POSITIVE MARGIN OR ARTIFACT

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OMR
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Date Joined Jul 2013
Total Posts : 26
   Posted 7/16/2013 2:55 PM (GMT -6)   
I have questions about the meaning of these positive margins in particular . 1. APEX: Positive , focal , right side. What does focal mean with this margin ? 2. PERIPHERAL: Positive , right lateral toward apex in area of capsular incision. What does capsular incision mean with this margin ? Could this positive margin be an artifact ?

az4peaks
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Date Joined Feb 2011
Total Posts : 105
   Posted 7/16/2013 4:04 PM (GMT -6)   
Hi OMR, - "Focal" means that the specific positive margin is singular and appears in only that one spot. "In area of the capsular incision" further defines (narrows) the location of the positive margin being described, as does "toward the apex". "Capsular incision" simply means where the surgical "cut" went through (penetrated) the "capsule", the area immediately surrounding the Prostate itself.

Most Studies show a focal margin as often having less unfavorable impact on recurrence, than those that are "multi-focal" and penetrate in more than one location. So, if you have positive margins, it is better to have it be 'focal'. Hope this helps! - John@redacted (aka) az4peaks

John, email addresses should not appear in comment text. They are allowed in your profile. (There is a radio button to make it visible when you edit your profile.) -- PeterDisAbelard

Post Edited By Moderator (PeterDisAbelard.) : 7/17/2013 6:24:45 AM (GMT-6)


Casey59
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Date Joined Sep 2009
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   Posted 7/16/2013 4:17 PM (GMT -6)   

I’m about 95% confident in this answer…I hope that this does more good than harm…

Your second question first:  Capsular incision (CI) refers to the urologist transecting either benign or malignant prostatic tissue, where the edge of the prostate in this region is left within the patient.  In other words, the surgeon cut across the prostate itself during the procedure.

Was it iatrogenic?  Certainly it was inadvertent.  It happens...although more commonly in obese patients, or with inexperienced surgeons…all part of the learning curve.  The apex is the most common location for a  capsular incision because it is hardest to access.  Would you care to comment on either your BMI or your knowledge of your surgeon’s experience level performing RPs?  Perhaps it will difficult to get a clear picture of exactly what happened on the operating table at this point…although the surgeon will certainly have an answer for you when you ask him about it. 

If tumor was transected, it appears that that could have an unfavorable impact on outcome (see THIS report); but if benign tissue only was at the margin, it seems that the outcomes are less clear…but probably not so much of an issue.

I’m not sure what your question means, “Could this positive margin be an artifact?”

 

 

Your first question was what “focal” means.  A focal positive margin is a small area which “just touches the edge.”  The opposite of focal in this regard is “extensive” which covers a large area.

 

 

 

Post Edited (Casey59) : 7/16/2013 3:29:10 PM (GMT-6)


logoslidat
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Date Joined Sep 2009
Total Posts : 2676
   Posted 7/16/2013 4:36 PM (GMT -6)   
Az4peaks, I trust all is well with you. Yourself and Gallileo were extremely helpful to me in my early diagnosis. This was on another forum, the name escapes. Not to draw attention to you, but you are the most knowledgeable man I have encountered in my journey. I used to think of the old stockbroker commercial when you posted. When Az speaks, people listen. Hope I have not embarrassed you with my admiration and a response is not needed. Just wanted you to know.
44 mos post op <.1 Pathology 4+3 tertiary5 pni+organ confine 27nodes disected-svi margin- age 70

OMR
Regular Member


Date Joined Jul 2013
Total Posts : 26
   Posted 7/16/2013 5:18 PM (GMT -6)   
Great answers guys ! This probably explains my low but detectable psa ( .028 -.030 ) on the ultrasensitive psa test ! The capsular incision may have left a large or small amount of prostate tissue in me how much i don't know  hopefully it's benign ! I'm not as concerned about the focal margin as i am about the capsular incision !

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 24125
   Posted 7/16/2013 6:20 PM (GMT -6)   
Are you reading this information from your post-surgery pathology report, or the actual surgical notes? If you don't have a copy of the actual surgical notes, you should ask for a copy for your records. Mine told me all kinds of things about the complications in my open surgery that I wouldn't have known otherwise.

