New Member's Husband Doing Well After RP But She's Worried About Positive Margins.

Hello,

I've been lurking on your forum for awhile. My husband had a RP in March of this year, and recovered pretty well. He's 100% continent, and is making very good progress on the ED front. I'd been researching and trying to get as much information as I could about positive margins. His path report showed gleason 6 as the biopsy had predicted with no PNI or SVI. They also spared both nerves. The not so great part was that he came out with 3 positive margins. He had his first PSA drawn at 6 weeks, and it was 0.03. He'll have another done next week. I just wanted opinions on his report. If I left off any information that you need, please let me know and I'll post as soon as I can get home to the report. This is a very informative forum, and I appreciate being able to find so much information and support here.

Gave your thread a subject -- PeterDisAbelard, Moderator

Post Edited By Moderator (PeterDisAbelard) : 7/10/2013 9:06:45 AM (GMT-6)

Welcome,

It's always better not to have positive margins, but as stated, it doesn't mean or guarantee that there will be recurrence. Hopefully not. Having a PSA test done that soon after surgery isn't the best test of things to be, but it is .03 this soon out, it should be much better at the standard 3 month post surgery PSA test.

Good luck, and hope his recovery goes well.

Please keep us posted.

david

Yes, most have the PSA test every 3 months for the first year ,sometimes 2 years depending on their stats, then it goes to 6 months, then to yearly after that. The next test should give you a better feel for how things went, don't put too much stock on that first early "read".

david

Hello wjsim,

When you get a chance if you could copy the text about the margins for us we might be able to tell you more. They will often mention the size of the positive margin (the smaller, the better, obviously) but there are other words they use that mean small, notably "focal".

As others have said the fact that his Gleason score remained a 6 in his post-op pathology report is good news. Gleason 6 cancer is usually not particularly aggressive and even if some was missed in surgery and the cancer recurs it is highly likely that the recurrence can be successfully treated.

PSA has a long half-life in the body and his reading at six weeks isn't bad. Doctors usually wait longer after surgery to give the pre-surgical PSA a chance to dissipate so they can get an accurate post-surgical level.

So the order of the day is healing and vigilance and not to worry. Worrying is neither helpful nor necessary in his case.

Keep us posted and do tell us what the report said about his margins.

Welcome to our corner of the world sorry you need to be here.

It's always a bit worrying to get something like that in the report -95% clear but for this one little thing.

All you can do is to keep monitoring the results and hope for the best. Even if it does come back, at G6 there is still plenty that can be done. It's easy for me to say don't worry but I know how hard it can be to put that thought out of your mind.

Hang in there - you'll do fine.
And keep us updated on future tests,
Andrew

wjsim: Gleason 6 has a very difficult time surviving outside the prostate according to my reading/ research. The trauma of surgery and modification of the blood supply to the turmor further make it unlikely to survive or migrate. But don't take our /my word for it. If you go to the POST SURGERY nomogram of the Memorial Sloan-Kettering institute and punch in your hubbies numbers; you will see that positive margins for a Gleason 6 only drop him down 1% point (from a 98% cancer-free survival at 10 years to a 97%).

Do yourself a huge favor and go to the address below and add hubbies numbers, hit calculate, and look at the great results in the upper left. You will sleep good tonight!

http://nomograms.mskcc.org/Prostate/PostRadicalProstatectomy.aspx

A reading of 0.03 at 6 weeks is also great news in my opinion. Most Doctors have the first test at 6 months. If sex, a DRE, or bicycle riding can have a major infulunce of PSA, imaging what all of the squeezing and manipulation of the prostate does to the PSA level during surgery. It must really spike! Since PSA "burns off" at a half-life rate of 2.5 to 3.5 days, one would expect that he still has not reached his lowest level or "nadir". To be honest, I would have been very nervous to get tested so early (at 6 weeks). I waited 6 months and got the ultrasentive test and got <0.01. I am sure your husband will do the same.

Your husband got a GREAT report, now go and enjoy it!

Bill K from NJ
PSA 3.3, free PSA 21%, Gleason 7, 1/12 cores positive
daVinci 7/2011, downgraded to Gleason 6, contained, 10% involvement.
total urinary control after cath removal, but 100%ED, Now at 2 years, ED resolved.
All subsequent PSAs <0.015.

