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Positive margin - now what? Other treatments?

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Posted 2/14/2007 4:48 PM (GMT 0)
I had my conventional open RP on January 16.  The surgery went well, but the path report shows what I have a single positive margin.  I do not yet have my first PSA after surgery.    The literature seems very mixed about what to do in this case, but focused on only two possibilities -- watchful waiting, or immediate radiation therapy.  Are any of you aware of any new information about this?   Part of my question is since we know where the positive margin is right now, does anyone a) go back in laparoscopically to take a little more or b) do a seed implant right on the spot to direct the radiation?   Any thoughts on either question would be greatly appreciated.   My plan at this point is if PSA is undetectable, to do watchful waiting.  Otherwise, I'm not sure.   Thanks, Tony
Posted 2/14/2007 6:54 PM (GMT 0)
Hi Tony,
I'm Tony, Too!. I am at the City of Hope today preparing for my surgery Friday. If given this choice I would likely opt for radiating the penetration area, but I certainly do not speak as an expert on this. Not yet at least. Like you I am a Gleason 7 and my PSA is 13.5. Both a bit too high for my liking and with a high probability of capsular penetration. I will be asking this very question in a few moments. As all cases are unique, stay tuned for my Doctors response and also someone here will check in with you soon. God Bless and Good Luck.

tc
Posted 2/14/2007 6:56 PM (GMT 0)
Tony,

You may need to do nothing. A single margine supposedly does not increase your odds of recurrence as much as an agressive (higher grade) cancer would for example. Get into Entrez PubMed and look in the urology abstracts under prostate cancer for some related information. Also, Urology Times or MedScape Urology. These are helpful places.

A 3+4 tumor acts more like a 3+3 so there is one good thing. Your PSA is low...good thing. Your tumor burden is not small by any means but it's still in that moderate range...another good thing.
Following your PSA with an ultra-sensitive test for a while is probably the wisest action at the moment. Even if there is a rise in your PSA, it may take years to become significant enough to treat. It could rise just a tad and remain there forever. So many variables. What has your surgeon suggested? So far I like your plan!

PS: Modified Citrus Pectin.....read about it in Entrez and Life Extension.

Swim
Posted 2/14/2007 7:16 PM (GMT 0)
hi tony

sorry to hear about your positive margins after surgery. the first question is what advice have you received from your surgeon about this? the members here would be interested in what he said.

there are many cases like yours where surgery is followed up with radiation when it appears that all of the cancer was not removed. you should get a PSA test which may give you some idea of how serious the positive margins are--the lower the better. after surgery it should go to zero. the purpose of surgery or radiation is to eradicate the cancer. i wouldn't want to risk retaining any cancer in my body after surgery if possible--that is the purpose of surgery (i.e., get rid of it). if you elect some form of radiation treatment, consider proton radiation because it is a safer form of radiation than x-ray (photon) radiation. i don't think you would implant any radioactive seeds in the margins where the cancer might still exist. the seeds are only implanted in the prostate as far as i know--you no longer have a prostate. it just means that some of the cancer escaped beyond the prostate capsule.

look for recent postings under "another newbie" discussing cancer recurrence after surgery. this particular case is more serious than yours, but i think you may find some helpful advice there. good luck and good wishes.

Dave
Posted 2/14/2007 7:18 PM (GMT 0)

Tony,

I had a similar experience.   open RP last June with a positive margin --- Swim is right (as usual).  You may have to do nothing, but do the ultral sensitive PSA as your doc directs.   Mine bounced around between .04 and .09 for a few months, then jumped up to .24.  My best research indicated .2 as the point where you want to act.

When I consulted with my onc radiologist, he was more concered with my age (46), pre-surg PSA (39) and tumor bulk (lots!) than the PSA recurrence.  I just now complted 36 sessions of daily IMRT radiation, and am on 6 months hormone thereapy.

Happy to report MINIMAL side effects from both --- heard a lot of "horror stories", but no real problems -- just an inconvenience.   There are also a hand full of proton therepy facilities, but I didn't see a huge advantage for salvage/adjuvant radiation on proton vs IMRT.

The only additional advice I'd give is is don't be afraid to consult with a radiation oncologist just to get their take on your situation, and to see at what point they'd treat you...GOOD LUCK

Posted 2/14/2007 8:30 PM (GMT 0)
sterd 82

you indicate that you have had no side effects from your IMRT x-ray radiation. that is good news! IMRT is the most sophisticated form of x-ray radiation today. however, keep in mind that with radiation, some of the longer-term side effects do no immediately appear. in particular, a certain percentage of men will experience some degree or possibly total importence down the road. in many cases, the impotence can be overcome with viagra and other similar drugs. rectal bleeding is also ultimately possible, although it is not usually very serious, at least with proton radiation.

you indicate that you did not see a huge advantage to proton therapy over photon (x-ray) radiation. there is no question that proton radiation is considered safer in terms of protecting good tissue surrounding the area being radiated. the benefit of proton radiation compared to x-ray radiation may not be seen until months or years after the radiation treatment in terms of the longer-term negative side effects that could appear. you indicate that you have heard a lot of "horror stories" about radiation (i assume you mean x-ray radiation), especially nasty rectal and urinary complications that happened years ago this is true of some of the more primitive forms x-ray radiation in years past before IMRT radiation came on the scene. i know that some experts believe that IMRT (x-ray) radiation is equivalent to proton radiation in terms of effectiveness and safety, etc. i personally don't agree based on my research. I will take my chances that i will ultimately have fewer negative side effects with the proton radiation treatments. with so many new proton centers opening across the U.S. recently, there has to be some advantage to it considering that each center costs $100 million or much higher.

i wish you the best of luck as you good forward and hopefully you will have rock botton PSA tests. anyone who has to endure surgery, radiation and hormone treatments to eradicate their PC deserves a gold medal of distinction among PC patients!