Good luck,

David
Age: 60, 56 at PC dx, PSA 16.3
3rd Biopsy: 9/8 7 of 7 Positive, 40-90%, 4+3
Open RP: 11/8, Catheter in 63 days
Path Rpt: 3+4, pT2c, 42g, 20% tumor, 1 pos margin
Incontinence & ED: None
Surgery Failed, recurrence within 9 months
Salvage Radiation 10/9-11/9, SRT failed within 9 months, PSA: Too High
Spent total of 1 ½ years on 21 catheters, Ileal Conduit Surgery 9/10,
7 other PC-related surgeries 2009-2012

OMR
Regular Member


Date Joined Jul 2013
Total Posts : 26
   Posted 7/16/2013 6:32 PM (GMT -6)   
Yes this is from my post surgery pathology report !

njs
Regular Member


Date Joined Jun 2013
Total Posts : 280
   Posted 7/16/2013 11:12 PM (GMT -6)   
OMR, what is the p-stage shown on the report? pT2 or pT3? If pT2, both PSMs are iatrogenic.

As Casey59 indicated, there are patient risk factors that can make PSMs more likely and the surgeon's skill and experience also play a large part.

As to your question about artifact, if you mean could it be a false-positive, yes that can happen. It is more likely to happen at the apex and can be affected by the surgical pathology protocol employed (e.g. shave margin vs perpendicular margin) at the apex.

The following papers provide more insights on nature and implications of PSMs:

http://www.ncbi.nlm.nih.gov/pubmed/17698141
http://www.archivesofpathology.org/doi/pdf/10.1043/1543-2165-133.10.1568
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3200270/pdf/PC2011-673021.pdf
Jan '13: PSA 1.23, small nodule on DRE (1st screening @ age 40)
Mar '13: Biopsy 2 of 12 cores GS 3+3: rt mid 10% and rt apex 20% w/ PNI+ Stage cT2a
Apr '13: Biopsy confirmed by Dr. Epstein @ Hopkins
May '13: open RRP by Dr. Burnett @ Hopkins. Both nerves spared.
Final Path: GS 3+3, organ confined (tumor extent moderate), SV and 11 nodes all negative (pT2a), negative margins!
PSA: 0.01 @ 6 wks

OMR
Regular Member


Date Joined Jul 2013
Total Posts : 26
   Posted 7/17/2013 8:11 AM (GMT -6)   
My p-stage is pT2c . So are you saying this was caused by the inexperience of the surgeon and not aggressive disease ?

Casey59
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Date Joined Sep 2009
Total Posts : 3172
   Posted 7/17/2013 8:28 AM (GMT -6)   
No.
 
What I said was:
 
Capsular incision (CI) refers to the urologist transecting either benign or malignant prostatic tissue, where the edge of the prostate in this region is left within the patient.  In other words, the surgeon cut across the prostate itself during the procedure.
 

Was it iatrogenic?  Certainly it was inadvertent.  It happens...although more commonly in obese patients, or with inexperienced surgeons…all part of the learning curve. 

 

Just because it happens more frequently with inexperienced surgeons does not mean it does not also happen with experienced surgeons, too.  What is your surgeon's experience level with the type of RP that you had...?  You probably asked him this question before surgery.  (Have you read the posting about the surgery "learning curve" in the thread titled "Newly diagnosed with PC? - read this thread first"?

 

It does not appear that the positive margin due to CI was due to aggressive disease.  What's probably more relevant at this point (besides the other positive margin) is whether the CI cut through tumor or benign tissue.  I can't tell from what was posted.  Might be one of the many good questions to ask...

 

 

added later in an edit:   BTW, pT2c is a good thing, and about the most common staging.  Although there were positive surgical margins, the tumor does not appear to have extended beyond the prostate.  That's a good thing!

 

 

 

 


I am an advocate for improved care for ALL men with PC.
-----------------------
Posts worth reading:
Newly diagnosed with PC? – read this thread first
Prostate Cancer “Quote-of-the-Day”
NYT essay: “'Cancer' or 'Weird Cells': Which Sounds Deadlier?”

Post Edited (Casey59) : 7/17/2013 7:54:21 AM (GMT-6)


OMR
Regular Member


Date Joined Jul 2013
Total Posts : 26
   Posted 7/17/2013 8:52 AM (GMT -6)   
Well im not obese 5'5 144 pounds pretty small guy ! Because of these adverse findings on my path report i now understand why the surgeon seems to be rushing me off to secondary treatment ( radiation ) eventhough my psa is low ( 0.028 - 0.030 ) and stable almost a year after surgery ! I still do not want to have secondary treatment until it's evident that im approaching BCR and i pray that is never !

