Advanced Prostate Cancer
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Positive surgical margin

Trying to gather information on anyone with a positive surgical margin after prostatectomy. My margin was 2 mm with a gleason 6. Should I opt for adjuvant radiation. I’m only 4 weeks out after surgery so I have not had a psa test done. Will get one at six week post op. I’m very concerned about this positive margin to say the least. Should I go ahead and schedule a PSMA ga 68 pet-ct scan regardless ofthe psa ? Will that test sho anything this early? Path report shows 10% tumor of prostate. 8% of the total tumor was gleason 6 and 2% of the tumor was gleason 4. Was in both lines. No lymph nodes no seminal vesicle invasion. Good path report except for the dang positive surgical margin of 2 mm gleason 6.

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Hi Lisa7739,

My husband was diagnosed 2010 and had prostatectomy 2011 with positive margins measuring 1mm. Glason 3+4. Involving 70% of the right lobe. The Urologistat at the time decided not to worry about it, just to keep in eye on the PSA which was undetectable for almost 3 years. The PSA increase to 0.5. He was referral to radio oncologist had 37 session of radiation but the PSA was still increasing.

Fast forward to July 2017 PSA 8.7. He had a axium pet scan that showed metastasis in 2 lymph nodes in pelvis area. I hope this help. The best to you.

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I forgot to mentioned that he had ct scans, bone scans, F 18 pet scan that didn't show anything, until he had the axium pet scan.

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Thank you so much for responding. We are trying to determine if we should go ahead and get adjuvant radiation now rather than waiting for the psa to tell us to. Do you by chance remember what the Gleason Score was for the 1 mm positive margin? Or perhaps the pathology report didn’t show the Gleason Score at the positive margin?

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The final pathology report Gleason grade 3+4= Gleason 7, involving 70% of the right lobe. Positive for focal extraprostatic extension with involvement of the posterior surgical margin measuring 1MM. He also had a pathology study that showed his cancer is intermediate risk. I'll always wondering if he had done radiation the story could've been different. I can't complain after 7 years my husband is still here with me, he exercise.. runs 3 miles 4 times a week, able to work, trying to live and enjoy life to the fullest each day God is good. I will pray that everything goes well with you. I'm positive you will do great.

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Also I wish your husband the best as well. Praying that they can remove those two lymph nodes and he can be back on the road to no worries.

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Prostate cancer may kill you. Stress will kill you much sooner. My opinion, don't rush to new treatment. It may greatly affect the quality of your life. First question to consider is bladder control. Are you incontinent? Wait for your post op PSA. If you have access to axiom, it may be a good choice, but be mindful early scans with undetectable PSA have limited value. Gather more facts and dont rush into any treatment because fear doesn't need to guide you.

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Thank you for your response. These are stressful times. My husband just turned 50. We have a daughter in college but also one who is only 11! We must find a way to keep this horrible disease at bay!

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You will keep it at bay. Treatment options are growing nearly by the month now. Both of you will see your 11- year- old graduate from college.

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I'm not a doctor and I don't want to influence your decision making. I would make the observation that those are fairly low Gleason numbers; they aren't scary aggressive anyway. You've come to the right place. Your task now is to educate yourself so that you can make informed decisions. Best of luck.

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Not only will the both of you will see your 11- year- old graduate from college, but you will see her get her medical license and make you both wait on the living room couch for two hours before she will see you.

Good Luck and Good Health.

j-o-h-n Wednesday 10/25/2017 6:14 PM EST

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Hi, for what its worth, here is my experience - I was diagnosed in Mar 2015 with PSA 7.8, Gleason 7, initial staging was T2 N0 M0. Had robotic surgery in Apr 2015 and path report contained bad news - seminal vesicle invasion, one lymph node positive (out of 17 tested) and a positive margin 1mm. Gleason 4+3.

Uro told me that he had seen 'small' margins before and not to worry. First PSA after operation was 0.026 which seemed to back up this assessment. However PSA went up at each 3 month check and was 0.1 by Christmas 2015. I was then referred to radiologist. PSMA scan showed nothing so we proceeded with IMRT to prostate bed. Next PSA test (May 2016) showed that IMRT had hit the spot and PSA was down to 0.067.

However PSA showed an increase with each subsequent test and was 0.5 by Christmas 2016. Another PSMA scan showed nothing. PSA was 2.5 by March 2017 and a third PSMA finally revealed a single tumour "just outside the field of radiation". The tumour was too close to rectum to allow more IMRT or surgery so I then commenced ADT.

So in my case I dearly wish I had done salvage radiation immediately after surgery. But you are in a slightly different category since you have no lymph node involvement and a lower Gleason.

BUT if you are young and fit - I say go for it because there is still cancer cells right there in your body. I had zero side effects from IMRT (I was 54) and I would not be afraid of radiation if you are in good condition. But I am not a doctor, and I notice that you didn't include your doctors reaction to positive margin - what does he/she say about it?

