POSITIVE MARGINS FOLLOWING SURGERY. WHAT TO DO NOW?

Hi again,

I will kick the dialog on positive margins off by copying excerpts from some of my postings and other people’s postings on this subject that I have seen on other threads. In many cases, I pulled out only the relevant part of a longer posting to avoid making this entry too long. I am sure that I missed lots of relevant postings so please excuse me if I missed your posting. Feel free to copy your (or anyone else's) old posting on this topic and add it to this thread or to start a new posting.

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THREAD: BenEcho10 Journal.   POSTED BY BenEcho10.   Date: 01/12/07.

PATHOLOGY: POSITIVE MARGINS: The pathology on my prostate showed that the cancer had penetrated the capsule of the prostate and that I had positive margins. This meant that my surgical stage was raised to T3a. This was precisely what the Partin tables had predicted (given my PSA, clinical stage, and Gleason score) but it was still very frightening. I had the dreaded positive margins. The good news was that no cancer was found in my seminal vesicles or in my lymph nodes. Although the cancer had escaped the prostate it did not seem to have gone anywhere. I have read (in Dr. Patrick Walsh's book I think) that any cancer left behind might die due to the lack of a prostate gland to support it or it might have been killed from the trauma of the surgery. Here's hoping. Still, I have read some statistics in Dr. Walsh's book that due to my high Gleason and positive margins I have about a 50% chance of recurrence down the road. I will have that hanging over me for the rest of my life.

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THREAD: BenEcho10 Journal.   POSTED BY: GreenAcres.   Date: 01/12/07.

As you can see by stats below, we're in a similar boat, although in a different age group. Our percentage of recurrence is high, but not enough to warrant any further treatment at this time, especially with an undetectable PSA count, which was our first "turn of luck" since last May. I was especially heartened to see your info regarding the possibility of cells dying out with nothing to feed on. We will remain encouraged with that.

We're scheduled for the next PSA in April and there will always be that dread. We think, though, that if the next one's clean, perhaps the worrying will subside somewhat.
________________________________________
Husband age 65
PSA on 5/1/06: 4.2 (had doubled in 13 mos. and rising monthly)
DaVinci Surgery 8/2/06
T2a (at biopsy)
T4c (at pathology) w/cancer cell leakage into fatty tissue
Post-Surgical PSA on 10/3/06 - undetectable!
Update: 11/1/06 - perhaps bladder neck involvement; 30%-50% chance of recurrence
Future: PSA tests twice-yearly for now

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THREAD:BenEcho10 Journal.   POSTED BY BenEcho10.   Date: 01/12/07.

 
I agree with you about not seeking out further treatment until it is more clear that it is needed. I have a 60 year old business acquaintance with similar stats to ours who, after his surgery, is doing chemo, hormone, and starts radiation shortly. I understand his desire to aggressively attack any possibly remaining cancer cells but I am having a hard enough time dealing with my side effects now. I sure don't want to bring on any more unless I absolutely have to.

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THREAD:BenEcho10 Journal.   POSTED BY:GreenAcres.   Date: 01/12/07.

I did question the doc on waiting until April for the next PSA and he "swore" to me that all would be well. We, like you, don't want to add any further issues unless absolutely necessary. Not for one minute did we regret the surgery - even if we had known of the spread, we would have wanted the prostate out first to know exactly what we're dealing with instantly. Luckily, we were good candidates for making that choice. For now, we will remain in la-la land about the change in predicted recurrence and keep riding on the .00000. I'll be drilling in on that one at our April visit.

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THREAD:BenEcho10 Journal.   POSTED BY: BenEcho10.   Date: 01/17/07.

I have been continuing to research the implications of my high Gleason and positive margins. From what I have studied, it sounds like my chance of recurrence within 7 years is 50% or more.

I am confused by the conflicting information that I have heard about whether it is better to go ahead and start immediate radiation and/or hormone treatments in the near future even with a 0 PSA right now or is it better to wait until my PSA increases (maybe it won't increase for years or even never.) I have heard that the sooner you start follow-on treatment the better the odds of killing the cancer or at least slowing the advance of any future recurring cancer and thus extending my life. On the other hand, I only have a chance of recurrence vs. the certainty of damage and side effects from the radiation and hormone treatment. What a terrible decision to force on someone. This disease absolutely, positively, stinks.

