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Apex, Base and a discussion on positive margins

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Posted 6/19/2018 9:16 PM (GMT 0)
Consensus seems to indicate that positive cores on apex side is not as favorable as positive cores on base side. How much emphasis would you put on positive core location when determining when/if to proceed to the next course of action? I think I read something today that positive margins occur more on the apex side?
Posted 6/20/2018 8:41 AM (GMT 0)
It is true that positive margins are more likely to occur at the apex, because the capsule is indistinct there. It is not true that apex tumors "are not as favorable" as base tumors. The risk level is the same. Risk is based on PSA, stage and grade - not location within the prostate.
Posted 6/20/2018 9:50 AM (GMT 0)
I’m glad you started this thread. That very point was brought up in my diagnosis thread a few days ago and I’m considering AS as I’m a G6 but both positive sticks were in the left apex. Tall Allen’s clarification is very reassuring to me.
Posted 6/20/2018 1:40 PM (GMT 0)
EJ you had not included a sig when I replied on the other forum, but now I see you are on AS. Do you know the locations of your + cores? It's probably nothing to be concerned about at this stage. But yes, PSM is more likely at the apex, which may lead to recurrence down the road. But if so (as I understand it) the PSM makes a more favorable target for salvage RT and in the nomograms that TA explained to me a few months back, having a PSM is actually more favorable in the event of BCR.

The problem with tumors at the base is that they grow undetected by DRE being tucked away under the bladder, as was the case with mine. But you already have your diagnosis, and it appears at this point to be favorable.
Posted 6/20/2018 1:46 PM (GMT 0)
Actually I read your thread and didn't want to hijack it. Welcome by the way. Other than a second opinion from Johns Hopkins, I think you can rest and think things out. I would ask about AS and an mpMRI right off the bat to give you that additional data. As far as I go, I have 4 cores on the Apex side this time around. 5%,5%, 20%,30%. The number of total positive cores is my concern.
Posted 6/20/2018 2:04 PM (GMT 0)
Hey Rob Lee,
Thanks for that info btw.
The 4 positive cores from the April 2018 bx were LL Apex=30%; L Apex=20%; R Apex=5%; RL Apex=5%. JH downgraded the 30% and 20% to 20% and 10%. March 2017 bx included LL Apex = 5%. My gut tells me I just have too many cores in general. The two bx's combined show less activity on the base side. Twice showed RL Base = 5% and MRI showed 2 lesions in that RL Base.
Posted 6/20/2018 2:06 PM (GMT 0)
Thanks for the welcome. It sucks we all have to meet here but I am so thankful we have this place. It’s been a tough few days but I really don’t know how I would have managed without everyone here. My brief 4 minute call from the Urologist was him giving me my numbers and telling me that with my numbers it’s very treatable. Somewhat comforting in the sense that I am not in imminent danger of dying but with no mention of AS and the possibility of delaying or even forgoing treatment with its possible side effects.. And the ONLY place I got the info is from everyone here. What a relief just knowing it’s possibly an option. I hope you can stay in AS indefinitely. Good luck!
Posted 6/20/2018 2:22 PM (GMT 0)

ejc61 said...
My gut tells me I just have too many cores in general.

You're right, that is a lot of + cores, but they appear to be low volume and low grade, at least at this point. Other guys who are more familiar with AS and radiation options for diffuse low grade PCa will likely chime in. Admittedly I'm not the guy to answer your questions going forward. I would say at your young age and stage that you have a good chance of beating this if you wish to proceed with treatment. Good luck!
Posted 6/20/2018 3:06 PM (GMT 0)

RobLee said...

ejc61 said...
My gut tells me I just have too many cores in general.

You're right, that is a lot of + cores, but they appear to be low volume and low grade, at least at this point. Other guys who are more familiar with AS and radiation options for diffuse low grade PCa will likely chime in. Admittedly I'm not the guy to answer your questions going forward. I would say at your young age and stage that you have a good chance of beating this if you wish to proceed with treatment. Good luck!

Thanks. I'll know better next week when I consult with Uro surgeon and RO.
Posted 6/20/2018 3:14 PM (GMT 0)

convertible68 said...
Thanks for the welcome. It sucks we all have to meet here but I am so thankful we have this place. It’s been a tough few days but I really don’t know how I would have managed without everyone here. My brief 4 minute call from the Urologist was him giving me my numbers and telling me that with my numbers it’s very treatable. Somewhat comforting in the sense that I am not in imminent danger of dying but with no mention of AS and the possibility of delaying or even forgoing treatment with its possible side effects.. And the ONLY place I got the info is from everyone here. What a relief just knowing it’s possibly an option. I hope you can stay in AS indefinitely. Good luck!

