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Prostate contained cancer but one positive margin

thor123
Posts: 3
Joined: Aug 2010

I had a radical prostatectomy five weeks ago and just now found out from my doctor what was meant by "tumor focally extends to the inked/cauterized margin in the left apex." Meaning: one positive margin. It's got me very spooked, I have to say. I know that a positive margin increases the chances of recurrence. The cancer was otherwise contained to the prostate. Anyone have any words of reassurance or advice? My doctor says I don't need radiation at present. I hate the thought that that cancer can still be in my body. I'm 57 years old. The Gleason grade was downgraded in the pathology report to 6, from a 3+4 in the biopsy.

lewvino's picture
lewvino
Posts: 1010
Joined: May 2009

thor:
Hi,,,sorry to hear your news but I'm in the same boat! Had my surgery Aug 15, 2009 and have a positive margin also.

If you don't have the book get and read Dr. Patrick Walsh's Book...Guide to surviving prostate cancer.

He has several great sections on positive margins. He talks at length about when to start treatment now or wait.

I have chosen to wait. All it means is have your PSA Checked more frequent. They recommend if you hit .2 then to start radiation. I'm almost at 1 year and pulling 0's. My Gleason stayed at 7 as 3+4.

Yes it is 'spooky' but From the statistics at John Hopkins they didn't see much difference in starting radiation right away or waiting.

They also point out several reasons why you might have a 'false' positive margin. Such as misshandling, or even the surgery cut right through the edge of the cancer. Dr. Walsh gives the suggestion that its like lightening hitting a tree...the tree dies and stuff around it....Surgery cuts through the edge of cancer and surgery kills stuff around it.

Just keep up your PSA Checks...If you would like to talk offline...let me know...be glad to. Believe me though it is still in the back of my mind...but I'm taking the approach to wait and see if the cancer comes back.

Others have chosen to start radiation but please discuss with your doc.

Also the APEX is the most common place for there to be a positive margin.
Larry age 55

thor123
Posts: 3
Joined: Aug 2010

First 3-month post-surgery PSA test was 0.02. The next was 0.03. Wasn't happy to see an increase, but the doctor wasn't too worried, saying that is was a minuscule increase and could even be lab error but we need to keep watching for a continuing rise. If if get to 0.05, he might have me talk to a radiologist to see what he thinks.

The doctor who actually did the surgery at Mayo said he doesn't even think I should be using the ultra-sensitive PSA measure but the one that triggers a warning at .1, but I guess I agree with my local doc that it's best to see what's happening sooner (even if it adds a bit to the anxiety).

bdhilton
Posts: 767
Joined: Jan 2010

I am 55 and we all have different perspectives based on our final outcomes on our post surgery pathology…The fact and from my perspective you downgraded to a Gleason 6 from a 7 in your pathology is the best news (less aggressive) and cause for celebration…the positive margin is anyone’s guess and what I have come to believe is that reoccurrence or not is just luck (destiny or what ever you chose to call it) …

My surgeon and oncologist both wanted me to have adjunct radiation after surgery and after doing my own research I talked to my oncologist and he agreed that he would do the same thing I am doing and wait to see it I get a PSA rise (to date I am having Zeros) then have salvage radiation… The trade off for me is a PSA test every 90 days but I believe the longer I go without radiation (or just get lucky on the side of statistics) the better off I am..