Does anyone have any thoughts on this subject or know of useful reference books or internet sites?

It is depressing to even consider the fact that I may not be done with this thing.

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THREAD: BenEcho10 Journal.   POSTED BY: Swimom.   Date: 01/17/07.

Ben,

---Heal as much as you can before doing anything more. 0.00 is worth waiting a short while IMHO but you have to do what is right for you.

---If you can get a year...maybe forever without further treatment, that would be a wonderful blessing. Somebody has to be that 50%! If indeed your cancer has spread, it'll show its face within months most likely.

---I know there is a protocol being used that takes a high risk case and slams it for something like 18 months with hormone deprivation and or chemotherapy. So far there is some promising early results.

Get into the archives of Entrez PubMed @www.ncbi.nlm.nih.gov or prostateline.com.....There are thousands of articles and abstracts that might help. IMO...and that's all it is; if it does reappear early, it won't be locally advanced therefore not going to be helped much by localized radiation. IF however the rise does occur (if its going to that is)more than 2- 3 years down the road then most likely the spread is local, not systemic. 0.00 may only last a year, it might last forever. So far 0.00 still means no cancer is detectable!!!

Good Luck, Swim

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THREAD:First Post.   POSTED BY: Mozart205.   Date: 01/20/07.

Hello:

While googling for online cancer forums I found this one.

Story in nutshell

* June 2006. Routine physical as 51 year old man. PSA in year increased from 3.7 to 4.6. DRE: prostate enlarged
* July 2006. Urologist recommended biopsy
* August 2006. Second opinion (bad feelings from first urologist) biopsy recommended.
* September 2006. Biopsy came back positive in one sample (had to be sent to JH to confirm). Preliminary diagnosis: Gleason 6, cancer likely confined to prostate. Although cancer is cancer, my research indicated that likelyhood of cure was very high if caught early, which this appeared to have been. Decided on the standard surgery, since it did in my mind seem to be marginally more effective.
* November 2006. Had surgery. Results showed positive at margins. Gleason upgraded to 7 (3+4).
* December 2006. First PSA post surgery. Results 0.1. Disheartening to learn it was not 0.0.

So..

It can be disheartening going from "high probability of cure" to "very real possibility this could kill me". I am trying to get a handle on this. One disheartening web site I visited indicated that at my stage, any further treatment I receive is only to extend my life, not curative.

Still, this could be overly pessimistic.

I have come to the realization the only things I can control here are (1) taking care of myself (diet, exercise), (2) attitute, (3) treatment choices.

There does seem to be strong anecdotal evidence that proper diet and exercise can at a minimum delay this disease. Since this is an area I can control, this is my current focus. I have lost 10-15 founds with 30 more pounds left to lose, until I am at my desired weight. Meanwhile I am trying wade through all of the information concerning diet and to separate the wheat from the chaff here.

I drink a glass of pomegranate juice daily, and have switched the focus of my diet towards fruit and vegetables. I still like my ice cream, but have limited it to once a week.

I also either walk or use the treadmill 30 minutes to an hour daily.

Incontinence at this stage is more a nuisance (minor leakage). Sex is another story, as my wife has shut down on me for over five years anyway. Whatever. This does make me feel uncomfortable when my urologist recommends a vacuum pump for me.

Am I being too pessimistic as to what my outlook is at this stage.

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THREAD: First Post.   POSTED BY: Rufus.   Date: 01/20/07.
Hi Mozart
I tend to agree with the others. You are being a little too pessimistic. 0.1 isn't tremendously bad and it was 1 month after. My urologist, like spins, absolutely refused to do my PSA until 3 months after the prostatectomy. Mine came back 0.87 and I had the same GS 3+4 and 20% involved with positive margins.
Be optimistic, super positive and let yourself heal. Life is great !!
Russ

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THREAD: First Post.   POSTED BY: GreenAcres.   Date: 01/20/07.

Same to all of the above. We know what a slammer it is to hear that "positive" margins and then the Gleason upgrade. Still, you're only 51 (that's the new 30, right?). Your PSA score is so low and probably undetectable. And, go read BenEcho's posts. He's the one who has researched information that prostate cancer cells "may" not be able to thrive outside the gland - they die off once the gland is removed. You're at a level where you can select many options and, like us, watch and wait for something that may never happen (we hope).

