Positive Margins and Reoccurance Rates

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John T
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Date Joined Nov 2008
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   Posted 1/30/2010 2:47 PM (GMT -6)   
 new study from researchers at the University of Toronto has shown that post-prostatectomy surgical margin status appears to have prognostic significance for patients in intermediate- and high-risk groups, but not for low-rsik patients.

Alkhateeb et al. accumulated data from 1,268 patients who received a radical prostatectomy for clinically localized prostate cancer at their institution between 1992 and 2008, but who received no other form of neoadjuvant or adjuvant treatment. They then assessed the relationship of age, pretreatment prostate specific antigen, pathological T stage, radical prostatectomy Gleason score, disease risk group, and surgical margin status to biochemical progression-free survival.

The results of this study showed the following:

  • The overall rate of positive surgical margins (PSMs) was 20.8 percent.
  • Median follow-up was 79 months.
  • Biochemical progression-free survival (bPFS) rates varied by risk group:
    • For patients with low-risk disease, those with PSMs had a bPFS of 94.9 percent vs. 99.6 percent for those with negative margins.
    • For the intermediate-risk patients, patients with PSMs had a bPFS of 83.0 percent vs. 93.5 percent for the negative margin group.
    • For those with high-risk disease, patients with PSMs had a bPFS of  571. percent vs. 78.5 percent  for the negative margin group.

According to the authors, these differences were statistically significant in a multivariate model when adjustments were made to address the other clinicopathological features. They conclude that, “Positive surgical margins are an independent predictor of biochemical progression in patients with intermediate and high risk prostate cancer. Patients with low risk disease have a favorable long-term outcome regardless of margin status and may be candidates for expectant management even with positive surgical margins, sparing them the side effects and costs of treatment.”

These data would appear to be “logically consistent” with experience, in that lower risk patients may, in any case, have generally less aggressive disease. It is evident from the data above that patients in the intermediate- and high-risk groups are at significant risk for progression regardless of their post-surgical margin status, and this is already known from other clinical series.

JohnT


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


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 1/30/2010 4:07 PM (GMT -6)   
John, some interesting stuff, and yes, I noted too, that these findings are consistent with reality of even cases we have been exposed to here at HW. I am assuming that it is just a type where it says 571. percent, sure it meant to say 57.1 per cent in stead?

David in SC

Good article. With numbers going into PC and velocity issues, it didn't take anytime for my one and only positive margin to produce post surgery PSA, as with Sonny and a few others.
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 : 4227
   Posted 1/30/2010 4:44 PM (GMT -6)   
I think that what is worth noting is that 20% will have positive margins and even with positive margins the chance of progression is well under 50% even for intermediate, and only 57% in high risk cases. There is virtually little risk in low risk cases.
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


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 1/30/2010 5:00 PM (GMT -6)   
For those in the low risk group, there would have to be some real comfort there.
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


Tony Crispino
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Date Joined Dec 2006
Total Posts : 8128
   Posted 1/30/2010 5:20 PM (GMT -6)   
John,
This article is from the New Prostate Cancer Infolink. Can you please attribute to them when you copy their material and post it here? The author is a personal friend of mine and he does permit us to repost his material, but he feels it appropriate to attribute this to the source.

Thx.

Tony
Prostate Cancer Forum Co-Moderator


compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7205
   Posted 1/30/2010 6:31 PM (GMT -6)   
John:
 
I'm confused. I'm in the intermediate risk group.
Are you saying that even if I have positive margins, my chances of NOT  having a critical PSA rise (to over 0.2) is 83%?
 
That sounds pretty darn good. I assume you are talking about a 5-year window?
 
