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DeVinci/Open surgery--how sure are doctors they removed everything

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Posted 6/11/2010 1:05 PM (GMT 0)
When a surgeon performs a prostatectomy (either open or DaVinci), can they tell if all the tissue they wanted to remove (prostate, seminal vesicles, lymph nodes, etc.) was actually removed in its entirety? Or is there some uncertainty (that surgeons will acknowledge) that some tissue can be left behind despite the surgeon believing it was all removed? Or, by looking at what comes out, can the surgeon say with certainty something like "We are certain we got the complete seminal vesicles and none was left behind"

Dan
Posted 6/11/2010 2:00 PM (GMT 0)

The real answer to this is, they don't.  That is why we stress gettin experienced surgeons.

The other answer is that the pathologist checks the margins of the removed tissue.  If they find any cancer cells in the margins, or edges of the tissue, they term them positive margins, and is an indication that they may not have gotten all of the cancer.

Posted 6/11/2010 2:34 PM (GMT 0)
Our surgeon told us that one of the 1st things they do is remove a few (nearby?) lymph nodes & tissue which are immediately sent to the on-site lab. If they come back positive (with cancer) they will know (somewhat?) more about how much else to remove. The lab has some time while the rest of the surgery takes place. That said, it's a big worry for us. Robotic scheduled for 6/14/10 at City of Hope with Dr. Tim Wilson.

This is all so scary, but we know we've done all the due diligence we possibly can.

Paella
Posted 6/11/2010 2:37 PM (GMT 0)
I think a good surgeon will remove the right bits.
When it transpired that I needed RT the rad guy said that while the prostate gland has a very defined shape margin and is thus easy to remove it is less obvious where the edge of something like the seminal vesicles or bladder neck is, and with the current emphasis on nerve-sparing it is also possible that tiny bits get left that are attached to the nerves.
I guess a good comparison might be that testicles are a clearly defined object which could be removed with certainty, but that all the wiggly tubes connected to them (epididimus vas etc) would be harder to cut out completley.

And I though that "Positive margin" in a path report meant that the cancer had started to spread beyond the gland and not thart part of the gland has been left behind.

Alfred
Posted 6/11/2010 5:00 PM (GMT 0)
I think it would be very unusual for a surgeon to accidentally leave part of the prostate other than tiny bits of tissue during attempts at nerve-sparing.
It is possible that if the cancer has spread to those nerves (mine had, they took them too), there might be some remaining, but that is a cost/risk of nerve-sparing to be considered.

(Added - Other posts made the point that tissue might be left if the bladder and rectum can not be cleanly separated, but I would hope the doctor would note that in his reports).

The cancer can also get out into the lymph nodes. They take what they estimate to be enough to test to see if it is clearly out, but they can't take them all. They took 12 in my case, all were negative. If it was the 13th one that was positive, then I lose.

I would not say that follow-up radiation (i.e. without a PSA rise) is "common". It was explained to me to be needed because of the aggressive type of cells they found. It was an after-surgery evaluation based on the pathology report. With the high costs, I can't imagine that it would ever be automatic unless you fell into certain categories (I did).

Post Edited (142) : 6/13/2010 3:18:27 PM (GMT-6)

Posted 6/11/2010 5:41 PM (GMT 0)
Even the very best (which I had) will tell you they got it all, but it is the final pathology that tells the tale. There are some areas where the membrane of the prostate capsule is so close to other organs (bladder, rectum etc.) that shaving the prostate from there can result in cutting across the edge of the prostate and leaving some tissue behind. But if there was cancer detected at that location, it will be called a positive margin...and thus no way to know if the cancer was just close to the edge and not protruding beyond the prostate. Thinking is now leading towards staging pathology with positive margins as a T3 because of the uncertainty. Most doctors will still wait until there is a definite rise in psa before moving forward with any additional treatment with a positive margin because of this uncertainty.

BTW...my surgeon removed the lymph nodes one on each side nearest the prostate ... but the pathologist only identified the right side...left side was either too damaged from removal or couldn't find it in the tissue sample that was given by the surgeon. Just goes to show...even the most experienced surgeon can't be sure "They got it all" at the time of surgery.
Posted 6/11/2010 9:34 PM (GMT 0)
Tony, you have me curious about staging guidelines.

