Most common failure mode for RP?

Hi All and thanks for reading,

As I understand, there are two difficulties faced by the surgeon during a Radical Prostatectomy (RP). One is that there is some blood loss, about 200ml more or less as I am told. The second is that the margins are so small physically. Sometimes a few non-visible cells are left behind.

My question is, what is it that most often happens with a recurrence?

Is it that, several years later, some PCa cells are found in the prostate bed (where prostate used to be)?

Or, is it that the PCa is found spread to distant locations due to the blood loss?

Can anyone venture an opinion based on what they have seen?

Surgical blood loss does not spread PCa. The cause of surgical failure is that there are PCa cells outside the surgical field. They could be outside the surgical margin, in the bladder neck, in lymph nodes and nerves leading from the prostate, or more distant as in bones, lymph nodes or sometimes other organs. These could all be microscopic at the time of dx and not detectable by either the surgeon or any scans.

I have read numerous times that about 35% of surgeries fail, concentrated among the intermediate and high risk situations. We have many such men on the forum. Low risk true G6 rarely fail as G6 can not spread away from the prostate so is most always all removed with the prostate. Failed surgery must be followed by salvage radiation in those cases where evidence shows there is still a chance for curative treatment.

Radiation as an initial treatment can cover a larger area than surgery can excise and can include the pelvic and some abdominal lymph nodes, common sites of initial PCa spread. A surgeon can not excise all the lymph nodes that radiation can treat because many simply can’t be found and the lymph vessels can not be completely excised, but may harbor PCa cells. In unfavorable intermediate and high risk situations radiation treatments have a much better success rate than surgery alone.

Thanks.
Keep it coming..

It is known as circulating tumor cells. It is estimated that 50% of men age 50 have PCa circulating tumor cells that can be detected in a blood test. Then that percentage increases in line with age. Prostate surgery and biopsies in no way increase this or pose cancer spread risk. PCa is very blood borne, but as Hal pointed out most of the cells can not get somewhere to take hold and thrive.

JNF has me thinking..
I read a book called The Cancer Code. It described a whole new theory of cancer that i had not heard.

It is now thought that mets are thrown off much earlier. But the first mets are very weak. Most can not survive. They get torn up flowing through the bloodstream. They try but can not survive if they are able plant themselves somewhere.

But... one makes it through the circuit.. and luckily.. lands back in the SAME organ it started from. Furtile welcoming soil from which it started.

It is a tougher critter than those around it. It throws off mets that also return. They get meaner and tougher.

Eventually, the newest mets can land anywhere and thrive.

This seems to go along with what you all are saying.

Most likely, any PCa cells spilled into circulation from an operation or procedure would be still too weak having not evolved yet.

From the studies I have read, positive margins are not that big a deal. Perineural invasion, Lymphovascular invasion, stage 3b and positive nodes are.

Most studies I have seen have determined that positive margins are a significant risk factor for BCR.

"It is known that positive surgical margins and a high Gleason grade (GG) of the margins have a negative impact on long-term oncological outcomes" Oncologic outcomes of organ-confined Gleason grade group 4-5 prostate cancer after radical prostatectomy (2022)

"Although numerous studies have reported that a positive surgical margin (PSM) is the most important predictive factor for biochemical recurrence (BCR) of prostate cancer (PCa), only a small number of studies have evaluated the predictive value of the Gleason score (GS) of the tumor at the margin in radical prostatectomy (RP). " Impact of Gleason score of the tumor at the positive surgical margin as a prognostic factor (2022)

Studies vary about the importance of PNI (perineural invasion), but the majority I have seen have concluded that PNI when seen at biopsy is statistically associated with the an increased likelihood of there being adverse findings (if surgery is chosen as therapy). Over time, prostate cancer tends to invade the fine nerves inside the prostate, and evidence of this in the small amount of tissue samples in a biopsy may indicate that the cancer has been around longer. It has not been demonstrated that PNI prognosticates recurrence, mainly because some studies have found that >80% of men who choose surgery have the finding of PNI. This points, rather, to the affinity of PCa for the nerves. Whether nerve infiltration is a major route out of the prostate for metastatic (non-contiguous) cancer remains to be seen, although there is some evidence for it. While someone might want to take PNI seen at biopsy into account in choosing a primary treatment (although MRI data would IMO be much more important), I have never seen post-RP PNI listed in a treatment algorithm/guidelines for adjuvant or salvage therapy.

Djin

RobLee said...
that's know as micro mets. I've forgotten the technical name for it.

JNF said...
It is known as circulating tumor cells.

I was thinking of Oligo-metastases, metastases that cannot be detected by current scans.

Rob, those tumors are large enough to be seen and then often be zapped with radiation. 5 or less are deemed to be treatable by current standards in the definition of oligo-metastases. Oligo loosely translated means ‘a few”. This classification of detectable and often treatable tumors has been in the standard of care for about 15 years. Dr. Snuffy Myers was a vocal proponent of treating them for cancer control.

The tumors that scans can’t see are micro-Mets. A clump of cells anywhere from a few hundred to more then a million. Active and dangerous, but too small to be seen unless under significant magnification. No scan can find them, but they can contribute to an increasing PSA expression.

50ml sounds nice and low.
Maybe due to a fairly experienced surgeon.

Blood loss isn't usually a problem with RP. If I remember the article, open RP averages 50 cc more than robotic. The blood loss from my open RP was just 100 cc.

Djin

Laparoscopic surgery in general causes minimal blood loss. The internal surgical camera requires low blood loss, otherwise there wouldn't be surgery.

My prostate was carved out with a cauterizing scalpel. There is no bleeding during the procedure. I've watched a video of the surgery (not my surgery), and most of everything in view is a shade of white.

I am hoping the scrotum swelling and purple color was not from manhandling… Although it may have been a convenient way to reposition my body….