What is your doc recommending for the future?
________________________________________
Husband age 65
PSA on 5/1/06: 4.2 (had doubled in 13 mos. and rising monthly)
DaVinci Surgery 8/2/06
T2a (at biopsy)
T4c (at pathology) w/cancer cell leakage into fatty tissue
Post-Surgical PSA on 10/3/06 - undetectable!
Update: 11/1/06 - perhaps bladder neck involvement; 30%-50% chance of recurrence
Future: PSA tests twice-yearly for now

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THREAD: First Post.   POSTED BY: LawInk.   Date: 01/21/07.

I agree with all the other posts - be optimistic. Our first PSA was undetectible, but the dr. had explained before that if it was point any number he wouldn't worry as the prostate cells take time to leave the body after surgery and don't mean cancer is still present.

Bob's brother had same surgery, same doctor 1.5 years prior and his PSA is still floating around between 0.1 and 0.2 and the doctor says there's still no cause for concern, only if in the future the numbers climb significantly, at which time radiation is the other alternative . . . certainly not the end!!!!

Focus on the positive; visualize those cells drifting slowly out of your body; tell cancer (with the small "c") it has NO PLACE IN THIS BODY!!!

Take care and stick with us! This forum rocks!!!!

;o) Linda & Bob
________________________________________
Bob (60) had laproscopic prostate surgery on Sept 27, 2006 - 2/12 malignant biopsy samples - gleason 3 + 3 = 6. Follow up PSA results and pathology results received Nov 14th are NO MORE CANCER! Gleason changed to a 3 + 4; cancer completely confined to prostate; (even a second more agressive, previously undetected cancer) PSA UNDETECTABLE. Next PSA check Feb 27, 2007.

Bob also takes Hydroxyurea to control Polycythemia (elevated red & white cells & platelets) has secondary condition . . Myelofibrosis) -- If anyone has experience or knowledge of these, please post us.

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THREAD: First Post.   POSTED BY: Swimom.   Date: 01/21/07.

Hi Moz,

Well, the surgery is over an now you can begin to move forward.

Your Doc explained that margins were positive but there is more to it than that...how positive and how many areas would say a whole lot more this early in the game. As for your PSA, 3 months might have been a better time frame for evaluation. Was this first PSA an ultrasensitive and if so/not, what is the limit of the assay used? If it is indeed a .1 then you may have something to be concerned about but perhaps not right now!! It is acceptable to wait that PSA out and have freedom from more treatment until it's necessary but soon enough to be useful. I've read a slow rising PSA could take years to never.

Your PSA was quite low to begin with and while it is true that a 3+4 is more agressive, your PSA doubling time is slow. IF there were to be a problem you may be looking at years before it shows it ugly face enough to require hormone treatment. Then ...there's the question of radiation now vs. later with the thought that whatever is there is in the prostate bed. Bottom line is Moz...this is not something that can be decided at this moment. I'm guessing another PSA is ordered for sometime in the next 1-2 months? A slope is pretty important to timing of treatment if a man needs more. Heck.....you could go back and have it be lower. That is very common too so we'll hope for that!. Good Luck.

swim

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THREAD: First Post.   POSTED BY: BenEcho10.   Date: 01/21/07.

Hi mozart 250,

Take a look at my stats at the bottom of this posting. As you can see, they are extremely similar to yours except that my Gleason is considerably higher. You might also want to read my thread (titled BenEcho Journal) where I cover my situation in more detail.

PSA: First of all, I think that a PSA of 0.1 and less is considered undetectable and 0.2 and above is considered detectable. From what Swim said above, it sounds like there might be a difference between <0.1 and =0.1. She is more knowledgable than I about the medical stuff so I have to defer to her on that topic. Perhaps you should ask your doctor for a better explanation. Also, as others have said, the standard thing is to wait until 90 days after your surgery to have your first post op PSA. I was told that it takes that long for your body to completely filter/remove the old (pre-surgery) PSA out of your blood. So until 90 days have passed, some PSA can remain in your blood from the cancer that has already been removed and this could improperly inflate your PSA score. That is why they normally wait 90 days. My surgeon said to wait 90 days but my local urologist wanted to do a PSA at 5 weeks and I was fortunate that it was 0.0 at five weeks. I would suggest that you wait until you are at 90 days post surgery and then ask to have them run the PSA test again.

