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High probability of positive surgical margin for PC located in Apex

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Posted 7/22/2018 2:01 PM (GMT 0)
As part of my study and research of different treatment options continues I came across this article regarding probability statistics of positive margin study left after RP for T2 and T3 tumors:

http://www.urology.uci.edu/prostate/Margins.html

This particular article provides an explanation on why there is a higher probability of Positive SM for tumor located in Apex and Lateral area. This is important for me to understand as this is the same area that requires treatment for my situation. This information is not that you normally can hear from doctors who recommend surgery.

I also have question: Is there a similar research on positive margins for radiation therapy, especially SBRT and HDR. I understand that surgical positive margins can be discovered after pathology report of removed prostate, or PSA trend over period of time is the only tool available to see if there is positive margin still present after RT?
Posted 7/22/2018 2:19 PM (GMT 0)
Not sure how far radiation extends outside the prostate bed, but if there are any cancer cells in the immediate margins, they are treated too, past that, isn't it already systemic
Posted 7/22/2018 2:50 PM (GMT 0)
Not a specialist by any stretch, but it is my understanding that the radiation field for SBRT is adjusted according to needs.
In other words, I am confirming what Fauntleroy wrote.

With respect to HDR (high intensity brachy?), I don't know.
Posted 7/22/2018 5:14 PM (GMT 0)
I made precisely this question to my no-much-communicative surgeon and he just answered that he will cut whathever he would judge suspicious. I talked also with two ORs. According to them, EBRT is precise to place the radiation inside the prostate while SBRT also takes care of some margins around it. I decided to go to surgery anyway. You have many factors to consider and it is difficult to be sure which weights the most. Good luck with your choice, whatever it is.
Posted 7/22/2018 5:33 PM (GMT 0)
Positive surgical margins occur most often at the apex (and the right apex most). But they also occur at the base due to bladder neck sparing, and mid-gland due to sparing of the neurovascular bundles. The surgeon can cut wider, but that increases the risk of side effects. You should only go to a surgeon who has a pathologist standing by to examine frozen sections. Many surgeons think they can see every bit of cancer, but often the cancer is too small to be seen.

HDR brachy and SBRT treat a margin outside of the prostate. The RO adjusts the margin based on the planning CT/MRI and/or the risk level of the patient. My planned target volume was 2-3 mm on the anterior side, but 0 mm on the rectal side. I know that my RO goes as high as 5 mm for high risk patients. There is no concept similar to positive surgical margins for radiation therapy. Recurrences may occur locally, however.
Posted 7/22/2018 5:48 PM (GMT 0)
TA, when I asked Zelefsky how often he sees cases like mine, where there was a positive frozen section that was converted to a negative final margin, his response was that he doesn’t see it much because most surgeons don’t do frozen section as a routine part of all surgeries. Point being from what I’ve seen, it’s not so easy to find a surgeon that does it.

I agree though it has its advantages.
Posted 7/22/2018 6:16 PM (GMT 0)
The reason I brought this up as I had group meeting of PC survivals with different type of treatments and RO who led this meeting mentioned that surgery is good option only if there is very good chance to get rid of cancer in one treatment. If there is high chance of leaving positive margin after surgery due to location of tumor, then radiation therapy is the best option. Why have two treatment with compiled SE if the same result can be achieved in one process.

One of the reason why positive margins are left after surgery is because of microscopic extensions not visible to the eye. I assume similar microscopic extension exist during radiation therapy. It can be taken care of during SBRT at certain margin level up to 5 mm for high risk patients and 2-3 mm for others. What if these microscopic cancer cells extend further then treatment field? Is there way to tell if all cancer was treated during radiation? There is a pathology report after surgery. Is there any test to see the real picture after SBRT other then PSA trend over period of time.
Posted 7/22/2018 8:04 PM (GMT 0)
We rely on PSA after radiation. If it reaches a nadir < 0.5 it correlates with excellent prognosis for no recurrence. If you need to see a pathology report - surgery may be a better option for you. Here are some questions ask yourself:

• Do I need to see a pathology report to tell me how contained it was?

• If I choose radiation, can I live with the fact that PSA goes down over a number of years, with bounces along the way, and never becomes undetectable?

• If the pathology is adverse and PSA does not become undetectable, am I prepared to undergo adjuvant radiation with all the potential side effects that entails? (Your doctor has hopefully run a nomogram showing the probability of this happening)

• If the radiation doesn't work, am I prepared to have a biopsy and possible focal brachy re-treatment?

• Which bothers me more - the potential for incontinence and ED after surgery or the potential for retention and irritative effects after radiation? (given the probabilities of those side effects)

• Do I understand the other possible side effects of surgery? (e.g., infection, hernia, climacturia, penile shrinkage, stress incontinence, etc.) Am I prepared to take on penile rehab?

