EPE and Negative Margins

New Topic Post Reply Printable Version
[ << Previous Thread | Next Thread >> ]

axle
Regular Member


Date Joined Feb 2011
Total Posts : 35
   Posted 4/27/2011 11:07 AM (GMT -6)   
The recent posts and discussions regarding those that should consider ART and those that will benefit most from ART are very interesting and informative.  Of course I am reading them with interest because I am a pT3b.  Thank you very much for that discussion.
 
Basically, I am having a difficult time understanding how one can have both negative margins and EPE.  It seems to me that if one has EPE, in my case to the right bladder neck, and clear margins of resection then the EPE is irrelevant.
 
Therefore why would a guy with clear margins still be at increased risk of BCR if he has EPE?  It seems the research indicates increased risk of BCR with EPE even with negative margins.
 
Also, during my surgery, the Uro/surgeon cut a urethra sample and a bladder neck sample for post-OP biopsy to make sure that the margins of resection were clear.  In my case they were both benign.
Age 58 @ DX; da Vinci on 1/26/2011
PSA History: 10/2005 = 1.7; 10/2007 = 2.8; 10/2009 = 3.6; 10/2010 = 4.9
Abnormal DRE in 2009; Increasingly abnormal DRE in 2010
Thank you POPs!
Biopsy 11/2010: GS = 3+4; 5 of 12 cores pos @ 40%
Post-OP pathology: GS=3+4; tumor = 35%; pT3b; SVI+; EPE+ R. bladder neck; margins neg.
Post-OP PSA 4/13/11 = <0.1

142
Forum Moderator


Date Joined Jan 2010
Total Posts : 7082
   Posted 4/27/2011 11:32 AM (GMT -6)   
I can't directly answer your question, but I also had EPE. Difference being that I also had positive margins, even after the surgeon cut wider than usual.
 
My surgeon also considered them as two unique factors in our discussions. I guess a rough translation would be that once the capsule is broken there would be more avenues for the cancer to get out into your system.
 
DaVinci 10/2009
My adjuvant IGRT journey (2010) -
www.healingwell.com/community/default.aspx?f=35&m=1756808

Newporter
Regular Member


Date Joined Sep 2010
Total Posts : 225
   Posted 4/27/2011 11:46 AM (GMT -6)   
I am just speculating:

EPE means the cancer had grown beyond the prostate capsule. However, in your case, your surgeon was able to cut beyond the capsule and cancer so that the specimen "wall" did not have cancer therefore a "negative margin". He was extra careful and took out some urethra and bladder samples to make sure they are clear of cancer. Looks like you selected an excellent surgeon. As for ART, as a Gleason 3+4, I don't think you need it but you might discuss with a radiation oncologist to see if that is relevant in your case.

As for BCR statistics, we are all different and it is what it is. My new attitude after surgery: I am now appreciating and enjoying every new day.
65 Dx June-2010 PSA: 10.7, biopsy: Adenocarcinoma, 1 core Gleason 6, 3 cores atypia; Clinical stage T2; CT, Bone Scan, MRI all negative

8-23-10 Robotic RP; Pathology: Organ confined, negative margins, Lymph nodes, Seminal Vesicle clear; PNI present; multiple Adenocarcinoma sites Gleason 3+3 with tertiary Gleason 4+. Stage: pT2,N0,Mx,R0

Catheter out 8-30-10 no incontinence, no ED. 3/2011 PSA: <.1

Kark60
Regular Member


Date Joined Jun 2008
Total Posts : 91
   Posted 4/27/2011 1:19 PM (GMT -6)   
I had EPE and negative margins; however, I also had BCR begin just around two years after surgery (see signature below). I don't know if some of the small stuff was missed during surgery then began to grow again, if "bad cells" were "dropped" back into the surgical field during removal, or if I had micro-mets that took some time to grow.

At the follow-up with the surgeon, he told me that about 30% of patients with "my profile" will have BCR (the profile includes EPE and negative margins).