I often wonder if I were really a Stage 4 vs. the Stage 2 on my patholgy report for 2 reasons:
1. I had a positive margin
2. I had recurrance within months of surgery

Does that logic make sense?

David in SC
Posted 6/11/2010 9:49 PM (GMT 0)
David....I know you are asking Tony this question but I believe that Stage 4 is confirmed mets...or at least that is the way I read it. Recurrence in the prostate bed isn't considered mets as it is still local. Even if it is suspected that distant micromets may have occurred, without positive identification it won't be considered stage 4 until pathology via biopsy or other tests confirm it.
Posted 6/11/2010 10:04 PM (GMT 0)
sorry, les, got my "handle names" mixed up. dont mind you answering or anyone else. thanks
Posted 6/11/2010 10:15 PM (GMT 0)

Purge,

Not sure if this is what you are asking, but hope it helps ....

From the fourth edition of the American Joint Committee on Cancer Staging Systems for prostate cancer: 

  • T0: no evidence of tumor
  • T1: tumor present, but not detectable clinically or with imaging
    • T1a: tumor was incidentally found in less than 5 percent of prostate tissue resected(for other reasons)
    • T1b: tumor was incidentally found in greater than 5 percent of prostate tissue resected
    • T1c: tumor was found in a needle biopsy performed due to an elevated serum PSA
  • T2: the tumor can be felt (palpated) on examination, but has not spread outside the prostate
    • T2a: the tumor is in half or less than half of one of the prostate gland's two lobes
    • T2b: the tumor is in more than half of one lobe, but not both
    • T2c: the tumor is in both lobes
  • T3: the tumor has spread through the prostatic capsule (if it is only part-way through, it is still T2)
    • T3a: the tumor has spread through the capsule on one or both sides
    • T3b: the tumor has invaded one or both seminal vesicles
  • T4: the tumor has invaded other nearby structures

Zen9

Posted 6/11/2010 10:37 PM (GMT 0)
Zen, I think so. I was labeled post surgery t2c. I am asking, am I really a t3 - because i did have one positive margin, and recurrance for me came pretty quick, so should I have been labled a t3 category. Thanks.
Posted 6/11/2010 10:44 PM (GMT 0)
I had some similar questions that I posed to my surgeon (who I thought was great) prior to the surgery.  Here are his answers from my original email, that may provide some perspective.  (caveat, I'm sure we also had a more extensive discussion of these topics during a visit with him, so please don't take it as some end-all be-all)

1.  Unilateral vs Bilateral nerve sparing -- is this an a priori decision based on expected surgical margin from the biopsy results (and if so, what's the plan?), or an in situ decision based on the actual surgical margin determined during the procedure?  ACTUALLY A LITTLE OF BOTH.  YOU GO IN WITH A PLAN  BASED ON CLINICAL PRE OP INFO BUT RE ADJUST IF INTRA-OP FINDINGS DICTATE- FOR INSTANCE IF YOU SAW SOMETHING SUGGESTING GROSS EVIDENCE OF EXTRAPROSTATIC DISEASE YOU MIGHT TAKE A WIDER MARGIN THERE OR DO A INTRA-OP "FROZEN SECTION" TO SEE IF THERE IS IN FACT CANCER THERE.  IN YOUR CASE- I'D BE INCLINED TO BE AGGRESSIVE IN ATTEMPPTING TO SPARE YOUR NERVES ON THE RIGHT IN THAT THE MAJORITY OF THE POSITIVE BIOPSIES WERE THERE BUT NOT TO BE AT ALL HEROIC about DOING SO ON THE LEFT.

