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Close Margins

User
Posted 07 Mar 2019 at 18:53

Negative margins are a good thing although according to a study not always as good as you think.

The report linked below says that if tumour cells are within 0.01mm of the margin, called a close margin in the study,  then it is classed as negative but the outcome is measurably worse than negative.

You might think 0.01mm is very small and thought a margin would be more than that but the margin is the edge of the prostate sample removed. 

This report says that in their sample, 6 years after the op a negative margin has a recurrence (at psa 0.2) of about 14%.  A close margin about 25%.  A positive margin about 36%.    It says T3a,  high Gleason and high psa are also more prevalent in the recurrences.  The writer suggests adjuvant treatment should be offered for close margins. 

Although do they normally measure to that degree.  0.01mm is very small and you’d think it could be classed as positive.  (I'd emphasise that the above is from one study and might not be the official figures for recurrence).

You might also think recurrence would be more likely for a close margin near the bladder or other adjoining cells.  You could also say a recurrence is sometimes declared at less than psa 0.2, e.g. 3 consecutive rises above 0.1. As always there are a lot of what ifs.

The report was written in 2015 using approx. 1600 samples from RPs done between 1998 and 2011 and had about 200 recurrences.  19% were positive, 15% were close.  I can't say I’ve read it in depth especially the statistical information.

Here's the link to it:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4428570/#!po=34.2105

In my own case I was told there is some good news your margins are negative.  I asked how big the margin is but was told it’s not like other cancers where they cut out say 4mm clear around the tumour cells.  Although I could perhaps have been told how far from the margin the cells are having been earlier told from the MRI it was near the margin.  Not sure if others would like to know or are aware of such information.  I'm not sure I want to know but probably would as I'm suspicious of what close to the edge meant in mine.  Any thoughts positive or negative?

Regards
Peter

User
Posted 08 Mar 2019 at 00:53
Sort of but the prostate is not removed like a complete orange with its peel - it is more like trying to remove the orange flesh from the peel while the fruit still hangs on the tree. The outer edge of the prostate is covered with nerve bundles and other stuff which is peeled away as much as possible but inevitably, when you peel an orange there is still some pith stuck to the outside of the segments. In non nerve sparing and partial nerve sparing, some of the peel comes out too - the whole lot is then encased in wax and sliced.

A negative margin means there were no signs of cancerous cells abutting the wax NOT necessarily that there were no signs of cancer breaching the gland - it is a way of saying "to the best of our knowledge we haven't left any of the cancer behind" rather than saying "to the best of our knowledge the cancer was totally contained inside the gland". That is why surgeons have to report their positive margin rates - it means they didn't get a clean peel. Positive margins are often amongst the nerve bundles that have been retained in an attempt at nerve sparing. If the patient is having non nerve-sparing, the surgeon removes the orange, the pith and the peel.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 08 Mar 2019 at 12:00
So let's be clear:

Negative margins = good

Positive margins = not so bad

If a recurrence happens and RT is required:

Negative margins = not so bad

Positive margins = good

Positive margins at RP should also be stratified into massive wide margin or tiny little margin. With a small margin the trauma of surgery will probably kill any remaining cells, with a large margin ajuvant or salvage treatment are probably inevitable.

User
Posted 08 Mar 2019 at 17:17
My post-operative pathology said there was a breach of the capsule ‘focally’ and moreover two lymph nodes were cancerous.

I currently have an undetectable PSA nine months later, so I am keeping calm and carrying on. If I were a doom-monger I could check on my chances of recurrence at the excellent Memorial Sloan Kettering Hospital prognostication Nomogram tool. Or I could have a consultation with Gypsy Rose-Lee on the Golden Mile in Blackpool. Both would be about as accurate.

The reality is that any cancer has every chance of recurrence, including our own Matron Kierkegaard’s dear father after thirteen years (I think).

I think the way forward is to be positive, and if there is biochemical recurrence, months or years in the future, there are therapies to treat it ‘With curative intent’, and cross that bridge when you come to it. If you ever do.

Cheers, John.

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User
Posted 07 Mar 2019 at 20:37
The fact is that you can have completely clear margins and still have a recurrence, while there are a few men that have been through this forum who had a positive margin but never needed salvage treatment. The margin is not the only or necessarily the most important predictor .... seminal vesicle involvement identified at biopsy is a bit of a flag, as is perineural invasion found at pathology, and a clear margin is no predictor of whether or not some cancer cells have floated off into the lymphatic system or settled in a bone unnoticed.

I think from your post that you are assuming the margin is also the edge of the prostate but they are different things.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 07 Mar 2019 at 23:55

Perhaps that's where I used the term margin near the end when I should have used 'edge' of the prostate.

I believe the margin is the edge of the sample removed which would usually be the prostate.  

There is another paper about Close Margins <0.2mm on the John Hopkins site although I haven't yet found it.

User
Posted 08 Mar 2019 at 00:53
Sort of but the prostate is not removed like a complete orange with its peel - it is more like trying to remove the orange flesh from the peel while the fruit still hangs on the tree. The outer edge of the prostate is covered with nerve bundles and other stuff which is peeled away as much as possible but inevitably, when you peel an orange there is still some pith stuck to the outside of the segments. In non nerve sparing and partial nerve sparing, some of the peel comes out too - the whole lot is then encased in wax and sliced.

A negative margin means there were no signs of cancerous cells abutting the wax NOT necessarily that there were no signs of cancer breaching the gland - it is a way of saying "to the best of our knowledge we haven't left any of the cancer behind" rather than saying "to the best of our knowledge the cancer was totally contained inside the gland". That is why surgeons have to report their positive margin rates - it means they didn't get a clean peel. Positive margins are often amongst the nerve bundles that have been retained in an attempt at nerve sparing. If the patient is having non nerve-sparing, the surgeon removes the orange, the pith and the peel.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 08 Mar 2019 at 01:09

Originally Posted by: Online Community Member

Negative margins are a good thing although according to a study not always as good as you think.

