Positive Margin at Bladder Neck...

Hello Everyone,

I just joined the forum. I wished I had known about it earlier. I had a bumpy journey over the last few months. First being diagnosed with prostate cancer and then having robotic prostatectomy at Johns Hopkins. My Pre-op PSA was 6.6, with 7 out 10 biopsy cores positive, with Gleason score 6 (slides read at Hopkins). I went to the Hopkins Multi-disciplinary clinic and got two recommendations: surgery or brachytherapy. I opted for surgery. My surgeon suggested robotic surgery, because he claimed to get better results with the robotic method, since he did both types (retrobubic and robotic).

Just two days ago I got a phone call regarding my post-op pathology report. I have not seen a printed version of the report yet, which I will get soon in the mail, but my doctor said that the Gleason score was updated to 7 (3 + 4), that the lymph nodes were clear, seminal vesicles were clear, there were no extra capsular extension, and that it was organ confined, but that there was a local positive margin at the bladder neck in an area where he cauterized. He said, that all we need to do now is just to follow the PSA, starting in 3 months.

Any advice on whether this is the standard procedure? Did anybody have a similar experience with local bladder neck positive margins?

I have several articles that indicate that positive margins do not produce a good prognosis, and in particular that bladder neck positive margins have the worse prognosis for recurrence.

My feeling is that I should consult a radiation oncologist, perhaps at Hopkins as well, and see what he says. Any thoughts from your collective wisdom?

Joe.

Hello and welcome Joe,

Having a positive margin doesn't mean you will ever have recurrence, but you could, and at the bladder neck, not the best place to have one.

I would not rush into any thoughts of having a secondary treatment at this point, i.e. radiation. You may or may not ever have recurrence, so you will want to save that "gun" for when and if you do.

In my case, had one tiny positive margin, but in my case, recurrence was declared within 9 months of surgery. Had salvage radiation, and it too failed in less than 9 months. Now dealing with advanced PC.

Best bet is to see how your next several PSA tests come out. If you start trending >.10, then it needs to be watched closely for recurrence. Long as it stays <.10, enjoy being in the "zero" club.

Best of luck to you,

david in sc

Good morning Joe and welcome,

Sorry you had to find us and glad that you did. This is a great group of men and women, everyone of them here with questions, some answers, and always with great support.

I presented much as you did, G6 pre surgery, and G7 post surgery. I only had one positive core, decided for surgery and had it performed in January of this year. Once "inside" my Doctor discovered why I only had one positive core, most of my cancer was actually in my bladder, still prostate cancer, but extending through the neck and into the bladder. He removed my prostate (nerve sparing) and a fair amount of my bladder.

Post surgery pathology showed positive margins on two sections of what was remaining of my bladder. I test every 3 months, next one coming up end of October. So far I am undetectable. My doctor says that either those few cells that were remaining died, or are dormant, or are so small in number as to currently be undetectable. If any cancer remains, it is likely localized to my bladder and radiation would address it. No more surgeries and no hormone therapy (as long as we stay on top of it).

I was very concerned the first month after my surgery. Some pretty dark days, and then...I came to see this cancer that had developed in my body as a gift. I have a much evolved outlook on life and the finite time we each have here on earth as a human being. I am grateful for the care my doctors have provided and continue to provide. I am well aware that the cancer may eventually require more treatment, and could possibly threaten my life some day, but I am at peace.

Take care Joe,

Pat

Thank you all for the input.

I have done more research on the issue of having or not immediate adjuvant radiation therapy following the outcome of a positive margin after surgery.

In this research, I came across the new joint guidelines the American Urological Association (AUA) and the
American Society for Radiation Oncology (ASTRO). I would like
to share this information with everyone, in case it might be helpful.

The announcement of the guidelines was made in May 2013 at this link:

https://www.astro.org/News-and-Media/News-Releases/2013/ASTRO-and-AUA-issue-joint-guideline-for-radiation-therapy-after-prostatectomy.aspx

The publication of the guidelines was in August 2013 at this link

https://www.auanet.org/education/guidelines/radiation-after-prostatectomy.cfm

The guidelines seem to suggest that there is a benefit in having adjuvant radiation therapy after prostactetomy with positive margins.