Casey59
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Date Joined Sep 2009
Total Posts : 3172
   Posted 7/17/2013 8:55 AM (GMT -6)   
see my added comment above about pT2c...we are posting at about the same time...

OMR
Regular Member


Date Joined Jul 2013
Total Posts : 26
   Posted 7/17/2013 8:58 AM (GMT -6)   
I know you are not a doctor but since my psa is low and there is now evidence of increase do you think it's ok to put off secondary treatment until there is evidence of BCR ?

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 7/17/2013 8:58 AM (GMT -6)   
Your PSA is under 0.1 a year after surgery and stable, and your surgeon is talking aobut SRT...I don't understand...!
I am an advocate for improved care for ALL men with PC.
-----------------------
Posts worth reading:
Newly diagnosed with PC? – read this thread first
Prostate Cancer “Quote-of-the-Day”
NYT essay: “'Cancer' or 'Weird Cells': Which Sounds Deadlier?”

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 7/17/2013 8:59 AM (GMT -6)   
What's your PSA history?
I am an advocate for improved care for ALL men with PC.
-----------------------
Posts worth reading:
Newly diagnosed with PC? – read this thread first
Prostate Cancer “Quote-of-the-Day”
NYT essay: “'Cancer' or 'Weird Cells': Which Sounds Deadlier?”

OMR
Regular Member


Date Joined Jul 2013
Total Posts : 26
   Posted 7/17/2013 9:10 AM (GMT -6)   
Yes my pre surgery psa was 4.9 ! All of my post surgery psa has been undetectable <0.05 twice by standard psa test same lab and detectable 0.028 - 0.030 ultrasensitive psa test different labs ! Yes he is suggesting I have radiation because of the detectable psa results eventhough it is fairly low !

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 7/17/2013 9:20 AM (GMT -6)   
As you said, I'm not a doctor...but I am a savvy PC layperson.  That reminder is important.
 
Note that 0.030 is also less than 0.05 (<0.05)...so this absolutely does not indicate any movement.  It simply indicates a change in the lower threshold of the test.
 
First thing is to triple check that you've got the decimal point in the right location...this is an error which happens more frequently that you might want to think.  You could call the surgeon's office and ask the nurse to read it to you if you don't already have it in writing yourself...make sure the nurse read it out two different ways to get it right.
 
Second, be aware that there is absolutely no such thing as "zero PSA."  The "zero PSA club" is a misnomer which sometimes causes undue anxiety amongst HW/PC members because their PSA is reported as something other than "<0.xxx", or "undetectable."  After surgery, and especially nerve sparing surgery, some tissue is left behind which can throw off measurable amounts of PSA. 
 
You have pT2c, an extremely low level of PSA one year after surgery (and no indication at this point of any increase).  I'm a bit flabergasted as to why your surgeon is talking about secondary radiation despite your PSMs. 
 
 
 
 

OMR
Regular Member


Date Joined Jul 2013
Total Posts : 26
   Posted 7/17/2013 9:28 AM (GMT -6)   
Yes i have the decimals in the correct place and copies of the results . I did have nerve sparing surgery . The surgeon started talking radiation after the first detectable psa result of 0.028 and then I did a retest 2 months later and it came back at 0.030 he seems to be concerned about the positive margins but I told him I don't want to be overtreated and may not never need secondary treatment !

A Yooper
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Date Joined Jul 2012
Total Posts : 1594
   Posted 7/17/2013 9:34 AM (GMT -6)   
OMR, I've been following your thread for some time now, and wanted to weigh in again.  Casey has been providing good information, I'll simply try to add to that.
 
First and foremost BE SURE that your decimal place is correct, meaning that your recent PSA results really were 0.028 and 0.030.  If that is correct, you do not have biochemical recurrence.  I too am not a doctor, but from everything I've read those PSA values at this point in your journey are not a concern.
 
To help out I found this table on the Harvard Medical School / Harvard Health Publications website:
 

Table 2: Guidelines for determining biochemical recurrence

Initial therapyPSA thresholdComments
Radical prostatectomy0.2 ng/ml on at least two successive testsSome physicians continue to use a higher threshold of 0.4 ng/ml or greater
Radiation therapy (external beam or brachytherapy)Three successive elevations in PSA compared to nadir (low point), regardless of actual reading, according to the American Society for Therapeutic Radiology and OncologyMany oncologists use a working definition that biochemical recurrence has occurred if PSA levels are greater than 1–2 ng/ml 12 to 18 months following initial treatment.

Ideally, post-treatment PSA levels should be less than 0.5 ng/ml, but this is rare; levels of 0.6–1.4 ng/ml may occur.