Dave
Posted 2/14/2007 9:31 PM (GMT 0)

Dave,

Thanks for the clarifications on my post.   Your're absolutely right on several key points.

Impotence is the biggest concern for post-radiation side effects.  Unfortunately, due to the nature of my particular prognosis, my original prostatectomy was non-nerve-sparing, so I was already dealing with that.  Incontinence can also sneak up on radiation patients over time, -- so far so good on that.

Looks like you're going to do proton as a PRIMARY therapy, as opposed to salvage therapy like I had.   I researched proton and talked to two different ceters, and I believe I would opt for proton  as an initial thereapy --- I was very impressed with the reports of fewer did effects, especially relating to potency.  I live about 3 hours from Bloomington Indiana where they do proton thereapy.  In my case, I really did not see as big of advantage because in salvage thereapy they tend to radiate around the prostate bed where they "think"  the residual disease might be, as opposed to zapping a specific tumor.  The marginal benefit didn't overcome the additional hassle in my case.  I think you're on the right track --- GOOD LUCK!

Posted 2/14/2007 10:22 PM (GMT 0)
sterd82

thanks for the response to my message. after what you have gone through, i hope and pray that you do not have to suffer side effects from radiation down the road. i have so much empathy for young guys like you with PC--it isn't fair. i thank my blessings that i didn't have to deal with PC until my later 60's after retirement. if i had been at your age, i probably would have opted for surgery. i didn't realize until lately the fairly large percentage of men that get recurrent cancer sometime after surgery. of course, we all have that hanging over our heads for the rest of our lives notwithstanding what treatment we select. however, you do what you have to do and hope for the best. message boards like this are very helpful because you realize that many men are in the same boat and going through the same trials and tribulations. until you actually get PC, you really have no concept of the true impact of PC on one's manhood. all the best.

Dave
Posted 2/15/2007 12:07 AM (GMT 0)
Any life altering illness has an impact on the person affected. None of us are thrilled by having to face mortality or the feeling losing our vitality. I was soooo thrilled to be done with woman parts at 33....what was I thinking? The high risk of cancer was gone...everything seemed great. Then...ya realize what all the hormones were really about! All is well, albiet not like the original equipment.
Life moves forward whether we're on the bus or not. We have to jump on board lest we miss the scenery.

Be Well, Swim
Posted 2/15/2007 5:00 AM (GMT 0)
hey ospc

I'm in the same boat, waiting for my first post surgery PSA.  I thought I was almost being overly agressive having robotic surgery with such a small amount in my needle biopsy.  When I received my post surgery report showing positive margin and capsule penetration on the side that was clear on the needle biopsy, my jaw hit the floor.  Having a gleason of 7 and pre surgery PSA of 4.7, and clear lymph nodes helps keeps my hopes up that my post surgery PSA will be low.  It's the waiting for a month that's driving me nuts now, but with prayer and good thoughts, I'll get there, and so will you.

Posted 2/15/2007 6:36 AM (GMT 0)
Hi Tony,   I agree with waiting until you PSA results come back. It is time to let the body heal and let the mind try to settle before you plow back into the research arena.     Take this time….. it really is important that you are “mentally” ready for the next stepping-stone.   And as Swim says….   You may be able to bypass the radiation if the scores come in good!!!!   Hope ~ keeps us all on steady stones.   Know we are here anytime you need us!!! Did you get the donut pillow???   Keeping you tucked extra close to our hearts at this time. In Friendship ~ Lee & Buddy
Posted 2/15/2007 10:06 PM (GMT 0)
Thanks everyone for the thoughts.
I'll stay in touch.

Tony
Posted 2/18/2007 7:53 PM (GMT 0)
Hi all,

This is a great thread.

I am Gleason 10, RRP in Nov 2006, with positive margins. From everything that I read, with my high grade cancer and positive margins my odds of recurrence are over 90%. I am still waiting to hear back from my surgeon but all my other docs are recommending further adjuvant (before my PSA increases) therapy.

I am very interested in all the discussion about different types of radiation for adjuvant therapy after RRP. Any additional information on that subject would be much appreciated.

Ben
Posted 2/18/2007 10:48 PM (GMT 0)
Ben - wonderful post surgery PSA - wonderful.
Your right... this is a great place to share with and learn from.
As you can see from my husbands stats we're not out of the woods and with the help of others here we're checking on possible additional treatment.

Wishing you all the best,
Susan
Posted 2/21/2007 5:41 PM (GMT 0)
Hi Susan,

Thanks for your kind words. I saw your thread. I hope that all works out well for you and your husband. This is frightening stuff but all the information on this website sure helps us to make the best possible decisions.

Ben
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