• Do I understand the other possible side effects of radiation? (e.g., fatigue, proctitis, hemorrhoids, frequency, urgency, burning while peeing, ED).

• Am I prepared to undergo radiation therapy and its side effects?

• Am I prepared to undergo surgery and its recovery?
Posted 7/22/2018 9:27 PM (GMT 0)
In summary, as Bart Simpson wisely said: dam.ed if you do, dam.ed if you don't. But I hope your choice will be right. Furthermore, I wish any possible option you have now is a cure so that you will be unable to err and you will not need any further treatment.
Posted 7/22/2018 10:13 PM (GMT 0)
I personally inclined toward SBRT or HDR treatment. If it was different area of prostate impacted, other then Apex, Lateral, or Base, then I would add surgery to this list. Ideally, I would like to have something like pathology report for after radiation treatment, but I guess it is not visible right now. May be with next generation of MRI.
Posted 7/23/2018 12:08 AM (GMT 0)
You will never have that after radiation because it takes 4-5 years for the cancer to disappear.
Posted 7/23/2018 1:39 AM (GMT 0)
One question to my mind is that if you irradiate a margin outside the prostate and if the tumor is at the apex, then the radiation may extend down to the urethra and damage it. It would suggest greater coverage than the surgeon cutting a wide margin, but it might result some urinary issues. It's a hard one to decide.
Posted 7/23/2018 2:57 AM (GMT 0)
Just make sure us hsve a great surgeon.at least 1500. 2000 no lessssss ..I asked my surgeon that question..did u know that 52 % are in the apex.....he said u have to be careful no matter where it is ...it’s just that in the apex is where the nerve bundle is that’s why it’s a bit more complicated
Posted 7/23/2018 2:19 PM (GMT 0)
Also even with a positive margin you only hsve a 30% chsnce of reoccurance...that’s still s 70 % chance of no reoccurance ...right ...when it comes to this we all look st the low numbers because they aren’t low enough ...if we looked at the weather and saw a 30% chance of rain we. Wouldn’t even bring and umbrella
Posted 7/23/2018 3:53 PM (GMT 0)
Stan-

Many of us intend to live longer than 10 years.
Posted 7/23/2018 11:58 PM (GMT 0)
I plan on living long enough to say, "When they did my treatment 30 years ago ... "

so far so good, 24 years to go...
Posted 7/24/2018 12:31 AM (GMT 0)
The uretha cell are more resistant to radiation than normal tissue.
Posted 7/24/2018 11:01 AM (GMT 0)
As it was mentioned in the link provided at the top of post:

" The area most prone to developing a +SM is the apex. There are reasons for this including the fact that cancer very commonly involves the apex and the apex of the prostate is sometimes “buried” deep underneath the pubic bone. This situation can be complicated a large vein which if the bleeding is not controlled well the surgeon is force to move along and the dissection loses precision." and "Both the apex and base of the prostate do not have an obvious boundary, rather the connection is more of a blending"
Posted 7/24/2018 11:05 AM (GMT 0)

Tall Allen said...
You will never have that after radiation because it takes 4-5 years for the cancer to disappear.

Tall Allen, I heard it take 2 years to reach NADIR for radiation treatment. I do not understand what do you mean 4-5 years for cancer to disappear? Do you mean re-occurrence?
Posted 7/24/2018 1:43 PM (GMT 0)

Tall Allen said...
Stan-

Many of us intend to live longer than 10 years.

I hope to live long enough to not be able to remember I have/had PCa smile
Posted 7/24/2018 4:13 PM (GMT 0)

Serge said...
Tall Allen, I heard it take 2 years to reach NADIR for radiation treatment. I do not understand what do you mean 4-5 years for cancer to disappear? Do you mean re-occurrence?

No. I mean nadir. I took 4 years to reach nadir (0.1 ng/ml), and in hindsight I'm happy about it.
Posted 7/24/2018 4:42 PM (GMT 0)
Allen....what would be the time horizon and approximate expected (good) nadir value after SRT?
Posted 7/24/2018 4:58 PM (GMT 0)
garyi- it is MUCH quicker after SRT because BCR is still defined as 0.2, but use of ADT will delay when you can know for sure. After ADT wears off, PSA should not go over 0.2. As always after surgery undetectable is best.
Posted 7/24/2018 8:16 PM (GMT 0)

Tall Allen said...
garyi- it is MUCH quicker after SRT because BCR is still defined as 0.2, but use of ADT will delay when you can know for sure. After ADT wears off, PSA should not go over 0.2. As always after surgery undetectable is best.

That’s what I suspected. Thanks, Allen.
Posted 7/24/2018 11:40 PM (GMT 0)
Serge, there is another forumer, slick7, who just updated an old thread. He had an apical tumor where a bulge was detected via MRI. However, he just had RP, and there was no EPE, while margins were clean. Another case, other than mine, where the MRI wasn't very precise.
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