After my oncologist reviewed my pathology report with me he told me to start living my live and enjoy…so my advise is enjoy the journey and take the positives where you can-

Peace

Exam Date and Time: 3/3/2010 12:00 PM Results Date and Time: 3/8/2010 8:18 PM
Final Diagnosis
A. Lymph Node, Right Pelvic, Excision:
-One Lymph Node, Negative for Metastatic Carcinoma
B. Lymph Node, Left Pelvic, Excision:
-One Lymph Node, Negative for Metastatic Carcinoma
C. Prostate and Seminal Vesicles, Radical Prostatectomy:
-Prostate Adenocarcinoma with Focal Ductal Differentiation, Gleason’s Score 4+3=7, involving both the Right and Left Prostate Lobes
-A tertiary Gleason’s Pattern 5 Component is Present
-Extensive Extra Prostatic Extension is Identified Involving the Right Apex, The Right and Left Mid, And The Right Base
-The Adenocarcinoma Focally Extends To The Inked Margin In The Right mid Prostate (Slides C8 and C9)
-The Adenocarcinoma Invades Into The Right Seminal Vesicle
-The Left Seminal Vesicle Is Free Of Tumor
-The Remaining Surgical Margins Are Free Of Tumor
-Intraductal Spread of Adenocarcinoma is Present (See Notes).
-Extensive Perineural Invasion is Present
No lymph vascular Space is Present
-The Dominant Tumor Nodule is Present in The Right Prostatic Base and Measures 2.2 CM in the Greatest Dimension.
-Additional Tumor Nodules Are Present In The Left Apex, Right Apex, Right and Left Mid Prostates, and The Left base. The Adenocarcinoma is Present In 24 of 34 Submitted Slides And Involves Approximately 18% of the Prostatic Volume.

-High Grade Prostatic Intraepithelial Neoplasia.
Note: The positive surgical margins are in an area of extra prostatice extension. The ductal differentiation is best appreciated in slides C33 and is focal in nature (less than 5% of the total tumor). A PIN4 immunohistochomical stains perform on block C23 supports the diagnosis of intrductal spread of carcinoma. Dr; Ximing Yang has reviewed selected slides for this case and agrees with the above interpretation of margin status and seminal vesicle invasion.

This test was developed and its performance characteristics were determined by the Northwestern Memorial Hospital Immujnohistochemistry Laboratory. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. This tst is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1900 (CLIA-00) as qualified to perform high complexity clinical laboratory testing.

The positive Control demonstrates appropriate positive staining. The known tissue negative controls were negative. The non-immune serum control was non-reactive.

Prostatic Cancer Staging Summary:

Tumor Type: Acinar with Focal Ductal Differentiation

Gleason Score
Primary + Secondary: 4+3=7
Tertiary: Pattern 5

Location Main Tumor: Prostatic Base
Location Additional Tumor Nodules: Left Apex, Right Apex, Right Mid, Left Mid, and Left Base

Extraprostatic Extension
Focal (<2 Microscopic FOCI): N/A
Established (Extensive): Present and Extensive

Margins
Apical Margin: Free of Tumor
Bladder and Urethral: Free of Tumor
Other Surgical Margins: Positive, right mid Prostate

Seminal Vesicles: Positive for Carcinoma
Location, If Involved: Right Seminal Vesicles

Perineural Invasion: Present

Lymphatic/Vascular Invasion: Not Identified

Total Lymph Nodes: 2
Number positive: 0
Tumor Volume Approximately 18%
Tumor (T): pT3b
Metastasis (M): pMX
Nodes (N): pN0

VascodaGama's picture
VascodaGama
Posts: 3041
Joined: Nov 2010

Hi thor
Your PSA of 0.03 is within the limits of remission. Urologists consider RP successful if PSA gets to the 0.06 mark or lower. Their statistics for patients with a PSADT (doubling time) of less than 6 month since RP would indicate a need to start a salvage treatment, but the trigger is taken as PSA=0.2 (it was 0.4 in my times).

Recently, because of the ultrasensitive PSAs, many doctors advocate for “the earlier is better”, however none of them ever indicated how earlier is the right time, as there is no conclusive trials yet. This way of thinking has created lots of controversy, because, apart from causing anxiety (as you said), it also leads to unnecessary treatments.
A Gleason score of 6 is the lowest in aggressivity, and if your PSA pre-op was lower than 10, you would be in the ranks of the Low risk Patients. You could not aspire for better prognosis.
Do you really need that RT the soonest?