POSITIVE MARGINS: Next, let's touch on the issue of positive margins. I share your dread about this. I too live in constant fear of recurrence due to my Gleason 10 and positive margins. This sucks but it is the reality of our lives. I think that the possiblity of recurrence within 7 years is something like 50%. That means that 50% of people like us do not have recurrence. Let's hope we are in that group. If there is a recurrence, I think that you then initiate further treatment, most likely one or more of radiation, hormone, or chemo. I have also read that you can have positive margins without having any cancer that escaped the prostate. I talk about this some on my thread. Better yet, read my source which was Dr. Patrick Walsh's book which talks about this.

RADIATION NOW VS. RADIATION LATER: This is the big question that I am wrestling with right now. Is it better to go ahead and do radiation right now? It might kill any remaining cancer cells but then again maybe we will be in the 50% group that was not going to have a recurrence. In that case, we have 100% chance of damage / side effects from the radiation vs. 50% of a maybe better outcome with the cancer. It seems to me that if you can wait on the radiation without adversely affecting your odds of killing the cancer, that would be the best thing to do to delay any further side effects as long as possible. So far both my surgeon and my local urologist say not to do any further treatments right now. I intend to do more research and discuss this further on my next appointment in about three weeks. I will post the outcome on my own thread.

I am sorry to have you join me and the rest of the small percentage of surgical patients who have positive margins. You and I share a lot of similarities in our situation (age, stats, dates of diagnosis / surgery.) Let's stay in touch. you might want to start your own thread (see Bluebird's helpful hints thread) so I (and all the others on this web site) have a good place to contact you. I wish you all the best.

Ben

Hi Pontiac,

Thanks for the tip.

Someone (perhaps you) suggested that site to me a week or so ago. I have been there several times over the past week, lurking and reading postings. HealthBoards seems to have more high Gleason people posting than HealingWell so at first I thought that it might have good information for me. However, most of HealthBoards high Gleason posters have selected treatment other than surgery right from the start so I didn't spend a lot of time reading their postings. I will go back and check out postings related to positive margins.

Thanks for the suggestion.

Ben

Hi Ben-
I'm the business associate mentioned earlier in his post-

My decision for aggressive treatment may not be the best for all to follow- the young oncologist we selected recommends a very aggressive approach in the treatment of PC.

Her thinking is to be constantly ahead of the curve rather than play catch-up.

I must say that I've been very lucky so far with my treatments- No unmanageable side affects other than ED due to the Hormone Therapy. I'm using the pump and taking Viagra. So far minimal hair loss, though I do have Chemo Brain for a week after treatment. Only one more Chemo to go!

R

By the way- I discussed your situation with the oncologist I am using- her main comment was that you consider taking action as soon as there is any movement in your PSA- and not necessarily wait for any pre-defined level. Food for thought?

Unfortunately you and I will never be cured (based on our Gleason/Staging)- so we can only hope to keep it in check, and as my Oncologist says, ready for what ever improvements in treatment occur in the next ten years!

We both are fortunate to have partners who are helping to look after us!

R

First of all, Ben, this is such a great thread. When I found these wonderful people back in June/July, there were only 7 pages of posts! Most, if not all, here at that time had been on the fortunate side with a "contained" diagnosis. We waltzed in here with our little 10% postive in one core and thought we'd skate on through, too. Never did we imagine otherwise until the path report. So, it's good to have such a sold and well-rounded base of information here in each and every thread.

If our PSA had come back anything but undetectable, we would certainly institute some action. As long as it stays undetectable, we will watch and wait (based on advice from surgeon and what we know at this point). Swim also reiterated that undetectable means pretty much that it doesn't exist - and it may never return. Yes, this cancer will always be with us; we just hope it minds its own business and leaves us alone.

In the meantime, there is always the possibility of alternative treatments (as opposed to the aftermath and potential for further damage from radiation/hormone/chemo) arriving on the scene.

Hi again guys,

I am continuing to read other threads and pull out items related to positive margins and also to follow-up treatment following surgery. I also want to be real clear that I am sometimes only extracting that portion of a much longer posting that relates to this thread and leaving out all the rest. It occurs to me that this might annoy or upset some of you whose postings I have “chopped up.” I really apologize if that is the case. I am only try to collect all related postings in one place and this seemed the easiest way. If someone wants me to delete a posting of theirs that I "chopped up" let me know and I will delete it.