Neoadjuvant hormone therapy and radiation therapyUnknown
 
 
Hope this helps. . . .
 
56 yrs old, excellent health - DX'd with PCa July '12
PSA 5.8
Biopsy 6/27/12
9 of 12 Gleason: 3+3 and 3+4 (All neg PNI)
Negative DRE’s / NO / MO / T1C / Gland size 40gm / Vol. 22gm
Volume Study 8/14/12
Casodex 50mg daily 5 wks prior 2 wks post BT
LDR BT 9/21/12 – no issues
3 mo PSA 12/20 0.48!
6 mo PSA 3/14 0.21!
9 mo PSA 6/18/13 0.30!

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 7/17/2013 9:42 AM (GMT -6)   
The difference between 0.028 and 0.030 is miniscule.  That difference is probably far less than the sums of the sources of test & source variation...far less. 
 
And, it is a long way from AUA's defined threshold of biochemical recurrence...which I posted to your in a seperate thread.  That definition was, of course, created exactly for men in your situation.
 
Let's see if this shows up:
 
        0.20 0.19 0.18 0.17 0.16 0.15 0.14 0.13 0.12 0.11 0.1 0.09 0.08 0.07 0.06 0.05 0.04 0.03 0.02 0.01
  I----I----I----I----I----I----I----I----I----I----I----I----I----I----I----I----I----I----I----I----I----I
    ^  ^                                                                                                                     ^ ^
BCR is 2 measurements                                                                                             you are here
above 0.20
 
 
You have already had surgery.  You know of the issues you have already had.  Secondary radiation will be more difficult.  If there are signs you need it, I wouldn't hesitate because it can absolutely be curative...but there will be consequences.
 
Have a frank talk about these numbers with your surgeon.  I'm not seeing signs that SRT (salvage radiation therapy) is needed.
 
Something seems to be amiss in why he is suggesting it...

OMR
Regular Member


Date Joined Jul 2013
Total Posts : 26
   Posted 7/17/2013 9:44 AM (GMT -6)   
Again the decimals are in the correct place , I have copies of the results and have talked to the surgeon about the results . It makes me feel as if he know he hasn't done something right to want and rush me into secondary treatment this soon when there is no evidence AT ALL of any increase ! I hate to think that way but it's just the way i feel !

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 7/17/2013 9:49 AM (GMT -6)   
What information did you gather about your surgeon's experience level?  Or, what's your preception, if you didn't gather info?
 
With what I know about your case, I would do nothing without a second opinion from someone very experienced in treating PC.

A Yooper
Veteran Member


Date Joined Jul 2012
Total Posts : 1594
   Posted 7/17/2013 9:53 AM (GMT -6)   
Probably because of the simple fact that I don't personally know you OMR, I have to say that I'm having a hard time understanding your concerns here - at least based on the facts of your PSA results. The numbers are what they are, and we've given you a ton of information that supports your PSA readings are not evidence of BCR.

At this point the only other thing I would suggest is that you find a new urologist and get another opinion from the medical world - to add what we have tried to support you with.
56 yrs old, excellent health - DX'd with PCa July '12
PSA 5.8
Biopsy 6/27/12
9 of 12 Gleason: 3+3 and 3+4 (All neg PNI)
Negative DRE’s / NO / MO / T1C / Gland size 40gm / Vol. 22gm
Volume Study 8/14/12
Casodex 50mg daily 5 wks prior 2 wks post BT
LDR BT 9/21/12 – no issues
3 mo PSA 12/20 0.48!
6 mo PSA 3/14 0.21!
9 mo PSA 6/18/13 0.30!

OMR
Regular Member


Date Joined Jul 2013
Total Posts : 26
   Posted 7/17/2013 9:58 AM (GMT -6)   
To be honest I didn't do a lot of in depth research ( big mistake ) on my surgeon but I did aske a few people who were either treated by him or has worked with him . Do you think he is just being overly cautious ?

OMR
Regular Member


Date Joined Jul 2013
Total Posts : 26
   Posted 7/17/2013 10:03 AM (GMT -6)   
@ Yooper , I already knew and understand the numbers when it comes to BCR and trust me i really appreciate all of you guys reminding me , it's just that i wanted to get another point of view as to why the surgeon would be talking secondary treatment now when clearly 0.028 eventhough detectable and 0.030 are both less than 0.05 NO EVIDENCE OF INCREASE AT ALL !Am I missing something ?
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