Mel
63 years old
PSA-- 3/08--2.90;  8/09--4.01; 11/09--4.19 (Free PSA 24%), this after 45 days on cipro! DREs have always been normal.  
History of BPH/prostatitis. PCA-3 test: 75.9 (bad news, guaranteeing I have to do....): Biopsy on 11/30/09. Result of biopsy:

5 out of 12 cores positive. Gleason 4+3. More specifically: 2 cores were 3+3 (one 5% and the other 30%) on one side. On the other side:2 cores are 4+3 (5%)--1 core 3+4 (30%) no peri-neural invasion. prostate is 45 grams. Stage: T1C

REVISED BIOPSY REPORT: The previous was read by Umich. Slides were then sent to Dr. Menon at Ford Hospital. Here is their report (much better) -- changes in bold print below:

5 out of 12 cores positive. Gleason 3+4. More specifically: 2 cores were 3+3 (one 5% and the other 20%) on one side. On the other side, 3 cores were 3+4 (5%, 5%, 20%)

 Surgery with Dr. Menon at Ford Hospital,  1/26/10. He says all looked good. Spared nerves. Awaiting pathology report, set for 2/2/10.

 


Ed C. (Old67)
Veteran Member


Date Joined Jan 2009
Total Posts : 2458
   Posted 1/30/2010 7:10 PM (GMT -6)   
Mel,
I think the article says the median was 79 months.
Age: 67 at Dx on 12/30/08
PSA 9/05 1.15; 8/06 1.45; 12/07 2.41; 8/08 3.9; 11/08 3.5 free PSA 11%
2 cores out of 12 were positive Gleason (4+4) and (4+5)
Negative CT scan and bone scan done on 1/16
Robotic surgery performed 2/9/09 Dr Fagin, Austin TX
Pathology report:
Prostate weighed 57 grams size:5.2 x 5.0 x 4.9 cm
Posterior lateral lesions measuring 1.5 x 1.4 x 1.0 cm showing focal capsular penetration over a distance of 3mm in circumference.
Prostatic adenocarciroma accounts for approx. 10-20% of the hemisphere.
Gleason 4+4
both nerve bundles removed,
pT3a Nx Mx, Negative margins
seminal vesicles clean, lymph nodes: not dissected
continent after 4 months
8 weeks PSA test 4/7/09 result <0.1
5 months PSA test 7/9/09 result <0.1
8 months PSA test 10/9/09 result <0.1
11.5 months test 1/21/10 result 0.004


tatt2man
Veteran Member


Date Joined Jan 2010
Total Posts : 2842
   Posted 1/30/2010 7:36 PM (GMT -6)   
hello
- I did an archive search here to no avail - and also googled on the internet - and found information but not clear in language -

question - what is the difference between - low risk - intermediate risk - and high risk - prostate cancer ?
Is it along the lines of PSA change - gleason level - post surgery grade level?

there was notation regarding slow growing and fast growing - but when dealing with positive margins - what dictates being part of the high risk group ( let alone low or intermediate) ?
My history ( see signature below) - Post Surgery Biopsy: pT3a- gleason 7 - extraprostatic extension - perineural invasion - prostate weight - 34.1gm - suggests a high risk group, especially with the doctor wanting to have surgery 3 weeks after biopsies.

Just putting things in order - today I did the main paperwork for Steve's and my taxes - just have to wait for remaining froms from work, etc - then off to H & R Block.

Thanks for listening.
hugs
BRONSON

P.S. I do enjoy the humour at this site - ( recent pork-viagra forum) helps lift the spirits

...
.................
Age: 54 - gay - with spouse, Steve - 59
PSA: 04/2007- 1.68 - 08/2009 - 3.46 - 10/2009 - 3.86
Confirmation of Prostate Cancer: October 16, 2009 - 6 of 12 cancerous samples , Gleason 7 (4+3)
Doctor: Dr. Mohamed Elharram -Urologist / Surgeon - Peterborough Regional Health Centre
Radical Prostatectomy Operation: November 18, 2009 , home - November 21, 2009
Post Surgery Biopsy: pT3a- gleason 7 - extraprostatic extension - perineural invasion - prostate weight - 34.1gm -
ED Prescription: Jan 8/2010 - started daily 5mg cialis
location: Peteborough, Ontario, Canada
............


