positive focal margin after prostatectomy

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roville
New Member


Date Joined Oct 2010
Total Posts : 4
   Posted 10/25/2010 10:49 PM (GMT -6)   
I am looking for advice on whether or not to have salvage radiation after radical prostatectomy.
My surgeon says it is not necessary, but I have done my follow up with another urologist who thinks I should get radiation.
Here is the pathology report: gleason pattern 6. No seminal vesicle,venous,lymph involvement.
estimated tumor volume - 4.5cc
Pathologic stage:pT2b,pNX, PMX.
Surgical margins: Tumor focally present at right lateral/deep margin.

I had the surgeon contact the doc who did the path report to get more info on the size of the positive margin. He got back to me and said that the positive margin was less than 1mm.

My post surgery PSA has been undetectable 9 months out. The conservative urologist thinks I should get radiation anyway.

Is there anyone out there with a similar scenario? I am 54yo.

Roville

proscapt
Veteran Member


Date Joined Aug 2010
Total Posts : 644
   Posted 10/25/2010 11:51 PM (GMT -6)   
I can see the arguments both ways but I am definitely not an expert in this. You might want to put your numbers through the Sloan Kettering online nomogram and see what your odds look like, if knowing that would help.

www.mskcc.org/applications/nomograms/prostate/

Added clickable html

Post Edited By Moderator (James C.) : 10/26/2010 7:47:54 AM (GMT-6)


English Alf
Veteran Member


Date Joined Oct 2009
Total Posts : 2215
   Posted 10/26/2010 7:50 AM (GMT -6)   
"My post surgery PSA has been undetectable 9 months out."

I'd reckon that is what matters.

A rise in PSA is the usual reason to go for SRT. A positive margin, especially less than one mm is not as bad as it may sound.
What your "conservative" uro seems to be suggesting is some sort of delayed Adjuvant RT something that is neither one thing nor the other.
Did you have a very high PSA or a fast PSA doubling rate before surgery? or is there some other aspect of your history that makes the uro want to reconmend RT for you when with an undectable PSA you should to my mind just carry on monitoring your PSA.

Elsewhere on the forum there has been a discussion about what exactly positive margins are, and that was in the context of PSA that was not undetectable: see
www.healingwell.com/community/default.aspx?f=35&m=1932021&p=1

Welcome to the Forum by the way.

Alf
Born Jun ‘60
Apr 09 PSA 8.6
DRE neg
Biop 2 of 12 pos
Gleason 3+3
29 Jul 09 DaVinci AVL-NKI Amsterdam
6 Aug 09 Cath out
PostOp Gleason 3+4 Bladder neck & Left SVI -T3b
No perin’l No vasc invasion Clear margins
Dry at night
21 Sep 09 No pads daytime
17 Nov 09 PSA 0.1
17 Mar 10 PSA 0.4 sent to RT
13 Apr 10 CT
28 Apr 10 start RT 66Gy
11 Jun 10 end RT
Tired
BMs weird
14 Sep 10 PSA <0.1
Erections OK

daveshan
Regular Member


Date Joined Jan 2010
Total Posts : 363
   Posted 10/26/2010 8:02 AM (GMT -6)   
Roville,
I recently had the same discussion with my Dr's, at first I was heavily in favor of adjuvant radiation knowing I had a focally positive margin and a G-8 T3b path'. My uro wanted to wait 'till healing is as far along as it's going to go, the radiation oncologist (IMO) saw a Mercedes payment and flat out told me I was stupid for not doing it immediately.

My decision was wait and see, I go for my 3rd post op' results today, blood was drawn last Wed, so far I'm undetectable since surgery March-1, if I become detectable rad' will go back on the table. The potential side effects of radiation were the deciding point. The slight benefit of Adjuvant rad' over Salvage against the possibility of not needing it at all was also huge.

It's your decision, and I hope you can find one you're comfortable with.
Best of luck and continued 0.0X whatever you decide
Dave in Durango CO
Diagnosed 12-09 age 55
07-06 PSA 2.5
01-08 PSA 5.5 (PCP did not tell me of increase or schedule follow-up!!!!)
09-09 PSA 6.5 Sent for consult with Urologist
11-09 Consult, scheduled for biopsy, found out about PSA from '08 (yes I was pissed)
12-09 Biopsy, initial Gleason 9 (4+5) later reduced to 8 with tertiary 5, ain't much but I'll take it.
01-10 Bone Scan, "appears negative"
03-01-10 RRP in Durango CO by Dr Sejal Quale and Dr Shandra Wilson, no naked eye evidence of spread, Vesicles and lymph nodes taken for microscopic exam.