I was told by one RO that my prognosis after BCR is "worse" with negative margins than positive margins. I completed SRT in February and have my first post-SRT PSA in mid-May.

I realize I'm not providing good answers here, just telling my experience with this situation...
Diagnosed at 47 (currently 50). Pre-surgery PSA: 13.7 Pre-surgery Gleason: 4+3=7. CT Scan, Bone Scan, PET Scan: Clear. LRP 5/28/08. Left nerve bundle removed. POST-SURGERY: Gleason: 4+3=7; 10% of prostate all quadrants involved; EPE left base & apex; extensive PNI present. Bladder neck, lymphvasular space, seminal vesicles, 17 examined lymph nodes, and all surgical margins FREE of tumor. T3a. Four-week post-surgical PSA = 0.1; Seven-week = .01; 10/08 – 4/10 PSA= 0.0; 4/10=0.1; 5/10 & 8/10 = 0.1; 9/10=.15; Prostiscint = negative; 12/10=0.3. 12/15/10 began 70.2 grays SRT and finished 2/10/11.

BillyMac
Veteran Member


Date Joined Feb 2008
Total Posts : 1858
   Posted 4/27/2011 6:54 PM (GMT -6)   
It is my understanding that EPE (extra prostatic extension) means that the tumour was outside (usually focally) of the prostate capsule. The capsule is slightly fibrous but quite thin (think of a plum rather than an orange). When removed it is usual to take the prostate and some surrounding tissue. The outside of that extra tissue is the surgical resection margin. It is therefore quite easy to have an EPE but clear surgical margins. I suppose this could be one of the drawbacks of robotic surgery. With no sense of feel as to the thickness of the tissue between the prostate and the bowel wall I would assume just how much of a margin the doc can take is an educated guess on his part. Too much and he's perforated the bowel (occasionally happens) ----- too little and the small amount of tissue taken may put what should have been a negative surgical margin at risk.

BillyMac
Veteran Member


Date Joined Feb 2008
Total Posts : 1858
   Posted 4/27/2011 7:03 PM (GMT -6)   
And just pure speculation on my part but I wonder how much of failed surgery (in the sense of eliminating the tumour) can be attributed to nerve saving surgery. Spread via the nerve pathways is well understood. The nerves that control erection are attached to the prostate surface and are peeled away delicately during surgery. But the nerves within the gland (which are removed) controlling contraction of the gland and the emission of semen you would think were somewhat interconnected with the erection nerves. It may well be that in a lot of cases of unexpected BCR the tumour may well have escaped into that erection controlling nerve system from the gland's internal nerve pathways.
Bill

reachout
Veteran Member


Date Joined May 2009
Total Posts : 739
   Posted 4/27/2011 7:05 PM (GMT -6)   
I had a more puzzling situation. EPE but negative extracapsular extension and negative margins. So maybe some cells were outside the prostate in an area where there wasn't a capsule. I guess the surgeon took out enough around the prostate that the sample contained the EPE cells, because the margins were clear.
Age: 66
PSA: 7 tests over 2 years bounced around from 2.6 to 5.6
Biopsy 8 of 12 positive, Gleason 3+4, T2a
DaVinci August 2009, pathology Gleason 4+3, neg margins, T2c
Continent right away, ED
Viagra, Cialis did't work, Trimix works well
Post-surgery PSA:
3, month: undetectable <.1; 6 month: undetectable <.014 (ultrasensitive); 9, 12, 15 month: undetectable <.1; 18 month detectable .05