Usually a discussion of all the options comes up when you schedule a cancer consultation with your Uro. The 4 minute phone call doesn't count. As far as AS, 50% of AS patients come off and go to intervention after 10 years due to changes in condition or even change of heart so it's understood it's one day at a time.
Posted 6/20/2018 3:58 PM (GMT 0)
TA stated
"It is true that positive margins are more likely to occur at the apex, because the capsule is indistinct there."

Isn't that a definition of a higher risk for surgery candidates? Indistinct capsule, harder to cut, maybe have to cut wider , do more collateral damage, leave behind microscopic cells
Posted 6/20/2018 5:04 PM (GMT 0)
I might agree with you on that, other than the "maybe have to cut wider, do more collateral damage" part. It seems to me that the indistinct tissues there would cause a surgeon to perhaps do more delicate scraping rather than cutting, being careful to not venture too far into critical tissues in the pelvic floor. Further up the prostate it's mostly wiring and plumbing that may be subject to the broad cut, like me. Just my thoughts on the matter.
Posted 6/20/2018 5:23 PM (GMT 0)
As for the number of positive cores, it puts you into a category called "low risk" rather than "very low risk" (which includes the additional "Epstein criteria": ≤2 positive cores, ≤50% cancer in any one core, and PSA density≤0.15). There is no "standard" AS protocol for entrance or treatment triggers. Johns Hopkins uses a very strict AS protocol. Sunnybrook (which has the longest running AS program in North America) and Memorial Sloan Kettering (MSK) use less restrictive AS protocols. The 15-year treatment-free survival was 56% at MSKCC and 55% at Sunnybrook — nearly identical. Johns Hopkins (JH), using tighter entrance criteria and more stringent triggers for intervention, reported 43% had avoided curative treatment at 15 years. 15-year metastasis-free survival (which tells us how successful their protocol was) was 98%, 97%, and 99% at MSK, Sunnybrook, and JH, respectively. This suggests to me that there is little to be lost and much to be gained by following less restrictive entrance and intervention criteria. Better diagnostic methods (like mpMRI-targeted biopsy or template-mapping biopsy) may be able to mitigate any small increase in risk.

Fauntleroy - apex tumors carry a risk for positive margins, mid-gland tumors carry a risk of NV bundle invasion, and base tumors carry a risk of seminal vesicle and bladder invasion. But as long as they are contained within the prostate (Stage T2) the risk of recurrence after surgery is about the same.
Posted 6/20/2018 11:08 PM (GMT 0)
Thanks for clarifying that TA. Maybe this should be another thread, but wouldn't radiation be a better treatment because it covers these areas just outside the prostate bed. As we all know,the biopsy that we are basing the treatment decision on, is from a very small sample only.
Posted 6/20/2018 11:50 PM (GMT 0)
I think that position of tumour has a lot to do with the prognosis...forgive me for cutting to the chase by wrapping all the many words...which need the art of a Master Rubic Cuber to figure out...in one simple word prognosis...division makes things more difficult...unity less so...the major tumours in my prostate were well away from the sides making the interior wall of the walnut and with that obviously the "harden" capsule the walnut was wrapped...there is quite a bit of information that comes from a few experts here...that receive only a token challenge...and they know why...some how tho...it is a sign of the time...cirque de politique...I always provide a salve for that which cuts...today it will go by the name...
Posted 6/21/2018 12:09 AM (GMT 0)
Fauntleroy - Radiation can reach anyplace inside of the capsule or not, so for T3/T4 cancers, I agree with you that it definitely has an advantage. An Italian group developed a new risk stratification system just for radiation patients:

/pcnrv.blogspot.com/2016/08/risk-stratification-for-radiation.html

No one wants to see any major changes in risk stratification systems because all clinical trials in this century have used basically the same system. if it changes, all that past data becomes useless.
Posted 6/21/2018 12:30 AM (GMT 0)
I was told by three doctors that Apex tumors were a higher risk for incontinance when having surgery. One of the deciding factors for me having radiation vs surgery.
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