Any treatment is done aiming at cure, and salvage radiation therapy has shown good results when it is applied in high doses to a target. Not just a simple irradiation of the prostatic fossa to “clean leftovers”. In this context your body must be ready to sustain the treatment with the lesser side effects possible. Your body needs time to sufficiently heal from your RP.
Each case is different, and our private choice is always the correct one. Hope you find what is best to you.

Take care
VGama

thor123
Posts: 3
Joined: Aug 2010

VGama, thank you for your very encouraging and generous comments.

A question: I can't anywhere on the Web find a definition of a successful RP, such as you note at .06. Having reached 0.02, does that constitute the nadir that I've reached and indicate success, even it if goes up to 0.03 or a little higher? Could you refer me to research on this subject?

Also, does "successful" in this context pretty much indicate a cure.

Thanks again.

Thor

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

Thor,

Regardless of the treatment method we choose to address our prostate cancer, we all face the risk of recurrence at some point. There have been several posts recently from men who have seen their PSA rise significantly 10 or even 15 years after their surgery. I think it’s pretty much how you individually define success, which could include how rapidly you return to continence and erectile function after surgery, how quickly you return to normal activities, and so forth. If success means that you don’t have a recurrence then you have to look at the definition of biochemical recurrence after RP. Many urologists define BCR after RP as a PSA greater than 0.2 ng/ml and rising. But there are other definitions that peg the threshold at 0.4 ng/ml and rising, or a single PSA reading of 0.6, and so on. Different studies use different definitions and obviously the number you pick as the failure point can have a big impact on the results and the threshold your doctor chooses to follow will have a significant impact on what, if any, follow-on treatments might be employed.

Several studies out of the VA and institutions like Sloan-Kettering and Johns Hopkins indicate that about a third of RP patients will see a recurrence (independent of definition) over a ten year period, but that the long term mortality is very low. In other words, just because it comes back doesn’t mean it’s going to kill you. (Ten year studies on BCR following radiation shows roughly the same recurrence rates as well as very low long term mortality but the definition of recurrence is significantly different as the prostate remains behind.)

In your case, a PSA of 0.02 ng/ml is 100 TIMES LESS THAN the definition has the lowest threshold for recurrence.

The definition of “cure” is a whole other matter. With metastatic cancers such as PCa, I don’t believe that we ever completely eliminate it from our bodies once it has taken hold. Even when the doctors tell us that it is “contained within the prostate” I believe that there are perhaps millions of cancer cells that have escaped into the blood stream or lymphatic system that, given enough time, will eventually begin to grow in some other location. The question is, whether that metastasis and subsequent damage to other organs can happen before something else kills us. Even men with a very low risk cancer and have a “contained within the prostate” pathology with negative margins have seen their PSA scores rise after several years. I suppose that a “cure” is good as long as it can’t be detected by any of the conventional means we have today. Personally, I think “survivor” is a more apt phrase.

prostateman
Posts: 18
Joined: Dec 2010

Thor, success is measured with a non measurable PSA reading after surgery. If you have a measured PSA then you more than likely have a recurrence and should consult with your oncologist. NO one here should be giving you any different advice than seeking professional advice. I wish you the best and please consult with your oncologist.

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

Prostateman,

Not sure who you think is giving professional advice here except that none of the studies or reports have ever suggested that success after RP is equal to a "non measurable" PSA. What are you basing this on?

prostateman
Posts: 18
Joined: Dec 2010

Giving professional advice? Having had a RP I believe I have a vested interest in understanding the risk and things to watch out for during my journey. Any measured PSA reading after a RP is a major red flag. The “cure” from a RP is based on no PSA reading. This is not my opinion this is a medical fact. If you would like I could provide some links or copy and paste some articles but you could just Google the same.