BillyMac
Veteran Member


Date Joined Feb 2008
Total Posts : 1858
   Posted 4/27/2011 8:26 PM (GMT -6)   
Reach, that is an interesting one. It doesn't seem to make sense to say you had an extra prostatic extension but a negative extra capsular extension rolleyes

logoslidat
Veteran Member


Date Joined Sep 2009
Total Posts : 6069
   Posted 4/28/2011 2:36 AM (GMT -6)   
billymac, your 303 pm post, I believe is inaccurate, and know it was speculation as you stated. My understanding is that the erectile nerves are , as you say outside the prostate, but do have to be "teased away" { my surgeons description } from prostate. The nerves inside the prostate, the PNI spaces that Walsh talks about.\, are in no way connected to the erectile nerves. They would get involved if there was epe in that vicinity, as they would be the path of least resistance, ie the microscopic spaces around the nerves. I am sure about the differentiation of erctile nerves vs internal prostatic nerves, but frankly am not sure how the whole spread thing works out side the prostate/ margins. I/m not a doctor , but do play one on TV, lol
Diagnosed 8/14/09 psa 8.1 66,now 67
2cores 70%, rest 6-7 < 5%
gleason 3+ 3, up to 3+4 @ the dub
RPP U of Wash, Bruce Dalkin,
pathology 4+3, tertiary5, 2 foci
extensive pni, prostate confined,27 nodes removed -, svi - margins -
99%continent@ cath removal. 1% incont@gaspass,sneeze,cough 18 mos, squirt @ running. psa std test reported on paper as 0.0 as of 12/14/10 ed improving

logoslidat
Veteran Member


Date Joined Sep 2009
Total Posts : 6069
   Posted 4/28/2011 2:40 AM (GMT -6)   
" they would get involved if there was epe in that vicinity.... " the erectile nerves, that is.
Diagnosed 8/14/09 psa 8.1 66,now 67
2cores 70%, rest 6-7 < 5%
gleason 3+ 3, up to 3+4 @ the dub
RPP U of Wash, Bruce Dalkin,
pathology 4+3, tertiary5, 2 foci
extensive pni, prostate confined,27 nodes removed -, svi - margins -
99%continent@ cath removal. 1% incont@gaspass,sneeze,cough 18 mos, squirt @ running. psa std test reported on paper as 0.0 as of 12/14/10 ed improving

BillyMac
Veteran Member


Date Joined Feb 2008
Total Posts : 1858
   Posted 4/28/2011 6:06 AM (GMT -6)   
Logo,
I was thinking along the lines that at some stage the various nerve pathways are within bundles. Various bundles of nerves which transmit feeling and control are contained within your spinal cord and from there connect to your brain stem. At various stages down your spinal column they branch out through openings in the vertebrae and on to the various organs and muscles. At some stage you would think that the nerves relating to overall sexual function would be within the same sheaf till they branch out to their separate destinations. Then again perhaps the separate nerve pathways are contained within their own sheaf. But like I said, pure speculation on my part.
Bill

Sephie
Veteran Member


Date Joined Jun 2008
Total Posts : 1804
   Posted 4/28/2011 6:15 AM (GMT -6)   
In my husband's case, the urologist knew from the biopsy that one of the positive samples taken was very close to the posterior edge. He planned his "approach" for the surgery and cut a wider than necessary margin around that area which resulted in negative surgical margins with a single minute focus of EPE. Husband is now 3 years post op, staged a T3a, and continues to pull zeros on his PSA.
Husband diagnosed in 2/2008 at age 57 with stage T1c. Robotic surgery performed 3/2008. Stage upgraded to T3a (solitary focus of posterior extraprostatic extension). Perineural tumor infiltration present. Apex margin, bladder neck and SVs negative. Final Gleason 3+4. PSA 0.0 thru July 2009. August 2009 - 0.1, September 0.3, October 0.0. Last PSA in April 2011: 0.02

reachout
Veteran Member


Date Joined May 2009
Total Posts : 739
   Posted 4/28/2011 7:36 AM (GMT -6)   
Billie Mac, the only way I can explain negative margins, negative extracapsular extension but EPE is as follows. I understand there is a part of the prostate that has little or no capsule. Maybe the pathologist found some cells just outside the prostate in that area but within the surgical margin, but the part of the prostate with the capsule was intact.