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4227
   Posted 1/30/2010 8:11 PM (GMT -6)   

Bronson,

According to the PCRI:

Low risk: Gleason<7; % cores<34%; PSA<10; no nodule; recommend no immediated treatment.

Intermediate risk: Gleason 7; % cores 34-50%; PSA 10-20; small nodule. mono treatment.

High Risk: Gleason 7; % cores>50%; PSA>20; large nodule; PSA velocity>2.  Combination treatment.

If you have any high risk stat you are high risk. Some other organizations may have a slightly different difinition for risk catagories; most agree with these but do not agree with the treatment recommendations for the risk catagories.

Mel, I don't know how they define BPSF whether it is .2 or simply a stable low psa.

 


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


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 1/30/2010 9:15 PM (GMT -6)   
I guess the question remains, what is the gleason ? Unless we have surgery, we don't know what the Gleason is for sure, and don't know if it has gone outside the margin.

So for a guy with a biopsy of 6, what does he do ? Assume it is a 6, do the BT or Imrt, or proton , etc., and forget about it ?

What if it is really a 7 ? One of the posters the other day went from a 6 to an 8.

These statistics in my view can only be a comfort to those who really know what the Gleason is, which is the surgical guys. The non surgical guys only know what the biopsy(s) showed, what the biopsy needle hit, and can only guess on margins.

Sometimes I think my brain is too small, and this PC is too complicated for me to really understand all the statistcal stuff.

That is why I am just going to be surprised at the next event in my journey. I certainly can't predict it, and statistics can only give me odds.

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


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4227
   Posted 1/30/2010 10:00 PM (GMT -6)   
Goodlife,
Your're forgetting about color doppler. It is an excellent way to confirm or change an initial staging. Of course it's not 100% certain, but is certaintly a much safer way to get information than a radical surgery.
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


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 1/30/2010 10:18 PM (GMT -6)   
John,

I'm not forgetting about it, and I wholeheartedly agree. But can it definitively give me a gleason and organ confinement of 99 %.

There are so many dots to connect. It is hard to read one report such as one referenced here without having it connected to the complete picture.

For a guy in small town usa, there aren't as many dots. For a guy in New York, there are too many dots.

It is a complex, complex issue that we can't readily see all at once.

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


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4227
   Posted 1/31/2010 12:10 AM (GMT -6)   
Goodlife,
It is complex, but the time to find out that it is or is not organ confined is before you choose a treatment, not after. I think this is what many patients are missing in the decision process.

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 : 8128
   Posted 1/31/2010 12:21 AM (GMT -6)   
John,
That would be great if there was a sure fire way of doing so. Not even color doppler is that accurate that it can see all extra-prostatic extensions. You may be able to improve your chances of knowing with it, but the best way still is with a complete prostate pathology.

Tony
Prostate Cancer Forum Co-Moderator


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4227
   Posted 1/31/2010 11:49 AM (GMT -6)   
Tony,
I agree with you, but you are missing my point. A pathological staging is always more accurate than a clinical staging. But as the study above shows that 22% of high risk patients that had a negative margins still had a reoccurrance; this is not even close to being "the only sure way to know".
A good experienced doctor using partin tables, nomograms, biopsy data and scan data like color doppler and MRIS along with psa history and other tests such as PAP and PCA3 can arrive at a pretty accurate clinical staging.
The clinical staging lets you arrive at a reasonable decision on treatment options. You only have one option is you want a pathological staging. Clinical staging is not 100% accurrate, and as we have seen neither is pathological staging. For me a pathological staging comes with some pretty high costs with very little additional information or added success.
If the the clinical staging shows that the PC has escaped or is located in an inoperable location one can choose radiation and not undergo the rigors of surgery only to have to undergo radiation. If a margin is identified, radiation can be expanded to beyond the margin to effect a kill that surgery couldn't reach. Clinical staging can also indicate when it is appropriate to begin HT or when to radiate a lymphnode.
You felt the best way to get an idea of your situation was through an invasive procedure that gave you a pathological staging and it worked for you.
I felt the best for my situation was to go through many non invasive procedures to get the best clinical staging I could, before making a decision.
I'm not saying which is best, none is 100% perfect, but you have to make the choice that you feel most comfortable. I'm mearly trying to present another informed way to get information without going through a radical invasive procedure that could have serious side affects. To many patients this would be appealing.
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 : 8128
   Posted 1/31/2010 4:23 PM (GMT -6)   
I never stated any sure things. It could be appealing I agree. It wasn't appealing for me waiting to see if a relapse occurred as opposed to being proactive.