I do not know why you are challenging such basic information that any urologist or oncologist would inform their patient. From what I have read from you have had some form of radiation with no side effects to date and I am truly happy for you and your treatment choice. I am new to this group and perhaps I am reading you wrong but you seem a bit combative and controlling of this board.

VascodaGama's picture
VascodaGama
Posts: 3041
Joined: Nov 2010

Hi Thor,
You are welcome. I like to be of help if I can.

PSA is becoming a controversy when discussed as a “threshold level” to indicate the status of a patient. Everybody agrees that PSA is (if not the best) the right marker to evaluate the performance of treatments, and doctors and institutions use it to establish their protocols in handling each case. Many of them use the term “remission” when we reach their established threshold.
After surgery (RP) some doctors take a PSA=<0.1 as their threshold of success (your doctor at Mayo), but the majority uses a threshold lower than 0.06. Your nadir PSA 0.02 and the increase to 0.03 surely fall into the remission levels of the majority of protocols.
Kongo above describes exactly the meaning of the term “Success” used by anyone in the world of prostate cancer ;(1) The time-to-recurrence or time of biochemical-free survival, and (2) The outcome-from-surgery and recovery.

There is an interesting document you may want to read, published by AUA named “Prostate Specific Antigen - Best Practice Statement, 2009 Update”. In one paragraph we can read as I quote “…A detectable PSA following radical prostatectomy is associated with eventual clinical disease recurrence in some, BUT NOT ALL PATIENTS. It may also be due to the presence of benign glands. The AUA defines biochemical recurrence as an initial PSA value ≥0.2 ng/mL followed by a subsequent confirmatory PSA value ≥0.2 ng/mL."

You may read the whole document at; http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/psa09.pdf

PSA used to be referred only into the one decimal place (0.X ng/ml). With the advent of the ultrasensitive test readings become on the two decimal places (0.XXng/ml). Now there is still a newer ultrasensitive PSA reading on the three decimal places (0.XXXng/ml).
These precise numbers may be useful to some cases but not to all, which leads to the need in establishing a lower detection limit (LDL). In the case of PSA for practical uses in prostate cancer matters, the limit is at <0.01ng/mL.
I know of a guy in hormonal treatment that had a blood test done in this super-ultra-sensitive assays with a result of 0.009ng/ml. That indicates the LDL of <0.01.

I read in one study that biochemical recurrence (BCR) was indicated with a threshold of PSA>0.01 (above LDL), however, the level indicated as the trigger for starting a salvage treatment is at the judgment of the care giver. (http://www.google.com/url?sa=t&source=web&cd=2&ved=0CB8QFjAB&url=http%3A%2F%2Fwww.drslawin.com%2Fprostate-diseases%2Fvirtual-library%2Fscientific-presentations%2F19-experience-with-ultrasensitive-psa-after-radical-prostatectomy%2Fdownload&rct=j&q=threshold%20PSA%20after%20RP&ei=jGoHTcbcM4mu8QPupKw2&usg=AFQjCNG2dNfkFv2WSVMTNaGHBtkYN-3fSg&sig2=6DPUmMgqvIXd6j_septrwA&cad=rjt)
I hope this answers your question. You can find many sites by goggling “threshold PSA”. Let me know if you need more information.
Meanwhile, give up with anxiety and ponder before making any decision.

Regards
VGama

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

Prostateman,

If you have a link to a study, report, or professional finding from a major medical association that suggests that a successful RP is defined as having “no measurable” PSA I would be grateful if you would post the link. As I suggested in my first response to Thor’s question about “success,” my personal (non professional) opinion is that a successful surgical (or any other treatment) outcome is in the eye of the beholder. Biochemical recurrence (BCR), on the other hand, is a technical definition related to PSA with widely varying definitions and interpretations. So perhaps our differing views of this subject are only a matter of semantics.

