2 cohorts, there were statistically significant differences in age of the patients, GS on biopsy, and pT stage on RP. No significant differences were found in preoperative PSA, GS on RP, pN stage, and estimated cancer volume. Patients undergoing FSA were younger than those not undergoing FSA (P < .001). Similarly, patients

Discussion

Intraoperative FSA of SMs is a frequent part of the standard procedure in most radical surgeries for solid tumors. In RPs, +SM is considered to be a poor prognostic indicator, which correlates with a high risk of biochemical recurrence [2], [3]. However, FSA has yet to prove a significant benefit to RP patients in terms of the risk of incomplete resection and subsequent biochemical recurrence [3]. Some of these studies lacked the control cohort of no FSA and/or involved relatively small numbers

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1

Y. K. and B. C. contributed equally.

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