Anyway, here are the new postings that I found:

Ben


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THREAD: Low Testosterone. POSTED BY: JazzInJay DATE: 01/09/07

. . . I had my prostate removed now about 3 years . . . Feb 04 . . . (I am now considering) some radiation treatment because my PSA rose from 0.1 to 0.2 The doctor I have now is going for radiation because he stated better to be safe than sorry. To soon to tell what it might be (prostate tissue or few cancer cells)....but if it is cancer again it will kill those remaining cells. . . .


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THREAD: Low Testosterone. POSTED BY: Swimom, DATE: 01/09/07

Jazzinjay,

. . . I question whether you need further treatment just yet with a PSA of .2. How long did it take for your PSA to begin rising and how quickly has it risen? I am thinking it should be watched a "little" longer to see if this really is a rise or perhaps a little prostate tissue left behind. Remaining tissue is always a possibility, especially where nerve sparing was done.

Taking care of yourself is certainly having a good effect on you so keep doing what you're doing. IF, there is a recurrence, you will be physically ready for any treatment. We'll all wish the best that treatment is a long ways away yet....or not necessary at all!
. . .

Swim


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THREAD: Low Testosterone. POSTED BY: JazzInJay DATE: 01/10/07

swim

I was -0.1 psa for two years post op. Then at about two and a half years I tested at 0.2, and then at three years it actually went down to 0.12! The doctor still wants me to start radiation treatments. I'm not sure it is the right course of action just yet. But he seems to feel any reading other than -0.1 is a bad sign. So when you think about it I guess it is a big difference between -0.1 and 0.12...and let's not forget when it was 0.20. I just hate to go through radiation if it is not necessary. But no one can tell me that for sure...not even the doctor. His stand is better safe than sorry! Would like to hear any advice out there!!!

Thanks Jeff

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THREAD: Low Testosterone. POSTED BY: Swimom DATE: 01/10/07

Safe than sorry? Jeff, are you sure you wouldn't like a second opinion on this? Maybe he's right but radiation is not like popping a vitamin. It's an invasive treatment with potential effects that aren't so fun to endure.

How long is your PSA doubling time right now Jeff? Protocols are saying sooner than later however, if it's a slow rise and you can buy a little more freedom by waiting until the PSA is .4 or .5 then buy that time. There are a lot of cases where a man's PSA edges up slightly but stays there for years or for good. If the rise is happening faster than 10 months then perhaps go ahead and do radiation now. In the mean time......and there is a mean time! Get into LEF (Life Extension Foundation) and read about Modified Citrus Pectin. I think you may be interested. Also, get a copy of your records and get a second opinion. Your Doc is the man you need to trust but a second opinion is still a smart thing to do. Hang in there Jeff.

swim



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THREAD: Low Testosterone. POSTED BY: Pete’s Co-Pilot DATE: 01/10/07

Jeff,
I hope you'll take Swim's advise and consider a second opinion. Radiation soft tissue necrosis is one of the possible side effects and it's definetly one of uglier ones to endure and treat.
Research your options, be pro-active in your health care program and THEN decide with your doctor which option(s) might be available to you. If it turns out radiation IS the right choice, then at least you'll KNOW it, can make an informed, educated decision and won't be left feeling "What if...If I'd only...would've, should've, could've".
A little "doctor" story for ya.. Once upon a time, I was caring for a young horse (5 yrs old) that was exhibiting symptoms of Cushing's Disease. Cushing's in horses is considered to be a more common condition in the "geriatric" horse - not unlike the PC problem in older men attitude, "Most of them will eventually get it"
Anyway, I had the vet come out, told him what I knew and requested he draw blood to confirm my dx. (no, I'm not a vet). He argued all the points - horse too young, never see Cushings @ this age, might be this, might be that.... "Humor me, will you doc? Just pull a couple vials and sent them off to Cornell, ok?"
When the blood work came back positive for insulin resistance, you better believe that vet was absolutely floored! But to his credit, he sucked in the "Dr." ego and said "Thank you! Sometimes I get "tunnel vision" and set on a certain path, not seeing or LISTENING to the caregivers who know my patients so well". He then proceeded to prescribe pergolide mesylate, a common treatment option for the condition. Already having done my research, my immediate reaction was to wait. I told him, "No, I 'm going to change his feed program - strict diet of beet pulp, (no grains) orchard grass/timothy hay (no alphalfa allowed), no carrots, cookies, treats of any kind. Let's re-test in 6-8 weeks and see if his glucose/cortisol levels come down". They did (but you knew that!) and 2 years later this horse is thriving and leading a wonderful life as a police mount!
The moral of the story; be a skeptic, get informed, weigh your options and then make your choice - in the end that's what it is...your choice.
Stay strong! ________________________________________
Pete's Co-pilot,
Lisa