Welcome. Positive margin is never a good thing ,however, it doesn't necessarily lead to recurrence. Dr Walsh's book touches on this subject. His first PSA is definitely good. I thing his next PSA will be critical. If it stays the same or goes down then hopefully he will be fine.

wjsim:
You are welcome. And remember that the results (approx 97%) that you get from the MSK nomogram is defined as:

Progression-Free Probability After Surgery-In the current model, this tool predicts the two, five, seven, and 10 year probability that a prostate cancer will not progress after radical prostatectomy -- i.e., that the PSA will remain undetectable with no other therapy other than radical prostatectomy.

Look carefully and you will see that this number epresents no BCR. If by some rare chance it did come back there is always salvage radiation. Gleason 6's after surgery are usually found in the prostate bed and very easily controlled by SRT. So the chances that PCa will ever affect his actual life span is incredibly, incredibly low!

My stats. are very simialr to your husband's. I am an engineer and it is in my nature to "look at the numbers" especially while making an important assessment such as regarding ones life. The MSK nonogram was introduced to me by my surgeon and it has given me great comfort over the past 2 years. It certainly should do the same for you. Good luck.

Bill K. from NJ

Hi wjsim,

njs, and the others, have given you some great info that should make you & your husband feel very confident. Johns Hopkins did a study a few years ago that included 17,000 Gleason 6 prostatectomies. And the instances of metastasization in those 17,000 cases was absolute ZERO.

As others have also noted, Gleason 6 cancer cells usually require the internal environment of the prostate for survival. If they happen to exit the prostate, they usually die. And, as some surgeons will note, the act of cutting into them (in the creation of positive margins) can also kill them before they have a chance to starve to death.

Positive margins also do NOT always denote that cancer cells were at the very edge of the surgical margin. I don't understand how it works, but it often depends on how the prostate was inked by the pathologist before the post-op exam.

In other words, a positive margin does not always mean the cancer cells can spread -- and, where Gleason 6 cancer cells are concerned, it almost never happens.

So it is time to breathe easy and enjoy the feeling of great relief.

By the way, your husband's PSA reading, at such a short time after surgery, is ALREADY officially a ZERO. Anything less than 0.1 is considered to be undetectable -- ZERO.

Best wishes,
Chuck

Resident of Highland, Indiana just outside of Chicago, IL.
July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA Sept. 2011 was 5.7.
Local urologist DRE revealed significant BPH, but no lumps.
PCa Dx Aug. 2011 at age of 61.
Biopsy revealed adenocarcinoma in 3 of 20 cores (one 5%, two 20%). T2C.
Gleason score 3+3=6.
CT of abdomen, bone scan both negative.
DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
My surgeon was Dr. Matthew Tollefson, who I highly recommend.
Final pathology shows tumor confined to prostate.
5 lymph nodes, seminal vesicles, extraprostatic soft tissue all negative.
1.0 x 0.6 x 0.6 cm mass involving right posterior inferior,
right posterior apex & left mid posterior prostate.
Right posterior apex margin involved by tumor over a 0.2 cm length, doctor says this is insignificant.
Prostate 98.3 grams, tumor 2 grams. Prostate size 5.0 x 4.7 x 4.5 cm.
Abdominal drain removed the morning after surgery.
Catheter out in 7 days. No incontinence, occasional minor dripping.
Post-op exams 2/13/12, 9/10/12, PSA <0.1. PSA tests now annual.
Semi-firm erections now happening 14 months post-op & VERY slowly getting a bit stronger.

wjsim - My husband is a G9 with positive margins; he just had his PSA done and he is still <0.01 after 4.5 years. Keep the faith.

So, other than the multi-focal positive margins, this is good news.

As mentioned earlier, GS6 is very good and probably the most important detail.

SVI absent is also very good. While SVI is unlikely, if present that would be ominous.

And finally, pT2 / EPE absent means his cancer was organ-confined, which is good -- especially given the positive margins. Positive margins in otherwise organ-confined disease are less concerning than positive margins in the presence of extensive EPE. And I was originally afraid there may have been extensive EPE when you said there were multiple positive margins.

So, try to look at the glass as half (or more) full. Many people with positive margins never have a recurrence. And if your husband does have a recurrence it most likely would be years down the road and would be highly treatable...