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testing margins during surgery?

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Posted 1/12/2015 5:24 PM (GMT 0)
In reading through Pratoman's thread...he mentioned that the doctor talked with his wife while he was still under. He was waiting for the frozen margins to come in to see if he needed to cut more. I've read other accounts on this site where they checked margins during surgery as well.

When I asked my local surgeon (robotic) if he does that...His answer was..."No. We used to do that but it's not something that's normally done now like it was in the past". This caught my ear.

What's the deal with this? Any input from others experiences??

Thanks
Crazy Dave
Posted 1/12/2015 5:37 PM (GMT 0)
My surgeon is Tewari, and I'm guessing he wouldn't be doing it if it wasn't useful. He's a cutting edge doc. (Not saying this is a cutting edge strategy, it's not new) He got positive margins, and wouldn't have known it if he hadn't had the tissue looked at before finishing up, so he got the chance to go in cut more and get a negative margin result. It's not a guarantee, but he told me 95% of the time it holds on final path.

I would ask the doc what it is that made it old school? Phys a better way to get some insurance been developed? I'm guessing he doesn't do it because he doesn't do it. I wouldn't use someone who doesn't, after hearing that not only Tewari, but David Samadi both do it.
JMHO
Posted 1/12/2015 6:03 PM (GMT 0)
Checking for margins during the surgery is also done with other cancers. A friend had surgery for melanoma and the doctor checked four times before getting negative margins. Certainly seems like an essential procedure when possible.
Posted 1/12/2015 6:22 PM (GMT 0)
my husband's uro specially had someone there to check margins (his surgery was in later afternoon) because she knew going in that he had EPE. She said she took everything she could get, and had to take a couple extra slices of bladder til the pathology came back with no cancer. However a week later the final pathology came back with positive surgical margins at bladder neck. She says its possible that there are no cancer cells on the other side of the margin.

So I don't know what is usual, but it sounded as if if may depend on the individual patient's case from what our surgeon said. However I sometimes misunderstand whats said when I'm stressed.
Posted 1/12/2015 6:23 PM (GMT 0)
This step (checking lymph node pathology intra-operatively) is very common in open RP procedures, and far less common in robotic procedures when there is a $2-million robot sitting idle during these additional time-consuming steps. In robotic procedures, the surgeon will usually use secondary information to make a call as to whether it is necessary/appropriate or not. For example, if they think the clinical diagnosis has very little indication for possible LNI, they will not take a frozen sample, but if the indication for LNI is higher they will. 

One exception is if the surgeon uses a bladder neck-sparing technique robotically; then, sometimes the bladder neck (not the lymph nodes) are intra-operatively examined...but again, they all like to keep that robot moving...

Crazy Dave/island time, the question to Pratoman might be whether his doctor sampled lymph nodes, or bladder neck, or something else I didn't address here...?

 

Post Edited (NKinney) : 1/12/2015 12:00:48 PM (GMT-7)

Posted 1/12/2015 7:35 PM (GMT 0)
My surgeon did the frozen section on the margins of the removed tissue, not the lymph nodes, and found positive margin at the Apex. That is where he cut more till he got to negative margins.
Posted 1/12/2015 9:37 PM (GMT 0)
I'd ask for it as part of the interview if you want the surgeon to do NV bundle sparing, bladder neck sparing, and urethral sphincter sparing, which is almost everybody. If the surgeon doesn't do it, I'd find another surgeon who does. I think it's more of an issue for robotic than for open.

- Allen
Posted 1/12/2015 11:14 PM (GMT 0)
I had frozen section taken while undergoing daVinci surgery. They came back negative, but I still had a positive margin on further examination by the pathologist. So there are no guarantees.
Posted 1/12/2015 11:20 PM (GMT 0)
Hi Prato,

Glad that you're doing well--and that Dr. Tewari was able to make a wider cut.

I think that checking during surgery is very important. And, as far as I know, Dr. Samadi does NOT routinely send anything to the pathologist during surgery.
Posted 1/13/2015 12:51 AM (GMT 0)
@Prato
@super max
@SophieW
@NKenney
@Tall Allen
@lapilot
@Melaine

Thank you. Every single response has given me information I would not have had had you not given it. I value and benefit from EVERY one.

Radiation oncologist in the am. Lol. You guys are great. :)
Posted 1/13/2015 1:08 AM (GMT 0)
Well shoot. lol.

I knew I needed to respond (and to a couple of ya I'm going to in more depth)....but what I didn't see coming was....After "thankin' ya"...i couldn't enjoy the game without telling ya that..."I don't know HOW TO REPAY you??"

Keep ya posted. That's all I know to do at this point.
Posted 1/13/2015 2:31 AM (GMT 0)
Lapilot, you are right, no guarantees. But having pathology done has to help the odds.
Tewari told me that with that extra step my chance of negative margins after having negative in the OR was 95%. Of course, I'm very nervous about the remaining 5%.


Melanie, thanks. Samadi told me he does have a pathologist in the OR. But who knows. Hope all is well with you.
Posted 1/13/2015 2:50 AM (GMT 0)
@Tall Allen. I agree. Time under anesthesia. .room to work...patients case...Dr's habits and beliefs. A lot could play into this.

JH will know.

They got my records today, btw.
Posted 1/13/2015 3:57 AM (GMT 0)
I don't think that margins can be guaranteesd until the full pathology is done and I'd be surprised if a surgeon would be able to wait for this particularly with DaVinci. I had open and my surgeon didn't wait. And my pathology result two days later was poor. So I ended up having ADT and SRT . So far so good!
Bob
Posted 1/13/2015 4:05 AM (GMT 0)
There may be conflicting studies and on going debate as to whether it affects success rates. But...it's a question I have. That's all.

Prato...waiting with you buddy.
Posted 1/13/2015 10:12 AM (GMT 0)
You are right Island. I went on pubmed.gov and found a number of conflicting studies about the benefit of intra operative frozen section. There doesn't seem to be general agreement.

As far as the cost of delay in Robotic surgery waiting for path, I don't buy it. I good doc will wait, mine does, while,waiting he took the time to call my wife and update her. If they do 3 surgeries in a day, and finish up at 4 vs 3, then I t doesn't matter. I was the third surgery of the day and the did it.

I would think in a large hospital, like where I was, with 3 robots, it would be less of a factor.
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