The EPE part is in the fine print detail of the pathology report. The last page has a summary and EPE is not even listed, only extracapsular is listed, and shows negative.

I asked my surgeon what that meant and he didn't know. He told me to not worry about it, the only thing that mattered now was the PSA. Since my PSA had been <.1 (and still is), I put it out of my mind until now. With an ultrsensitive .05 now I'm really wondering what's going on.

I'm seeing an oncologist in a couple of weeks and will ask them to look into it. Maybe they would like to review the slides. I don't really have direct access to the pathologist myself, but I'm sure they can get whatever they need.
Age: 66
PSA: 7 tests over 2 years bounced around from 2.6 to 5.6
Biopsy 8 of 12 positive, Gleason 3+4, T2a
DaVinci August 2009, pathology Gleason 4+3, neg margins, T2c
Continent right away, ED
Viagra, Cialis did't work, Trimix works well
Post-surgery PSA:
3, month: undetectable <.1; 6 month: undetectable <.014 (ultrasensitive); 9, 12, 15 month: undetectable <.1; 18 month detectable .05

AJ 47 (Maryland)
Regular Member


Date Joined Aug 2010
Total Posts : 64
   Posted 4/28/2011 7:48 AM (GMT -6)   
Here's what Walsh writes in his book that may help to answer your question (Page 366 of 2nd ed.:
 
"What are Surgical Margins Anyway?
 
This is a confusing point for many men.  When the prostate is removed, it should be covered by several layers of tissue.  It may help to think of the cancerous prostate as a gift in a box . . . and the tissue surrounding it as wrapping paper.  After RP, your prostate goes to the pathologist, who immediately coats the outside of the entire specimen--outlining the wrapping paper--with India Ink.  . . . .  If the cancer is all contained within the box, we call it organ-confined.  Even if the cancer penetrates the box (this is capsular penetration), it can still be completely covered with wrapping paper.  We call this specimen-confined.  In both cases, the men are considered margin-negative.  If the cancer has penetrated the box and the wrapping paper as well, this is called a positive surgical margin.  the pathologist can see cancer cells at the edge of the India ink, and this suggests that there may be cancer beyond the outermost edge, where the surgeon removed the prostate.  In chapter 8, we talked about men who had positive margins with organ-confined disease.  How does this happen?  Imagine, to continue our box image, that the package has been damaged; there is a tear in the wrapping paper and the box.  Some of the bx may even be missing.  This is how a man can have a positive margin even if his cancer is still confined inside the prostate."
PSA 1.5 to 3.2 in 11 months. First 12 core biopsy on 2/10 negative in 11, atypical in 1. Second 13 core biopsy on 5/10 at Hopkins positive in 2 with Gleason 3+3 (focal). Robotic "Super VIP" Mani Menon 8/10. Postop G 3+4 (70%/30%). Focal ECE right posteriolateral mid. Neg. margins, lymphs, SV. Post op PSAs 9/14 <.1; 1/11 <.1; 4/11 <.1.

Ed C. (Old67)
Veteran Member


Date Joined Jan 2009
Total Posts : 2460
   Posted 4/28/2011 12:11 PM (GMT -6)   
I had EPE and negative surgical margins. My pathology report showed that cancer was found 1.5 mm outside the prostate but my doctor took tissues up to 5 mm beyond the prostate capsule thus the negative margin. He also took out both nerve bundles. So far my PSA has been <.005 after 27 months. I have always wondered if removing the nerve bundles has improved my chances despite my Gleason 8.
Age: 67 at Dx on 12/30/08 PSA 3.8
2 cores out of 12 were positive Gleason (4+4)
Davinci surgery 2/9/09 Gleason 4+4 EPE,
Margins clear, nerve bundles removed
Prostate weighed 57 grams 10-20% involved
all PSA tests since (2, 5, 8, 11, 15, 18, 21, 2 years <.008? ) undetectable
27 months: .005