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Here is an update on my research:

#1: From what I read, based on my positive margins and Gleason 10, my odds of recurrence within 7 years are about 96%. Having radiation (and perhaps hormone and chemo) will reduce the odds of recurrence. However (and this is very important) even though your reduce your odds of recurrence my online research shows no consensus that this has any for certain impact on long term survival.

#2: My locals docs indicate that I should consult with an oncologist (and probably have radiation) and we are still debating whether or not to do this.

#3: However, my Johns Hopkins surgeon says that Johns Hopkins reseach suggests not to have radiation (and near certain damage) until after the PSA rises. We flew half way across the country for the expertise of Johns Hopkins and we are leaning towards doing it their way.

We are still considering what to do but we are currently leaning towards doing nothing until the PSA rises.

Please note that a critical factor in my personal situation is that the cancer escaped my prostate (as evidenced by the positive margins) but it did not show any signs of having taken hold anywhere outside the prostate. If you have signs that your cancer took hold somewhere outside the prostate (the most common symptom would be seminal vesicle invasion) then waiting may not be a good idea. You may need further therapy right away even if your PSA is 0. Obviously you should talk to your doc about this and possibly see an oncologist.

Good luck to all,

Ben

Hi Ben,

in about an hour I will be in front of my oncologist.  I have three margins positive, and the the seminals fully involved.  I don't believe I have a waiting option.  Today we are deciding on what to do.  The doctor will give us our three options, radiation, Taxotere, HT and what order would be best. We may decide on the "dam the torppedoes" approach.    We are considering experimental treatment as well.  Will keep you posted.

Age 44

Surgery 2/16/07

Post Op

T3B N0 Mx

Gleason 4+3=7

Three margins positive, seminals involved

PSA on 2/28 is .9, hopefully falling.

Unfortunately, a significant number of us RP patients have positive margins.  People tend to look at the odds, and assume that it will not be them, but it appears to be many.  I had one positive margin but my seminal vesicles and lymph nodes were cancer free, so I opted for "adjuvant radiotherapy"  beginning about three months after surgery.  I had a total of 65 Gray of RT.

 

The research I found indicated that RT is better sooner rather than later.  For example, see JAMA, March 17, 2004--Vol 291, No 11.

 

It is well established that hormone therapy does not cure cancer, but may slow its growth.  Since my PSA has been undectectible since surgery, I elected to not have the hormone treatment.  My surgeon recommended against the hormone therapy and I will not consider it unless my PSA rises.

 

Best to all.

 

Allan

TC,

If my seminal vesicles had been involved, I think that I would not be 50/50 about radiation like I am right now. I think that I would be about 90/10 in favor. I hope that you have a productive meeting with your oncologist.

I will be curious to hear what your oncologist suggests. Do you know if oncologists specialize like in Prostate Cancer or do this do all kinds of cancer? So far, I have been told that they do not specialize but I was curious about this.

Ben

Hi Alan92,

I know what you mean. There do seem to be more guys with positive margins than I would have expected. I will look at the JAMA article that you mentioned.

Thanks for the information.

Ben

I had the IMRT (65 Gray) and the side effects were mild fatigue late in the treatment plus more frequent urination.  It also seems to have stopped my recovery of erections.  So, you do pay a price although I don't have the fatigue or frequent urination anymore.  I expect to be taking screw shots (Trimex) for the forseeable future.  But I will have no complaints if I continue to be cancer free with normal urination. Sex is fine with the Trimex, you get a full erection in a few minutes.  Better than walking around in a blue haze from the pills, IMHO.

 

I would encourage everyone to consider RP, especially at Johns Hopkins, but get the best "staging" you can to make sure the cancer is organ confined.  I think the MRI has a lot of promise for better staging but right now diagnosis is subjective.  I had three oncologists and two urologists tell me than my disease was organ confined.  Go figure.

 

Best to all.

 

Allan