2.  What more do you do a) while you're in, or b) afterwards, if the surgical margin on one or both sides is not good?  A) IF YOU SUSPECT A MARGIN MIGHT BE POSITIVE YOU MIGHT RESECT WIDER OR SEND EXTRA MARGIN SAMPLES  B) ALONG THE LINES OF BILL CLINTON'S FAMOUS LINE OF "THAT DEPENDS ON WHAT THE DEFINITION OF IS IS"- IT DEDEPENDS ON HOW POSITIVE THE POSITIVE MARGIN IS.  iF THE MARGIN IS POSITIVE AT THE SURGICAL MARGIN ( AT THE EDGE OF ALL TISSUE RESECTED- IMPLYING THAT THERE IS LIKELY TUMOR LEFT INSIDE, ADDITIONAL RADIATION THERAPY MIGHT BE CONSIDERED.  IF THE POSTIVE MARGIN REFERS ONLY TO THE TUMOR BEING THRU THE CAPSULE OF THE PROSTATE IN A VERY SMALL FOCUS BUT IF THE SURGICAL MARGIN (E.G. THE SURROUNDING NERVE TISSSUE FOR EXAMPLE) WAS CLEAR, ONE MIGHT THEN BE MORE CONSERVATIVE AND FOLLOW YOUR PROGRESSS WITH PSA TESTING ETC.

 
Posted 6/13/2010 7:52 AM (GMT 0)
Paella, I will be thinking about you and Mac on Monday!  I wish Ron's surgery was so soon.  We meet with the surgeon on 6/15/10.

Thank you Zen9 for the information on the stages!

Aimzee

Posted 6/13/2010 4:37 PM (GMT 0)
Well, I asked my surgeon on Friday how sure he was that he got everything out and he basically said there is no 100% guarantee but said he was a close to certain as possible in my case that he got everything out and then backed it up with the following info:

1) With DaVinci, the view of the tissue is excellent (I think he implied better than open surgery), with hi magnification and very hi definition camera very close to the tissue being removed.
2) All my tissue was normal looking and well differentiated (inflamed tissue tougher to deal with)
3) No abnormal tissue issues (bits that were stuck to bladder or rectal wall). If this situation occurs bits of tissue are more likely to be left behind.

So, there is no 100% guarantee, but there are things that contribute to the likelihood of it all being removed.

Dan
Posted 6/14/2010 10:20 PM (GMT 0)
Leaving something behind is probably not likely with the gland itself considering that the gland is removed in its entirety. They place it in a bag and it's pulled out through the large incision. The lymph nodes and surrounding tissue are only sampled. I had a recording of my RALP and saw the doc place the gland in a bag and pull it out. There are a few videos you could find on the internet that show the RALP procedure. Here's one http://www.orlive.com/methodisthealth/videos/da-vinci-robotic-assisted-prostatectomy2
Posted 6/14/2010 11:32 PM (GMT 0)
I still maintain that a lot of this is still an experience thing. A doctor with 800 to 1000 surgeries is more apt to remove everything , plus any surrounding tissue. If your nerves are tangled in the PC , minute amounts of PC can be left in a nerve sparing attempt. More experienced doctors make more experienced decsions. IF they don't think they can get it all, they snip the nerve.

I have a young uro who is learning Davinci. I think by last count he has 25 under his belt. I asked how it was going and he said well. He said, " I had a few positive margins at first, but O am getting better."

I did NOT have him do my surgery. I had an EPE, but my surgeon was experienced enough to take the tissue around it , giving me negative margins. If he had just taken what he thought was the prostate, my numbers would most likely not be as good.
Posted 6/14/2010 11:45 PM (GMT 0)
Regal, your post about radiation following surgery is incorrect...about 30% of surgical patients require radiation treatment after. That's not "most every time" but rather 3 out of 10 men.
Posted 6/15/2010 7:03 PM (GMT 0)
All...lets review Forum Rule #4

4. No posts that attack, insult, "flame", defame, or abuse members or non-members.

We don't need this thread to be closed...some very good questions are being asked.

Posted 6/15/2010 7:12 PM (GMT 0)
Aimzee,

It is true that around 30% of people undergoing surgery will require some follow-up. But that being said, keep in mind that it is usually those at high risk as determined by the final pathology report. Higher risk such as capsular penatration, seminal vessel involvement and positive margins favor a recurrence that will require followup- but not always. I wouldn't be too worked up about secondary treatments right now. Concentrate on the the 1st line treatment of being cured. If and only if you need any type of follow up treatment, then address those concerns at that time.