03-16-10 Removal of cath' and pathology results of samples.
Multifocal carcinoma with areas of Gleason pattern 3, 4 and 5, Overall Gleason grade 4+4 with tertiary 5, Bilateral involving 21% of left lobe, 3% of right lobe, Invasion of left Seminal vesicle, Tumor focally present at left resection margin, 9 lymph nodes removed all negative, Tumor staging pT3b NO MX

04-23-10 PSA <0.04....... 06-07-10 PSA <0.04..... 08-03-10 <0.04
05-03-10 1 week without pads
06-28-10 ;-)

roville
New Member


Date Joined Oct 2010
Total Posts : 4
   Posted 10/26/2010 8:43 AM (GMT -6)   
I tried to input my data into the Sloan-kettering nomogram, but could not enter my numbers.
Have you had success with using the nomogram for post prostatectomy?

Roville

daveshan
Regular Member


Date Joined Jan 2010
Total Posts : 363
   Posted 10/26/2010 8:53 AM (GMT -6)   
After you enter your numbers and hit calculate one would expect to be taken to a new page, I hit calculate several times before I looked in the upper right corner of the page, there is a "results" frame that changes to show the numbers.

lewvino
Regular Member


Date Joined Jul 2009
Total Posts : 384
   Posted 10/26/2010 9:13 AM (GMT -6)   
If you haven't all ready read Dr. Patrick Walsh's book Guide to surviving Prostate Cancer. He has several sections on Positive margins. I have a positive margin following my surgery Aug. 2009 and am monitoring PSA on a frequent basis. In fact just had the 14 1/2 month post surgery draw this morning and will now the result next week.
 
Of course its a personal decision to make with you, your loved ones and your Doctors input.
 
Larry
Age 55 / age at diagnosis 54, PSA 5.1
Robotic surgery 08/12/09 at Vanderbilt, Nashville TN.

Final Path report:

20% of the prostate Involved
Tumor graded at T2C
Overall Gleason 3+4 (7)
Lymph Glands Clear, Positive Margin Noted in Right Apex
First post Surgery PSA - 0
Six month PSA - 0
Ten month PSA - 0

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4225
   Posted 10/26/2010 9:25 AM (GMT -6)   
With a confirmed G6 and low psa you should wait, as the risk is low. Even if you did get a reoccurrance your chances of dieing from PC would be very rare even without futher treatment. If you were a G9 You should be doing radiation and HT immediately. You treat the disease you have, as all PC is not the same.
JT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7203
   Posted 10/26/2010 9:37 AM (GMT -6)   
I am in the same boat, with a worse pathology.
 
I am waiting, but it might not be for long as my PSA is rising.
 
Mel
PSA-- 3/08--2.90; 8/09--4.01; 11/09--4.19 (PSAf: 24%), PCA3 =75 .
Biopsy 11/30/09. Gleason 4+3. Stage: T1C. Current Age: 64
Surgery: Dr. Menon @Ford Hospital, 1/26/10.
Pathology Report: G 4+3. Nodes: Clear. PNI: yes. SVI: No. EPE: yes. Pos. Margin: Yes-- focal-- 1 spot .5mm. 100% continent by 3/10. ED- in progress. First post-op PSA on 3/10/10-: 0.01. PSA on 6/21/10--0.02. 9/21/10--0.06

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 10/26/2010 11:30 AM (GMT -6)   
Sometimes, the positive margin can be a false one. As the surgeon cuts through, he may have left an exposed area of the tumor, which would indicate a positive margin, but leave niothing on the other side, or have cauterized the area as part of the removal.

I would also wait if it were me. Tough call, but radiation isn't just a quick walk in the park either.
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
1 year psa (364 days) .01
15 month PSA <.01

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 10/26/2010 11:43 AM (GMT -6)   
goodlife said...
Sometimes, the positive margin can be a false one. As the surgeon cuts through, he may have left an exposed area of the tumor, which would indicate a positive margin, but leave niothing on the other side, or have cauterized the area as part of the removal.

Hi there, Goodlife!
 
I learned a new word last week — iatrogenic — which means an “inadvertent adverse effect or complication caused by or resulting from medical treatment.”  [I enjoy expanding my knowledge by re-using newly learned words in my own sentences so as to solidify my understanding of them.  I used to get a word-of-the-day daily in my email, but stopped it when I was overrun with emails of all varieity.]  The more specific term for the type of iatrogenic finding that you described is a "capsular incision."
 