In one study I read recently, the authors used as many as ten different definitions of BCR to analyze data in an attempt to reach some sort of scientific consensus as to what the best definition of BCR might be. You may be interested to read this report from the Journal of Clinical Oncology which can be found at: http://jco.ascopubs.org/content/24/24/3973.short. This paper specifically addresses the issues we are discussing here. As Vasco describes in his comprehensive post, different institutions use different levels of PSA readings to set thresholds for when intervention would be recommended or not, since the presence of a detectable PSA does not always mean that prostate cancer will progress.

Given the advent of the ultra sensitive PSA tests available today, most men who have an RP have some detectable level of PSA following surgery. If we used the definition you suggest is common in the field to describe “success”, then all of these RPs (including Thor’s) would be “failures” and I do not believe that is the case. In fact, I believe that since most men do not progress to a technical definition of BCR then most surgeries could be considered successful, even though there is a detectable level of PSA. Many posters here have described an initial PSA score after surgery that rapidly dropped within several weeks and then stayed that way for years. Even though most of the prostate is removed at surgery, it’s not like unbolting a carburetor from a car engine. Depending on the surgeon and technique, prostate tissue is always left behind and is capable of generating some amount of PSA after surgery.

I agree that a rising PSA for anyone (even those who have had radiation treatment) might be a cause of concern but more important than the actual number itself is the rate of rise or PSA velocity. Many urologists have different views as to what constitutes a tripwire for further intervention and the significance of the PSA readings. Some do not recommend the ultra sensitive PSA tests. Others recommend treatment at the earliest sign of PSA rise while others take a “wait and see” approach. I think it is important for men to understand the logic behind their doctor’s reasoning and be aware of alternate views that might prompt them to seek a second opinion.

I certainly don’t mean to be combative or controlling (eerily reminiscent terms often used by one of my favorite posters who “took a break” about the same time you arrived) but it seems to me that the more each of us learns about prostate cancer in our individual journeys the less we understand about the extremely complex mechanisms going on within our bodies and the plethora of factors that affect the growth or remission of our cancers. I have learned the hard way to be suspicious of too simple explanations of what causes what to happen with respect to prostate cancer. I think that if we put forth an opinion on this board, we ought to be prepared to explain our logic and back it up with references where appropriate so readers can make an informed decision about whether or not to buy in to it or even if it applies to their own individual case. I am fully aware that some might not always agree with me or agree with me even a little. There is a wide degree of controversy among professionals, surgeons and radiologists alike, about prostate cancer treatments so it's not surprising there are differing opinions on this forum as well. Understandably there are sometimes emotional or heated exchanges. After all, we’re betting our lives on our decisions so we ought to have strong opinions about these things. I think most would agree that a spirited exchange of views is healthy and productive and I look forward to continued exchanges with you in the future.

I hope you will feel free to share more about your background so we can better understand the perspective of your posts.

Best

prostateman
Posts: 18
Joined: Dec 2010

Kongo,

I believe I have already stated my position which is medically factual in that a successful RP is when you have no measurable PSA (less than .01) and when a measurable PSA comes back be it 6 weeks or 20 years later it is a red flag and is a strong indicator that a recurrence is pending. I believe that any guy who has had a RP understands this and dreads their PSA tests. I see no need to cut and past articles to defend a known fact.

I am sorry that you feel that I do not contribute like others with “comprehensive posts” but I am here just to share a few stores, give support and state my opinion on matters that specifically affect me and the specific treatment I had.

Now I “eerily reminiscent terms often used by one of my favorite posters who “took a break” about the same time you arrived” Well I do not know what to say to that?

You have asked several times now for me to “share more about your background so we can better understand the perspective of your posts” not sure what that means but I have shared what I want to share.

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

Well, I think we've run over this dead cat enough times. I don't agree with your contention about what is or is not a successful RP and your assertion that your opinion is a "medical fact" is not persuasive, at least to me.

We are all entitled to our own opinons and I'm sorry if you felt I was prying into your private background. Most new posters share their pathology but if you aren't comfortable doing that, no worries from my perspective.

Best to you.

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