Good luck in your journey

Post Edited By Moderator (James C.) : 6/15/2010 10:06:08 PM (GMT-6)

Posted 6/15/2010 9:52 PM (GMT 0)
First warning: Any further posts containing anger, insults, snideness , off topic matter or rules violations will be deleted automatically, no need for me to spend time typing out an explanation. Let's drop it folks and return to the subject at hand. Continued off topic posts will be sent along to the owner to review. I really hate being the bad guy, but we have no need for anything that creates anything but help, info and support for our members.

Oops, I didn't read to the end, so missed the last 2 posts dealing with race. So no more of that, either... devil smilewinkgrin
Posted 6/16/2010 1:34 AM (GMT 0)
Aimzee,

I earlier in this thread made the observation that followup radiation is not "common" - at least in my definition of the word, which would mean more than 50% of cases of PCa. I stand by that observation.

One of the considerations you must always put first is that we are not the common cases. In the group of friends I've developed here, no one walked away from the first treatment "cured". For each poster here, there are likely many, many others who get a clean treatment and great results. They don't come here because they don't need that extra support. They are also the ones who make things difficult for us, as they make PCa seem like the "easy" cancer. Mine is not.

My case of aggressive cancer, with a much worsened pathology in respect to the biopsy, and the almost certain need for follow-up radiation is not "common".

As I mentioned earlier, insurance companies would put a quick stop to radiation for the sake of profit. Looking at my bills, they would have required a cheaper approach unless they do believe this will lower their risk for higher costs later. They won't pay for two PSA tests in the same year.

You must not take one thread as the ultimate answer. Most of us here are not doctors, as far as I know. We are offering our experience and sometimes opinions, which must be considered in that context.

The objective is to come out alive, and to stay that way until something else gets you. There are side effects, and sometimes PCa comes back. If you understand that many do well, and that a few don't, it will help deal with the stress, and both find and adjust to your personal and unique "new normal".

Ask good questions, accept only reasoned and precise answers, and don't panic.

And as always, my best wishes for an uneventful journey.
Posted 6/17/2010 11:08 AM (GMT 0)
To get back to the original question, it would seem that if the surgeon studied the results of the biopsy - e.g., exactly where the cancer was found in the prostate - then he/she could better "plan" the surgical route they'll use. For instance, our uro/surgeon knew that one of John's positive cores was right on the edge of the prostate so he knew going on how he was going to approach the gland. He came in from the opposite side and cut a wider than necessary margin around that area. While John's surgical path report stated a single foci of extraprostectic extension on the right side, no positive margins were noted in the report. the robot also allowed the surgeon to take a close look all around the gland to inspect the surrounding tissue to see exactly where and how wide he needed to cut. That's where surgical experience comes into play.

On another note, thanks to James for keeping this thread going without all the fuss. I missed the dust-up here but am glad that our moderators are here to keep things civil.
Posted 6/28/2010 5:33 PM (GMT 0)
 

Dan it seems we are having a similar PCa journey with dates, PSA's, surgery, etc.

Thanks for replying to my posts... your info is very helpful and this is the first forum I have ever participated in.    My DaVinci was May 24 so I am just ahead of you in chronology.

Diagnosed in March from PSA test 4.8 (up from 2)

Biopsy in April  6.5 Gleason

Pathology after surgery was excellent results - margins clear

6 week blood test is July 6

My question is should we worry about the upcoming PSA test?

I am 53 with no family history of Cancer anywhere.  I have 3 sons who now have inherited this concern from me.

Take care.  Thank you for your input.

Posted 6/28/2010 6:56 PM (GMT 0)

jahfreak,

Is your first follow-up PSA important ?  yes.  Does it give clues to what went on when the surgeon snipped out the prostate ?  yes  Should you pay attention to it ?  probably

Should you worry about it ?  No.  Can you make youself not worry ?  Probably not.

We need to develop an "it is what it is" attitude about these things if possible.  Worry only adds to your problems.  Depression is a common occurence after surgery.

Also, the first PSA can be a little misleading.  Some doctors take them at 6 weeks, which can still show some residual PSA.  Some, like yours, wait longer. 

Welcome to the other side.  Good luck on your recovery !

Posted 6/28/2010 7:38 PM (GMT 0)

Very helpful and encouraging.  Thanks goodlife

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