Also, I reckon a PSMA scan at this time is waste of time and money. You are unlikely to see anything until PSA reaches 2, which hopefully will never happen to you if you take the right steps now.

Best of luck, I hope that you get this sorted before you join the advance PCA club.

Regards, Hazard

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Had to drive 3 hours for surgery so path results were discussed via telephone. Doctor didn’t seemed too concerned about the positive margin. He just said the first psa test would tell us more. No lymph nodes were taken during surgery as dr said biopsy showed no lymph node involvement. Path report did say no seminal vesicle involvement. Do you mind me asking where you live such that you have great access to the PSMA test?

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Hi, I live in Melbourne Australia so that probably doesnt help you. PSMA scan costs $650 at local hospital. Its not a lot of money compared to some other cancer-related expenses but in hindsight the first 2 were a total waste of money as I now know that PSA was way to low to produce any visible images. My radiologist should have known that.

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Hello Lisa,

I am not competent to tell you what you should do but, in spite of that, I'm going to share some thoughts I have about your situation.

First of all, the fact that your husband is so young (to me, at 71, 50 is looking wonderfully young) and, if the cancer is cured, the two of you might look forward to decades of healthy life - that might incline me towards aggressive and definitive treatment. By "definitive" I mean treatment that can not just hold down the cancer, but actually kill all of it so that no further treatment will ever be needed.

Radiation can potentially do that. Unfortunately, as you know, there's no way to know for sure if it will do that, or if he needs it at all.

Positive margins indicate that some cancer is probably left behind, but it can and does happen that the bit of tumor left, deprived of it's environment of being connected to the prostate, will die on its own. As I understand it, that can happen because the cellular mutations that enable tumor cells to live outside the place of their origin (prostate, breast, lung, wherever) are different from the early mutations that initially create the cancer. In fact, there may very well be tumor cells already circulating in the blood stream, but they are very likely incapable of living that way and will soon die with no treatment at all.

Here's what I recommend that you do.

First, find a real expert to advise you on this. The expert will probably not be your local urologist, your local oncologist (unless that person is a specialist in prostate or "genitourinary" cancers), or maybe even your local radiation oncologist (who may be good at performing the radiation but maybe not as knowledgeable about the whole situation.) Make an appointment to see him or her.

If you live in the U.S., I suggest looking for a specialist at one of the National Cancer Institute's "Designated Cancer Centers" - research hospitals and medical schools where top quality people who keep up with the latest research are to be found. See:

cancer.gov/research/nci-rol...

Click "Find an NCI Designated Cancer Center" to search by state.

Secondly, think about your own goals and priorities. Do you think you would be willing to trade-off a risk of additional adverse effects of radiation treatment in order to get a possible improvement in your chances for a full cure? Would you be willing to accept the short term (e.g. 6 months) adverse effects of short term (e.g., 6 months) hormone therapy (loss of libido, hot flushes, muscle weakening and tiredness) along with the radiation in order to improve the odds of radiation killing all the cancer?

These choices are very difficult to evaluate because you don't know whether you need any of this, or how much improved your odds will be with each addition to the treatment. However, I think it is important to discuss these questions with each other before you see the doctor. S/he may be able to tell you what s/he would do in your situation (though you sometimes have to drag it out of him or her), and that's very valuable to know, but it's even more valuable if you've already considered the issues.

After all that you may still not have a strong feeling about what to do, but you will have done your best. You make your choice and hope it works out.

I hope it does too. I wish you the very best of luck.

Alan

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Thank you for taking the time to respond to my situation. It is so nice to get others opinions on the situation. If only we could know for sure it would certainly make the decision so much easier....

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One more thing.

I searched Google for ( radiation of positive margins after radical prostatectomy ). Here was a particularly useful looking hit including advice from top experts.

harvardprostateknowledge.or...

Alan

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I also had positive margin at base, Gleason 7 . But my pathology was much worse: Gleason 4+5, bilateral SVI, and EPE in area of margin but 10 lymph nodes dissected were clear. My Psa never went to zero and climbed to .3 in seven months . Since then I’ve had RT three times along with HT as PCa appeared again in lymph nodes and femur.

You’re much lower risk but a positive margin means some PCa escaped. Standard of care is to have SRT as soon as you’re continent if psa increases at all. If you wait for a scan nothing is likely to be seen until Psa is much higher like 2.0. If I were you I’d contact an experienced RO.

Bob

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Yep, it's tough to make any decision now until you see what the PSA is after surgery. In fact, you might need a couple of PSA tests before you make any decisions. I had a worse initial diagnosis when I was 50, and was put on Lupron immediately on diagnosis, then had a RP the next month in December 2015 and then adjuvant radiation in August 2105. So take your time, don't stress yet and see what your doctor has to say. With a Gleason score that low, there's nothing immediate you need to do. Even with a score of 9, I didn't decide to do radiation until 6 months after surgery.

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Thank you so much for your reply. I had my first psa done six weeks after surgery and it was 0.00! Will repeat again in a month. Praying it also will be at 0.00.

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