Significance of Positive Margins

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Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 7649
   Posted 2/7/2010 2:43 AM (GMT -6)   
Positive Margins ~ To worry or not to worry... That is the question.

The following study is from the Mayo Clinic from 1990 to 2006. 11,729 patients, pretty solid information. Usually I don't like single center studies, but there are a few centers that have such great data it's hard to not be interested in these results. Mike Scott has done us a favor and broken it out well...from the "New" Prostate Cancer Infolink...

prostatecancerinfolink.net/2010/02/06/what-does-a-positive-surgical-margin-actually-predict-after-surgery

Mike finishes the article as follows:
The authors note that their data show a distinct reduction in the frequency of positive surgical margins (at least in their series) over the past 20 years. They conclude that the presence of a positive margin after radical prostatectomy does increase the probability of biochemical recurrence, local recurrence, and the delivery of salvage therapy. However, it does not reliably predict risk for systemic progression, cancer-specific death, or overall mortality.

A critical question does remain unresolved, however. What is the standard of care for a man with a positive surgical margin after radical prostatectomy? At present it seems to us that the precise care needs to take account not only of the size and number of the positive margins but also other risk factors, most particularly including the preoperative and postoperative PSA level, the pathological Gleason score, and the pathological stage of the patient’s disease. A 55-year-old patient with a PSA level > 10 ng/ml, a Gleason score of 8, and a positive surgical margin is presumably at greater risk for clinically significant (as opposed to just biochemical) recurrence than a 55-year-old with a PSA of < 10 ng/ml, a Gleason score of 6, and a positive surgical margin.

My own commentary:
While I know I fell into the very high risk category, I see a lot to be hopeful for. Many of our guys here should also. Positive margins should not automatically be construed as a failed surgery. As Mike points out well...

Positive Margins are not a significant predictor of:
1> Systemic Progression
2> Cancer specific death
3> Overall mortality

We tend to view positive margins as a huge negative, and they certainly are not a positive in spite of their designation, but positive margins are useful information. They are not a death sentence, nor a failed surgery. However, what you do once you have them identified, if anything, remains controversial.

One other point...
Mayo Clinic reports this interesting tidbit...
From 1990 to 1995 Forty-One (41.1%) percent of surgeries had positive margins...
From 1996 to 2000 Thirty-Two (32.0%) percent of had positive margins...
From 2001 to 2005 only Nineteen (19.6%) percent had positive margins...

The Mayo Clinic started as one of the pioneering centers using the Da Vinci robotic system in 2001...While they still do open procedures as well, it would appear that adding the RALP has not at all negatively impacted the number of cases with positive margins...

Tony
Prostate Cancer Forum Co-Moderator

Post Edited (TC-LasVegas) : 2/7/2010 1:17:36 AM (GMT-7)


Bootheel
Regular Member


Date Joined Oct 2007
Total Posts : 300
   Posted 2/7/2010 10:26 AM (GMT -6)   
Very interesting article Tony.  I had a positive surgical margin after surgery as you can see from my stats.  I completed IMRT and my PSA
stayed the same on my first followup visit.  I am hoping that my appt this month will show a decrease. I read that it may take up to a year to go down.  Hopefully that will be the case for me.
Age 65
Diagnosed 10/12/07
PSA 6.3
Biopsy 18 core samples, 2 positive <5%
Stage T1a Gleason 6 (3+3)
LRP  1/29/08
Post-op
Gleason 7 (3+4)
1 positive margin (.3cm)
T2C
4/16/08- Started Bi-mix injections 
5/15/08- 1st Post-Op PSA 0.07 Undetectable
8/11/08 -2nd Post-OP PSA 0.02 Undetectable
8/15/08- No more pads as of today  Whoopee!!!
11/13/08- 3rd post-op PSA 0.02 Undetectable
03/02/09- 1 yr. post-op PSA .09 Undetectable
05/13/09   PSA .18 (ouch)
Started IMRT June 13, 2009
Completed 37 treatments July 31, 2009 (66.6gy)
11/23/09 Post IMRT PSA .18


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 24026
   Posted 2/7/2010 11:27 AM (GMT -6)   
Its easy to see why having a "Positive margin' makes us react often the way we do. And while stats on a piece of paper don't always translate the same confidence in person. When you see what one little positive margin did to me, to Sonny, and other men here, that basicially had instant recurrance, or at least in less than a year from surgery, it makes you wonder. But then we have other brothers with positive margins for years, where nothing bad happens. Wouldn't it be nice if even one aspect of PC could ever be consistent?

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 43 days, 1/10 - Corrective Surgery #4, and Caths #11 and #12 in at the same time


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 3666
   Posted 2/7/2010 2:21 PM (GMT -6)   
This is certainly good news for those with positive margins, I have alwas heard that about 50% of positive margins never progress and this provides some verification.
I also have a different take on the study. Many patients choose surgery because it will give a certainty to their treatment. Since there is a 23% progression with negative margins plus a current rate of 20% postive margins with surgery (of whiich 50% will never progress), certainty is an illusion.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 7649
   Posted 2/7/2010 2:48 PM (GMT -6)   
I hope I never gave anyone the impression that any treatment leads to any certainties. There are no certainties, but rather getting as much information as possible. Surgery can still give you that better than any other treatment option. Most who recommend or select RP are hoping to better know the extent of spread better than leaving the prostate and surrounding tissue inside unexamined. I believe that to be true.

But it's here nor there. This post is about positive margins and what they mean. Basically, don't despair, at least out of the operating room. Most positive margins are not going to spread enough to be life threatening. But if you have them with higher risk disease, or perhaps positive seminal vesicles, there is a lot more information to act on. Still some will await for a relapse that never happens. That's good news.

Tony
Prostate Cancer Forum Co-Moderator

Post Edited (TC-LasVegas) : 2/7/2010 12:51:09 PM (GMT-7)


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2603
   Posted 2/7/2010 5:54 PM (GMT -6)   
I still wrestle with the cause of positive margins.

I realize that most of it is dependent on the progression of our PC, but there also appears to be some ( or maybe a lot of) surgical skill involved.

I have seen men here who have some of the best surgeons have positive margins, and some with not so well known surgeons have negative margins.

From a mechanical perspective, it would seem if you saw an EPE, or area that appeared to be compromised, you could just cut a little wider. I also believe that is why DaVinci is advantageous becaus they are seing it at 10x magnification.

I am thankful for own case, which I feel would have had a positive margin with a different surgeon, but I could be way wrong. I'll still be thankful tho.

The study I posted on another thread said that positive margins could be the ouside cells of the cancer that were cut in the surgery, and the rest of the cell dies.

Who knows ? I just hope we can continue to develop techniques that all bit eliminates positive margins.
Goodlife
 
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injection
No pads, 1/1/10,  9 month PSA < .01

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