Concerns after RP

[Rams91]

Hi,

I had a RP two weeks ago (radiation was ruled out because of severe existing urinary symptoms) and have concerns with regard to my pathology report. My surgeon, who I carefully selected because of his extensive experience in prostate health and PC (over 4K RPs) does not share my concern and says it is not material. Somehow, I am still concerned. I would appreciate if I can receive feedback from experts on this panel if anything can be done at this stage to prevent or lessen the severity of a possible BCR because of the positive margin identified in the pathology report. Here are excerpts from the pathology report:

A,B.C multiple Lymph nodes , negative for metastatic carcinoma

D- Bladder neck margin, benign fibromuscular tissue, no prostatic gland or carcinoma identified

E- Prostate and seminal vesicle prostatectomy

Prostatic adenocarcinoma, GS (3+4=7)

Tumor focally extends to right anterior resection margin ( focal Gleason pattern 3

, <3mm in length)

Specific Data:

Grade: Grade Group 2 (GS 3+4 = 7), % Pattern 4 = 30%, Minor Tertiary pattern 5 (less than 5%)

Estimated % of prostate involved by tumor : 11-20%

EPE, Bladder neck invasion, Seminal Vesicle invasion, Lymphovascular invasion

NOT Identified

Margins Status: Invasive carcinoma present at margin, right anterior

Primary Tumor pT2, pN category pN0

I read that anterior PSMs have less chance of recurrence compared to posterior PSMs, but still, positive margins increase the odds of recurrence few years down the road. I cautioned my surgeon in my pre-op visit regarding my concern on surgery in general and PSMs and the use of intra-operative frozen sections. He assured me that he routinely utilized that, and a pathologist would be standing by. Seems it has not been the case. As far as other components of a perfect trifecta he promised, he has done a great job with the other two so far. No incontinence and ED improving 2 weeks after surgery.

Any advantage of sending the slides to Epstein for second opinion? I didn't see any reference to PNI in the report. Thanks.

[Tall_Allen]

Great that you're recovering so well. Focal positive margins are not an indication for adjuvant radiation. It has been found that waiting for PSA to rise affords the same benefit as immediate radiation. There is no harm in waiting.

prostatecancer.news/2019/09...

Radiation on top of surgery may set your recovery back.

[Rams91 in reply to Tall_Allen]

Much appreciated Allen.

[Rams91 in reply to Tall_Allen]

Hi, a follow up to my previous post last year, my PSA is now on an uptrend although still below 0.1 threshold. My surgeon is not concerned but I find it hard to share his feeling. My Ultrasensitive PSA tests taken every three months were 0.029, 0.021, 0.051 and 0.059. Is it time to see a radiation oncologist? Any harm in waiting longer?

[Tall_Allen in reply to Rams91]

Wait at least until 0.1

[Rams91 in reply to Tall_Allen]

That's what my surgeon said. But reassuring to check with you as well. Thanks.

[MNFarmBoy]

A physical reason why positive surgical margins (PSM) don't necessarily mean that viable cancerous cells remain: The urologist who performed RP on me in Dec. 2018 explained that they use cautery around the prostatic fossa to stop bleeding. Of course, such heat kills some cells, so with luck, that cautery might kill the few cancerous cells present in small PSMs.

In my case the PSMs were reported as <2 mm, and, so far, so good: PSA results have been below the limit of detection (<0.014 ng/ml for that laboratory). Of course, I still am sweating out the PSA results, but the testing interval has increased from 3 months to 6 months, so at least not as often.

Best wishes for you to continue on the path to full and lasting recovery!

[aceace12]

Did you ever consider Active Surveillance ?