BillyMac
Veteran Member


Date Joined Feb 2008
Total Posts : 1858
   Posted 4/28/2011 6:11 PM (GMT -6)   
Ed,
That is along the lines that I was thinking. My doc said his surgery was nerve sparing but he would not be sure till he got there. Turns out my then 4+3 (75% was 4 going in and was upgraded to 4+4 post surgery) was very extensive on both sides but within the gland. He made a decision, given the extent, that sparing the nerves entailed an unacceptable risk, so he took a wide margin. Surgical resection margin was negative, although at one point the margin was "disrupted" as in AJ's post. 3-1/2 years now of <0.01. It always makes me wonder "what if" if he was determined to spare the nerves.

BillyMac
Veteran Member


Date Joined Feb 2008
Total Posts : 1858
   Posted 4/28/2011 6:18 PM (GMT -6)   
Reach,
I had my post surgery slides looked by a different pathologist about six months after surgery while looking at whether to have extra treatment. The first post surgery pathologist upped my biopsy Gleason 4+3 to 4+4. The second pathology downgraded it again to the original 4+3 but what I did like was they specified the grade of the cells in the region of the EPE. If yours are looked at again it might be worthwhile asking them to note the cell grade in the region of your EPE.
Bill

reachout
Veteran Member


Date Joined May 2009
Total Posts : 739
   Posted 4/28/2011 6:31 PM (GMT -6)   
I have a dumb question. When the PSA starts going up after surgery, the standard is SRT. But what if the nerves were spared and/or lymph nodes were not removed? Why couldn't the surgeon go back in and remove all that hoping to get cells left behind?
Age: 66
PSA: 7 tests over 2 years bounced around from 2.6 to 5.6
Biopsy 8 of 12 positive, Gleason 3+4, T2a
DaVinci August 2009, pathology Gleason 4+3, neg margins, T2c
Continent right away, ED
Viagra, Cialis did't work, Trimix works well
Post-surgery PSA:
3, month: undetectable <.1; 6 month: undetectable <.014 (ultrasensitive); 9, 12, 15 month: undetectable <.1; 18 month detectable .05

logoslidat
Veteran Member


Date Joined Sep 2009
Total Posts : 6069
   Posted 4/28/2011 8:59 PM (GMT -6)   
I have often wondered that but bet insurance wont cover, tho why not actually srt ain't cheap. Could be by the time they get back in there the cost benefit ain't there. Its probably quite a mess in there for a long while. I mean it was 6 mos be for I felt anywhere near normal, I had lymphocele complication, who wouldn't with 29 nodes dissected, but it was worth it to me. I think the Doc went the extra mile, tho, but more likely, I was a fit healthy man who could withstand 4 1/2 hour surgery and had his team , teaching hospital remember, take turns sliceing and a dicing in there. I met them all , beautiful people really. I knew going end he would be doing the " important parts him self. Whoever stiched me up was an arteest, 4" scar barely visible. You like see???
Diagnosed 8/14/09 psa 8.1 66,now 67
2cores 70%, rest 6-7 < 5%
gleason 3+ 3, up to 3+4 @ the dub
RPP U of Wash, Bruce Dalkin,
pathology 4+3, tertiary5, 2 foci
extensive pni, prostate confined,27 nodes removed -, svi - margins -
99%continent@ cath removal. 1% incont@gaspass,sneeze,cough 18 mos, squirt @ running. psa std test reported on paper as 0.0 as of 12/14/10 ed improving
New Topic Post Reply Printable Version
Forum Information
Currently it is Thursday, September 20, 2018 9:46 AM (GMT -6)
There are a total of 3,005,059 posts in 329,193 threads.
View Active Threads


Who's Online
This forum has 161760 registered members. Please welcome our newest member, Adrianna1023.
309 Guest(s), 7 Registered Member(s) are currently online.  Details
SoMuchFun, mattamx, leelee112233, C_G_K, SharonZ, Anna7ella, Normal59