The numbers in the study are RP alone, and in many cases a patient has so much more information to decide if they want to add anything else to treat my disease. This as opposed to guessing a more aggressive approach is better suited for treatment. Again I only speak of intermediate and high risk cases. Low risk cases have a 99.6, or 4 men in 1000, of having to do any follow up therapy. The categories of intermediate and high risk have a better education of their disease than anyone in the clinical staging process can provide. For example:

I was high risk after RP. I knew the following (This data hasn't changed much and I used the MSK Nomograms) :
1> Without further treatment I ran a risk of 42.9% of bFRS, at age 44, by month 78 (6.6 Years)
2> With Adjuvant HT and RT I reduced my risk to less than 15% for bFRS at month 96.
3> If I had no positive margins, I would have had a 6.5% of bFRS, and I could have left the
SRT, and HT in the back pocket.

My point is only a complete pathology revealed that I was G4+3 with EPE and SVI High risk as opposed to G3+4 contained Intermediate risk. It is not known if any other clinical method would have determined these differences. I could have improved my chances of knowing with CDU, but it would not have been as clear a picture as the complete pathology and definitely not if I had chosen another modality. As for the SE's? I chose doctors wisely, and my youth may have worked well for me, and I have full functionality 3 years after RP. No ED drugs, no pads.

I think the stats above are quite useful.

Tony
Prostate Cancer Forum Co-Moderator


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 1/31/2010 4:45 PM (GMT -6)   
Keep in mind that you need extra-capsular extension to have positive margins unless the physician fails to remove the entire prostate. That does happen in extremely rare cases (1 in 15,000 or more). But the data after RP is extremely useful regardless of the treatment modality. In other words, anyone who chooses radiation can know that the uncertainty of disease progression will match the surgical pathology results and prediction rates. My point is that the more variant those predictive factors are, the more important it is to know for sure. I know many men who had prostatectomies that were found to be stage 4, either by lymphatic invasion, or by bladder or rectum invasion. There is no definitive outcome with these results. Ralph Valle, seen in the videos I just posted, was a stage 4 gleason 8 guy. He is doing great 17 years later. He was G6 at clinical staging. But he acted quickly after his RP and was able to do as well as he has, I believe, by taking the right actions after RP.

Tony
Prostate Cancer Forum Co-Moderator


compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7205
   Posted 1/31/2010 7:54 PM (GMT -6)   
John:
 
I asked:
>>>>>>>>>>>>>
I'm confused. I'm in the intermediate risk group.
Are you saying that even if I have positive margins, my chances of NOT  having a critical PSA rise (to over 0.2) is 83%?
>>>>>>>>>>>>>>>>>
IS THIS CORRECT?? It just doesn't sound right. I hope it is correct
 
Mel

63 years old
PSA-- 3/08--2.90;  8/09--4.01; 11/09--4.19 (Free PSA 24%), this after 45 days on cipro! DREs have always been normal.  
History of BPH/prostatitis. PCA-3 test: 75.9 (bad news, guaranteeing I have to do....): Biopsy on 11/30/09. Result of biopsy:

5 out of 12 cores positive. Gleason 4+3. More specifically: 2 cores were 3+3 (one 5% and the other 30%) on one side. On the other side:2 cores are 4+3 (5%)--1 core 3+4 (30%) no peri-neural invasion. prostate is 45 grams. Stage: T1C

REVISED BIOPSY REPORT: The previous was read by Umich. Slides were then sent to Dr. Menon at Ford Hospital. Here is their report (much better) -- changes in bold print below:

5 out of 12 cores positive. Gleason 3+4. More specifically: 2 cores were 3+3 (one 5% and the other 20%) on one side. On the other side, 3 cores were 3+4 (5%, 5%, 20%)

 Surgery with Dr. Menon at Ford Hospital,  1/26/10. He says all looked good. Spared nerves. Awaiting pathology report, set for 2/2/10.

 


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 1/31/2010 8:52 PM (GMT -6)   
Mel,
I'll answer that ~ yes...at least at a median month of 79. But please understand with caution, you don't know what group you are in until you get your pathology results from the surgery. I was G3+4=7 before surgery, and while 4+3=7 after surgery technically had me still in the intermediate group, the positive seminal vesicles changed that. I was now considered high risk. The study above is based on Post RP results.

Tony
Prostate Cancer Forum Co-Moderator


6071
Regular Member


Date Joined Jul 2008
Total Posts : 112
   Posted 2/1/2010 8:25 AM (GMT -6)   
Tony
hi
i think you can have positive margins without extracapsular extension
Age 61 at DX
Biopsy 7/2008 Positive 1 of 12 cores positive 3+4 5% To 10%
Open Radical Prostatectomy 15/10/2008
Stage pt2c
Post op staging Gleason's Score 3+4=7
apical margin is focally positive
no extraprostatic extension
Seminal vesicles and lymph nodes clear
Catheter out on the 13/11/2008
4 week PSA < 0.1
26/1/2009  < 0.1
20/4/2009 < 0.1
11/6/2009 ultra sensitive psa 0.07
20/7/2009 < 0.1
26/8/09 Starting photon 3D CRT
13/10/09 Radiation Finished
25/11/09 ultra sensitive psa < 0.05
 







Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 2/1/2010 8:53 AM (GMT -6)   
6071, I had a positive margin without any extra capsular extension, so I know you can.
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


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 2/1/2010 10:20 AM (GMT -6)   
I guess I have to rephrase that...

You both are correct. However, there is call to differentiate T2C classifications that have positive margins to be called T3a if the reason for a focal positive margin isn't prostatic incision during RP. Prostatic incision is where the surgeon cot so close to the prostate that they cut through some of the cancerous tissue and the prostate capsule. However, Jon Epstein has noted that not all positive margins are extra prostatic extensions. According to the article below, the designation of not declaring EPE is based on clinical significance, one focal frame as opposed to more than one. The attached article is from 2003, and is still in play today. But Epstein has in fact written that the reason that T2C cases designated with positive margins have an increased failure rate is that the focally positive margin is actually a small extension and it should be designated as such ~ Thus T3a ~ extra prostatic extension. David this is likely you seeing as how you went right to relapse..

However, I need to change the above statement to read that you can have a positive margin without EPE though I think I am technically correct. The physicians cut can be so close, perhaps too close to the prostate, that he can shave the cancerous tissue without it being designated as extension. I did reference that you can have a positive margin without extension above...

www.ncbi.nlm.nih.gov/pmc/articles/PMC1502366/

My apologies for the confusion. Perhaps one of the many reasons why I am not a doctor?

Tony
Prostate Cancer Forum Co-Moderator

Post Edited (TC-LasVegas) : 2/1/2010 9:29:42 AM (GMT-7)


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 2/1/2010 10:46 AM (GMT -6)   
Tony, I have believed all along that I am in a Stage III situation, not the Stage II as per my pathology report. My quick recurrance is one evidence of that I believe
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

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