Welcome New Member Sister111 Who Has a Question

Hello and Welcome, Sister111.

The post-op finding of positive margin(s) vs. negative ones is a separate issue from positive vs. negative lymph nodes.

(Margins refer to the cuts made by the surgeon. You want negative margins, which indicate that no benign and/or malignant tissue was left behind at the cut margins. Positive margins result when either (1) the cancer extended too far into adjacent tissue to be removed without damaging the neighboring anatomical structure or (2) the surgeon made an inaccurate cut. The second is more common during the surgeon's learning curve for the RP procedure. Positive-margin rates are monitored in this period.)

When prostate cancer spreads, it has an affinity to travel via the lymphatic system to lymph nodes, especially pelvic nodes, and, of those, those closest to the prostate in the lymph-node chains draining the prostate are the more likely to be positive. Usually the biopsy Gleason score determines the number of lymph nodes the surgeon removes (or, more precisely, the anatomical area that the surgeon will clear of nodes). I would say that about half of surgeons remove no nodes for Gleason 6 (3+3) biopsies and the other half 1-3 nodes. Then, as the biopsy Gleason score goes up, the number of nodes removed does also. As an example, I had a G10 (5+5) biopsy, and 16 nodes were removed at my RP (none of which were positive, fortunately).

A finding of positive or negative lymph nodes after surgery does not tell you what was left behind. One assumes and hopes that negative nodes predicts that the remaining nodes are also negative. If one or more nodes were positive, there is logically a higher chance that there may be metastases or micrometastases in the remaining nodes, although it is also possible that all one's positive nodes were removed.

Depending on many factors (e.g., pre-op PSA, final Gleason score, post-op PSA values and trend, percentage of prostate involved by the cancer, other findings such as seminal vesicle invasion, EPE, and lymph-node status), a decision will be made whether adjuvant treatment (pelvic radiation and/or ADT) is advisable, or whether one can wait and use the PSA trend to determine if and when salvage RT and/or ADT is indicated at any time in the future.

If his PSA did not drop to an undetectable level a month or two after surgery, this "persistent PSA" is serious, since it indicates prostatic tissue remains after surgery, perhaps in the form of mets. Adjuvant therapy is usually advised.

Advanced scans may be helpful for locating remaining positive nodes.

More information would be helpful if you have it:

What was the biopsy Gleason score (since 11 nodes were removed, I would guess perhaps G7?
What was the post-op Gleason score?
What were the pre-op PSA and the post-op PSA values?
Was a bone scan done in the workup? If not, his doc will likely want one now.
Were any enlarged lymph nodes seen on any workup imaging (e.g. CT scans?)
What have his doc said about follow-up diagnostics and treatment?

All the best,

Djin

The surgeon makes certain necessary cuts to free (dissect) the prostate, plus any additional ones needed, like from fatty tissue surrounding the prostate. You'd have to watch actual surgery videos to get a better idea of when cutting is needed as opposed to other separation techniques -- I would think the cuts go around the prostate, but are probably a little or very discontinuous, depending on the "latitude" (top to bottom of prostatte). Although my surgery took 4 hours, my uro/surgeon said he had no trouble freeing my prostate and that it "popped out." Other men's prostates may be more adherent to adjacent structures and require more cutting.

All that counts as far as the surgical margins go, is that the only benign cells were observed in the post-op path exam. Again, surgical margins have nothing to do with lymph-node status. Lymph nodes are separate structure outside the prostate capsule. You doc may or may not be able to tell from the report whether the positive node was closer or farther from the prostate, but I'm not sure this matters. (When I mentioned a couple of my removed nodes were iliac nodes, my uro/surgeon didn't think the pathologist can always tell with great accuracy).

Let us know how the meeting with his doc goes and, later, his first PSA result. Remember, we are not docs and I'm giving general info as I've come to understand it

Djin

Post Edited (DjinTonic) : 12/17/2020 8:27:39 AM (GMT-7)

logoslidat said...
the way I read sisters 111 was that only one node out of 11 was removed...your analysis was great untill the very end of your post Dgin..." since 11 NODES were removed.I would guess 3+4(gleason score) perhaps....I reckon as long as you and threader are on the same page...hey what do I know...???...im out of the business of commenting on this stuff as it is usually received non positively(in keeping with the 800 lb nodes in the threaders post and...less so...in your reply) or just ignored...scalpel out of hand....this is what happens on forums like this and why there is routinely misinformation...in an a continuous game of telephone...if this post is misunderstood...consider it karma negative or positive...ich mach nix...regards logo

Where would the other 10 nodes be ? A path report contains the total number of nodes removed and, out of those, the number that were positive. Surgeons don't remove a single node when the biopsy is G7 (4+3), which is why I guessed a G7 biopsy above when I saw the number 11. BTW, the N1 in a path report means that one or more nodes were positive, as opposed to none, N0. Similarly, an R1 means that one or more surgical margins were positive, as opposed to R0. Why the letter R, you ask (well, I did)? I believe it stands for "Resected margins."