I will read the guidelines more carefully and get a second opinion from a radiation oncologist.

I uploaded my current stats as a signature below.

All the best to all,

Joe.

Hi Purgatory (David),

Thank you very much for your input and your advice. I will take into account before my next move. You guys had much more time to learn and to think about the important issues, and I am very happy to have found this forum.

Since I do not know anyone personally that is affected by prostate cancer, I am just happy to learn and share what I learned with everyone.

I hope that your progression is under control. Let us keep fighting this beast and never loose hope. Life is a precious gift!

All the best,

Joe.

My radiation was "just in case".....

Hi NJS,

Thank you very much for your input and your advice.
Your suggestions are very wise.

I will check carefully my pathology report when it arrives in the mail,
and once I read it and learn more about the key issues, I will be able to ask my surgeon and pathologist the right questions.

The points that you raised are very important. As far as my
notes go (from the very short conversation with my surgeon), he called the bladder neck positive margin "focal" with less than 3mm extent and the Gleason score at the margin was 3+3=6. Indeed, it seems intuitive that a smaller margin and smaller Gleason score at the margin are more favorable. Do you know any publications from centers of excellence which give estimates on the likelihood of recurrence based on Gleason score at the margin and margin extent?

As far as I could tell from the phone conversation with my surgeon,
the cancer was confined to the prostate, and there was no EPE, which seems to indicate that my positive margin was due to an iatrogenic incision. Apparently the surgeon cut into the prostate,
making a pT2 stage into a pT2+. However, I read that it also possible to be a pT2+ from at pT3 stage, when there is EPE locally. So I plan to ask a question about this at my next conversation.

It seems also that the dissection of the bladder neck in robotic prostatectomy is done via electrocauterization, so it is possible
that the cancer cells left behind in the proximity of the margin
may die due to heat or lack of blood supply. But cells further away from the cauterization path may survive. I will prepare a question about this as well.

I think that you are right that it is uncommon in the US to initiate adjuvant radiation treatment just because of a focal positive margin. However, I have read that in Europe it is more common to have adjuvant radiation therapy for any type of positive margins. The new combined guidelines of ASTRO/AUA (that I found on the internet and posted in a previous note) seem to suggest that it is beneficial to have adjuvant radiation treatment earlier, rather than later, as it is standard in other types of cancer, even before biochemical recurrence. This might be because of some degree of arbitrariness in defining the cutoff PSA value for biochemical recurrence after prostatectomy, which varies from 0.1 to 0.5 depending on the studies. Anyway, I will consult also a radiation oncologist to hear his opinion about this issue, and will ask the very important question that you raised about the radiation side effects on a recently operated patient.

I have noticed that you had your surgery at Hopkins as well, and that you had a PSA test at 6 weeks even though there were no adverse pathological findings? Isn't that too early? I asked my surgeon if I needed to get a PSA test earlier because of the positive margin and he said that there is no need.

Thanks again for the input and all the best,

Joe.

Joe,

I live in Sacramento and was treated by the chief of Urology at Kaiser. DaVinci in January of 2013. I am very happy with my Kaiser coverage and service. The doctors that are on my team are great (I have epilepsy and have a Neurologist in addition to my Urologist and Oncologist - too many ..ist's in my life!). I also am very happy with the $$. Very expensive surgery and treatment, all for just $500!

Take care

Pat

Thanks, Joe.

Another tidbit of advice I like to give in general (this is after dealing with 4 bouts of potentially dangerous cancers, including my current PC), is to never let the cancer define who you are as a person. We don't really know each other away from HW, but whoever the real "Joe" is, needs to remain being "Joe". Joe may have PC, but the PC isn't Joe, if you follow me.

Even in my situation with failed treatments, fast climbing PSA, chronic fatigue and severe chronic pain issues, I am still the real "David". And I don't worry about things (you can ask other's here about that), and that includes PSA tests, etc. I will keep being me, for as long as I can. I am not happy about my condition and prognosis, but I am still happy about being me, and my life, and my wife, my family, and happy about the things in life that I enjoy.

From my perspective and situation, its all about QOL (quality of life), not quantity of life. And that is the focus of my oncologist as well.

