Positive Margins -- Will I need additional treatment?

[SmasherOfAjumma]

3 months post RALP and PSA is undetectable by standard test. My surgical pathology results are pasted below. Do you think I will need additional treatment? I have not spoken to my urologist yet, since the PSA results just came in. Whatever he says, I may consider getting a 2nd opinion from Johns Hopkins. What do you all think, based on the below pathology?

Grade: Grade group 1 (Gleason Score 3 + 3 = 6)

Intraductal Carcinoma (IDC): Not identified

Cribriform Glands: Not identified

Treatment Effect: No known presurgical therapy

Estimated Percentage of Prostate Involved by Tumor: 21 - 30%

Extraprostatic Extension (EPE): Not identified

Urinary Bladder Neck Invasion: Not identified

Seminal Vesicle Invasion: Not identified

Lymphovascular Invasion: Not Identified

Perineural Invasion: Not identified

Margin Status: Invasive carcinoma present at margin

Linear Length of Margin(s) Involved by Carcinoma: 5 mm

Focality of Margin Involvement: Multifocal

Margin(s) Involved by Invasive Carcinoma: Right anterior

Margin Involvement by Invasive Carcinoma in Area of Extraprostatic

Extension (EPE): Not identified

Gleason Pattern at Margin(s) Involved by Carcinoma: Pattern 3

Regional Lymph Node Status: All regional lymph nodes negative for tumor

Number of Lymph Nodes Examined: 7

Pathologic Stage Classification (pTNM, AJCC 8th Edition)

Primary Tumor (pT): pT2

pN Category: pN0

"There is an area on right near the surgical margin. The grade group remains 1, with negative nodes. I expect an excellent outcome."

[Justfor_]

Your pathology report shows overtreatment. Gleason score 3+3=6 is hardly prostate cancer. You could very well had been placed under Active Surveillance. Switch to ultra sensitive PSA and if/when it breaches 0.06 ask again.

[SmasherOfAjumma in reply to Justfor_]

I was on active surveillance for two years, against the advice of my first urologist. I had two biopsies that showed Gleason 3+4, so the downgrade to Gleason 6 was a nice surprise. I decided on surgery because my PSA jumped from 3.2 to 5.1.

[Tall_Allen]

The Gleason pattern at the margin is only pattern 3, so it is unlikely you will need salvage radiation. BTW, there are much better places to go for a second opinion on salvage radiation - JH is relatively weak in that.

[SmasherOfAjumma in reply to Tall_Allen]

Thanks. Where would you recommend?

[Tall_Allen in reply to SmasherOfAjumma]

Where are you located?

[SmasherOfAjumma in reply to Tall_Allen]

Philadelphia. When I was 1st diagnosed, I had my biopsy sent to Johns Hopkins, because they make it easy to get a 2nd opinion and they were recommended here I think.

[Tall_Allen in reply to SmasherOfAjumma]

Yes, Epstein is very good Eric Howat reading prostate biopsies. Radiation oncology is entirely different specialty. At Fox Chase, I'd recommend Eric Horwitz.

[Rams91 in reply to Tall_Allen]

Allen, I had positive margin of grade 3 <3mm and have been asked to start salvage radiation a bit more than a year after surgery. No invasion in any other area. pT2, pN0. PSA at 0.08 from 0.02 and 0.05. This is at Georgetown which I know is somewhere you highly recommend. Not looking forward to six months of ADT and 5 weeks of IMRT. The presence of low grade 3 at margin never entered the discussion with RO and MO there. Should it have?

[Tall_Allen in reply to Rams91]

I think you can wait for a more decisive PSA increase. Was this Sean Collins?

[Rams91 in reply to Tall_Allen]

Yes. He confirmed it is a BCR and if looking for a cure, now is the time for SRT.

[dentaltwin in reply to Tall_Allen]

Possibly dumb question--if extraprostatic extension was "not identified" but the margins weren't clean, doesn't that imply the entire prostate wasn't removed?

[Tall_Allen in reply to dentaltwin]

It means that he cut into the cancer. The pseudo-capsule around the prostate doesn't extend all the way down to the apex, so where to cut is often a matter of judgment. I think it's a good idea to have a pathologist standing by to check the frozen sections of the surgeon, but many surgeons think they can tell somehow (I guess God talks to them (insert snark emoji here))

[dentaltwin in reply to Tall_Allen]

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, although not in the "nerve-sparing" area. 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) 4+ years following surgery. 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!

[RJAMSG]

I had 3+3 at margin <1mm, overall grade 3+4, going on 41 months of undetectable; it’s weird that they picked up some 4 on your biopsy and then suddenly it is gone, I guess the biopsy removed it all 😊

[j-o-h-n]

Shoot I made it to 86 years old and did it without knowing WTF is a SmasherOfAjumma. I Googled it and I still don't...........

Good Luck, Good Health and Good Humor.

j-o-h-n Tuesday 03/21/2023 8:40 PM DST

[SmasherOfAjumma in reply to j-o-h-n]

You should Google Ajumma (and definitely look at the images). I am he who "smashes" the Ajumma. At least I was before getting a prostatectomy.

[j-o-h-n]

I already did....and I'm still perplexed.........I think it's best if you stick to smashing pumpkins instead....

Good Luck, Good Health and Good Humor.

j-o-h-n Wednesday 03/22/2023 1:33 PM DST

[fluffyfur in reply to j-o-h-n]

You always make me laugh. Haven't been here in a while but thanks 🥰

[j-o-h-n in reply to fluffyfur]

Thank you and you're so warm and fluffy...... (nice to see you)

Good Luck, Good Health and Good Humor.

j-o-h-n Tuesday 03/28/2023 10:12 PM DST

[Papillon2]

👍