The capsular incision positive surgical margin (which is caused by the surgeon's knife) may or may not have resulted in some cancer tumor being left behind, and when tumor is left behind by capsular incision it may or may not result in recurrent PSA failure (a.k.a. BCR).  So, not a "false" PSM, but one that may not cause BCR.
 
By the same token, a non-iatrogenic PSM may or may not result cancerous cells left behind which may or may not result in BCR.

Post Edited (Casey59) : 10/26/2010 12:00:09 PM (GMT-6)


daveshan
Regular Member


Date Joined Jan 2010
Total Posts : 363
   Posted 10/26/2010 12:10 PM (GMT -6)   
Roville,

Just came back from Uro's, another <0.04 and we talked more about Adjuvant vs. Salvage radiation. She setup another appt with the rad' oncologist's partner, as you may have guessed I did not like the first guy, I'll talk to him on the 3rd of November. Our decision as of now is to hit it if/as soon as it sticks its nasty nose into the detectable range, we've set a tentative target of 0.07 or higher.

Hitting it at 0.07 technically makes it Salvage but we're hoping that it's early enough to be most effective. I just can't bring myself to chance the possible side effects on a "probably".

Your path may be different, I wish you well whatever you choose.
Dave in Durango CO

tarhoosier
Regular Member


Date Joined Mar 2010
Total Posts : 486
   Posted 10/26/2010 12:50 PM (GMT -6)   
Ro:
I vote for watching and waiting. Your low G score, otherwise fine path results and small (1 mm) margin tell me that no further treatment is recommended at this time. If your undetectible is less than 0.01 (<.01) I am convinced you are good for the long haul.

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 10/26/2010 1:35 PM (GMT -6)   
Casey,

False positive margin is easier for my uneducated brain to visualize, but I will try to remember iatrigenic.

Heck, I am having trouble remembering my dog's name !

I think I have exceeeded my ability to absorb new words, or have to drop two off for every one I learn.
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
1 year psa (364 days) .01
15 month PSA <.01

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3741
   Posted 10/26/2010 9:01 PM (GMT -6)   
I agree with John T and the others..Your Gleason 6 and almost perfect pathology undetectable PSA all point to holding off on the radiation...I would watch that PSA very closely (every 60 days) for a while and as long as it was undetectable, I would not accept the side effects and complications that ART or SRT might entail..But the decision is yours..Doing it NOW is indeed the conservative approach, but I'm not sure the gain is worth the quality of life issues that are on the table..as always, JMHO..
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
age 61: 5.2
age 64: 7.5, DRE "Abnormal"
age 65: 8.5, " normal", biopsy, 12 core, negative...
age 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
age 67 4.5 DRE "normal"
age 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RRP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9

tarhoosier
Regular Member


Date Joined Mar 2010
Total Posts : 486
   Posted 10/27/2010 7:43 AM (GMT -6)   
Fairwind:
Doing radiation now for this man is not the conservative approach, it is the aggressive and risky approach, without evidence of recurrence.

Mark L.
New Member


Date Joined Oct 2010
Total Posts : 2
   Posted 10/27/2010 3:47 PM (GMT -6)   
Hi,
New to this web site. Just happened to stumble on to this discussion. I have prostate cancer and share some similar characteristics with you. Biopsy 10 cores, 1 with slight amount of cancer. PSA 4.0, Gleason 6. I decide to have surgery, robotic. Path report comes back bad. Positive surgical margin 6mm, T3b, Gleason (3+4)=7. Doctor says to watch PSA, if elevated RT. First year PSA less then .1. At about the one year mark it comes in equal to .1. We go for IMRT 68Gy, 38 sessions. One year later PSA is still undetectable.

In conclusion I watched for my PSA before I took action. I did have the Radiation Oncologist all lined up for this event. Hope this helps, it can be stressful.
I'm 56 and this all took place within the last year.

God Speed

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 10/27/2010 7:37 PM (GMT -6)   
Hey Mark,

Welcome to HW. Thanks for sharing your story.

You are a classic example of the inability of biopsy to tell us the whole story.
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
1 year psa (364 days) .01
15 month PSA <.01

roville
New Member


Date Joined Oct 2010
Total Posts : 4
   Posted 10/27/2010 10:41 PM (GMT -6)   
Thanks gentlemen for all your knowledge and support. I will have my one year PSA draw next week. Assuming it stays undetectable, I will just monitor PSA results, eat well, try and keep the stress level low, and thank the creator for the blessings I have everyday.

Roville
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