David in SC

Hi Lewvino,

Thank you for your note and for your well wishes. I hope that your salvage radiation therapy produces good results. Let me know how it goes. I am
considering the possibility of having adjuvant IMRT just because of the positive margin, and having my first Post-Op PSA test done a bit earlier than the 3 months recommended by my surgeon.

What was the size of your positive margin (in mm) and what was
the Gleason score at the margin?

All the best,

Joe.

Hi DonaldJ (Don),

I think that we are in a similar boat. My surgeon's plan is also to have PSA tests every 3 months initially and see what happens. However, I am considering getting my first PSA earlier and having adjuvant IMRT.

I read that BN positive margins are very common with inexperienced robotic surgeons, so I was very surprised when I got one, as my surgeon was reasonably experienced. How about your surgeon?

I hope that everything goes well with you. I will keep you posted on my progress.

All the best,

Joe.

Dear NJS,

Thank you for references, if you have them handy in PDF format, feel free to send to my e-mail, otherwise, I will check them out in PUBMED. The paper that I read was also from Epstein's group, but it was specific for bladder neck margins.

Phillip M. Pierorazio,* Jonathan I. Epstein, Elizabeth Humphreys, Misop Han, Patrick C. Walsh and Alan W. Partin, THE JOURNAL OF UROLOGY Vol. 183, 151-157, January 2010.

Regarding your comment... "One thing I really appreciated about Hopkins was the sincere assurance from Dr. Allaf that "We'd don't abandon our patients". He told me they get a surprising number of emails from distressed patients who had their surgery done by other well-known, high-volume RALP surgeons and ended up with positive margins only to find that out that the surgeons then refused to even discuss with them!"

I was happy in choosing Hopkins for my surgery, and my initial preference was to have the standard open retropubic procedure, but I was reassured by my surgeon that with the robotic alternative he would get better results. I am bit in shock with the positive margin, because the Hopkins rate is very low (less than 2%), and because during the visit the day after surgery my surgeon was very confident that the surgery was a great success. In any case, I will try to think positively, and I hope that the G6 score at the margin will not cause trouble. I will ponder on your suggestion of being conservative.

I was wondering why did you choose open versus robotic surgery?

So far my post-op recovery has been very good. The catheter phase is almost over. I will have it removed in two days. The date for removal was set by my surgeon at the day I left the hospital. Is twelve days unusual for catheter removal? I read in the post-op instructions that the catheter should be removed between 10 and 14 days after surgery.

As far as continence and potency I have nothing to report yet, but I hope that your recovery on all fronts is going well after a few months after surgery. Keep in touch and also let us know how you are progressing.

All the best,

Joe.

robot said...
The paper that I read was also from Epstein's group, but it was specific for bladder neck margins.

Phillip M. Pierorazio,* Jonathan I. Epstein, Elizabeth Humphreys, Misop Han, Patrick C. Walsh and Alan W. Partin, THE JOURNAL OF UROLOGY Vol. 183, 151-157, January 2010.

Joe,

After reading the abstract for this paper and a couple others it cites (Buschemeyer et. al., Yossepowitch et al), my impression is that they are good news for your case.

My impression is that while PSMs at the bladder neck are associated with higher rates of recurrence vs PSMs at other locations, like that may be due, at least in large part, to confounding factors. I.e. PSMs at bladder neck are usually associated with aggressive / invasive disease and isolated / focal PSMs at the bladder neck are quite rare (only 79 out of nearly 17,000 patients in the Pierorazio series -- some some / many of which presumably may have still had EPE an not been pT2). The paper states:

"A multivariate proportional hazards model predicting biochemical recurrence-free survival and cancer specific survival was fit with prostate specific antigen, Gleason sum and pathological stage to determine the significance of a positive bladder neck margin... A positive bladder neck margin was not a significant predictor of outcome (p = 0.4) on multivariable analysis."

So, if your case is truly a focal iatrogentic PSM in otherwise pT2 disease, I would have to think that your risk is significantly lower than the typical PSM at the bladder neck.

Post Edited (njs) : 9/9/2013 7:15:17 AM (GMT-6)