Djin

Post Edited (DjinTonic) : 12/17/2020 8:45:45 AM (GMT-7)

Im more confused now then earlier...did not sister say that only one node was removed out of 11...is that not a factual statement at the very beginning of her initial post...speculation be dammed... any way pca vernacular is confusing...newbies and veterans beware of misinformation....at its best...communcation is tenuous in any venue....and again why forums like this have a subtle contagion of...again ...negative/positive depending on context...heck life is all context and perspective....well Im off to say yes...or is it no...to the world///pick your "poison"

Hi Sister - It is my understanding that prostate removal and lymph node removal are separate procedures done during the prostate removal surgery where the lymph node part is done after the prostate is removed when required.

There is a "stuff" around the removed prostate regardless of how it comes out. The pathologist is given this intact mess in a little bag and he sorts it out. The surgeon or pathologist covers the removed prostate with an ink so that the removed surface is highlighted and can be defined relative to limits of the actual prostate when the sections are made.

I think for the purposes of your brother's situation, he has a positive lymph node and EPE as additional risk factors to the G7(4+3) classification. EPE means that cancer is past the limits of the prostate, negative margin means that the surgery did not cut into the protruding section which means it was contained within the surgical margin.

Once cancer is living outside the prostate limits, it becomes an additional risk factor based on the many studies done over the years. Cancer in the lymph node is the same issue. The two together are 2 risk factors with greater risk than either one by itself. Keep in mind these are just probabilities and statistics and do not apply to any specific case.

I went through similar analysis pains after my surgery and the first items of business is full recovery from the surgery and the PSA test at 3 months or 12 weeks. Absolutely nothing will be done prior to that time so no sense getting too worried about the future while he has his hands full with the recovery.

At three months, the story will become much more clear (he has a PSA or he doesn't). In either case, he will have to visit a radiation oncologist (RO) and discuss possible treatment options. I would guess that adjuvant radiation (ART) will be proposed and include the lymph nodes. If his PSA is undectable, it provides more time to consider options and consider salvage radiation at a later time. If his is measurable then they will be more insistent on beginning shortly after 3 months.

Hope this helps a little from a PCa patient and not a doctor. The doctors will provide most of the info at the 3 month checkup if it goes like mine did.

Sistah111. Apex =top...Base=bottom...negative margin = positive....positive margin=negative

All this is canceled out in quantum mechanics lol

Djin - I edited my first paragraph so I says what I meant.

The number of lymph nodes removed seems to be more a function of the urologist than anything else. Some do not get lymph nodes taken when it seems like they should, others have many taken out that would seem to be excessive for the diagnosis. There is negative side of taking too many lymph nodes so you would think that the criteria would be better established.

Thank you all for your help.

A little more information — there was a notation written by the pathologist about the one small pelvic metastasized lymph node. He wrote: “Immunohistochemical stains for pankeratin are attempted, but the small focus of metastasis is gone on deeper levels.”

Any thoughts?

Thank you.

I went into open surgery as a 3+4 and had 29 nodes removed all negative (remember kids...this is good)...to mumbo’s point...this to my view created a “ fire wall “...that still holds(yes I am aware that systematic cancer may be around that was there for years...even tho path report showed not only prostate contained but capsule contained as well...I realize this containment concept will confuse sis 3...but I for one believe newbies should come to a forum with a basic knowledge of this disease and not just “depend” on a few “experts “ to do all the heavy lifting for them...support is a two way street...this is my opinion only and should not be construed as negative support but as positive...listen and learn...logo

What I would do if that were my report would be to send it to Dr. Epstein at John’s Hopkins in Baltimore, MD.

This is very easily done. It usually consist of nothing more than a call to your surgeon’s office requesting that everything be sent to him for a second opinion.

That node may not even be cancerous. Dr. Epstein’s word I would go with.

Good luck and take care.

Sister, kudos to you for being your brothers advocate! I am the same for my husband... it’s a very important role. One thing we have learned iduring my hubby’s prostate cancer journey is that you must advocate for yourself !
The next step is to send your brothers pathology slides to Dr. Epstein at Johns Hopkins. He is the leading prostate cancer pathology expert in the world... literally. He is also incredibly generous with his time. He will consult with you via email or phone after he has examined the slides. If your insurance doesn’t cover it, the self pay is SUPER reasonable... it’s less than $300 I believe.

Skypilot56 said...
Hi Sister and I concur with the other guys that a negative margin is good news. I see your Husband's path said he was a t3 with possibly a lypmh node that was positeve. My guestion for the guys is if they find that the cancer has spread to the lymph node would the diagnosis be changed from stage 3 to stage 4? Larry

Sister stated the post-op path score, which is indicated with a leading "p", in her original post: pT3a N1.

The T staging indicates whether local growth was confined (pT2) or not to the prostate. He is pT3a and not pT2 because there was EPE. They did find that cancer had spread to the lymph node, which is why he is N1 rather than N0. The status of local nodes can be 0 or 1 regardless of the pT score. Similarly, the status of surgical margins is indicated separately, so, for example, a pT2 staging can be with negative (R0) or one or more positive (R1) margins.

Skypilot, you were pT3b N0. pT3b refers to spread to at least one seminal vesicle (you would have been pT3a if you had only the EPE). But all your many nodes removed and examined were negative, so you were N0.

TNM staging separates the prostate and neighboring anatomical structures (T) from mets local nodes (N) and mets to more distant nodes and/or other organs or tissue (M). Spread by contiguous (i.e. non-metastatic) growth outside the capsule, into the seminal vesicles, bladder neck, bladder, bowel, etc. is all contained in the T staging as I understand it.

Djin