 

Interestingly, it is said now that negative margins aren't such a good thing if there is a biochemical recurrence as the implication is that the recurrence isn't just down to a few cells left behind in the prostate bed.

What is really interesting about your link to the Uni of Washington research is the high proportion of men who apparently did not have a recurrence despite a positive margin - this will be music to the ears of a number of members :-) 

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 08 Mar 2019 at 11:53
Play with this nomogram:

https://www.mskcc.org/nomograms/prostate/salvage_radiation_therapy

If you have negative margins and a recurrence your chance of an enduring remission goes down by about 5%

User
Posted 08 Mar 2019 at 12:00
So let's be clear:

Negative margins = good

Positive margins = not so bad

If a recurrence happens and RT is required:

Negative margins = not so bad

Positive margins = good

Positive margins at RP should also be stratified into massive wide margin or tiny little margin. With a small margin the trauma of surgery will probably kill any remaining cells, with a large margin ajuvant or salvage treatment are probably inevitable.

User
Posted 08 Mar 2019 at 14:59

Originally Posted by: Online Community Member
The fact is that you can have completely clear margins and still have a recurrence, while there are a few men that have been through this forum who had a positive margin but never needed salvage treatment. The margin is not the only or necessarily the most important predictor .... seminal vesicle involvement identified at biopsy is a bit of a flag, as is perineural invasion found at pathology, and a clear margin is no predictor of whether or not some cancer cells have floated off into the lymphatic system or settled in a bone unnoticed.

I think from your post that you are assuming the margin is also the edge of the prostate but they are different things.

 

This has got me worrying, Mr L ’s pathology had said that the margins were negative, but was close to the edge at 0.1mm to left posterior circumferential margin, just focally anterior,  prostatic fat sent separately is free of neoplasia. staging is T2c but perineural invasion was found. I thought PNI wasnt significant in pathology finding?

User
Posted 08 Mar 2019 at 16:04

Originally Posted by: Online Community Member
Interestingly, it is said now that negative margins aren't such a good thing if there is a biochemical recurrence as the implication is that the recurrence isn't just down to a few cells left behind in the prostate bed.

When I was being diagnosed it seemed surgery was a more certain treatment than any other and being able to have later RT after was another benefit.

After reading more it now seems that RT can be better if there is local spread and perhaps the benefit of later RT in my case isn't as big as thought.   I found out late my tumour is in the apex which seems away from the bladder so reducing the benefit of RT towards the bladder.  That being said I can't think of a case where I'd prefer a positive margin.

Thanks for the description of margin it's a useful insight.

Reading Mrs L's post below I'm surprised anyone is told or it's reported their tumour is 0.1mm from the margin as the study gave the impression it was special research.  Is that sort of information standard.  I haven't got my report and have erred on the side of not asking for it.

User
Posted 08 Mar 2019 at 17:17
My post-operative pathology said there was a breach of the capsule ‘focally’ and moreover two lymph nodes were cancerous.

I currently have an undetectable PSA nine months later, so I am keeping calm and carrying on. If I were a doom-monger I could check on my chances of recurrence at the excellent Memorial Sloan Kettering Hospital prognostication Nomogram tool. Or I could have a consultation with Gypsy Rose-Lee on the Golden Mile in Blackpool. Both would be about as accurate.

The reality is that any cancer has every chance of recurrence, including our own Matron Kierkegaard’s dear father after thirteen years (I think).

I think the way forward is to be positive, and if there is biochemical recurrence, months or years in the future, there are therapies to treat it ‘With curative intent’, and cross that bridge when you come to it. If you ever do.

Cheers, John.

User
Posted 08 Mar 2019 at 18:31

Good stuff Bollinge old boy but not sure that Gypsy Rose Lee is still there. Madame Petulengo has a booth at the entrance to North Pier though.  Here's to good psa tests.

User
Posted 08 Mar 2019 at 20:43

Originally Posted by: Online Community Member

When I was being diagnosed it seemed surgery was a more certain treatment than any other and being able to have later RT after was another benefit.

After reading more it now seems that RT can be better if there is local spread and perhaps the benefit of later RT in my case isn't as big as thought.

If it was as simple as that, almost everyone would have the same treatment as happens with other types of cancer. It is wrong for people to suggest that surgery is the ’best’ option and RT is somehow a runners up prize for men unfortunate enough not to be able to have surgery. Our urologist says that in the future people will be horrified and fascinated to hear that prostatectomy was ever a thing, and I know that at the annual uro-oncology conference it has long been accepted that forms of radiotherapy / non-surgical routes will be the gold standard in the future. 

The idea that surgery offers the benefit of possible salvage RT if needed is also flawed thinking although you will see it pushed forward regularly to men making treatment choices. The fact is that if you need salvage treatment then your chance of full remission drops considerably regardless of which treatment came first or second. "I will have surgery and if it fails I can still have RT" is not as helpful a thought as "which treatment is least likely to fail in my case"

We didn't understand that and John had RP even though the diagnostic letter from the urologist said he had a 55% chance of recurrence (despite Bollinge's relationship with Gypsy Rose Lee, the MSK nomogram is often a reliable tool). Fortunately, when it recurred the stat was that salvage RT had an 80% chance of being successful for him and so far, things are looking good. I don't know whether RT had an 80% chance of being successful as a primary treatment but even if it had, I don't think J would have gone for it because his greatest instinct was just to get it cut out asap. 

Edited by member 08 Mar 2019 at 20:51  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 08 Mar 2019 at 23:57

Those are good points but to be fair to my doctors they didn't promote surgery over RT or say it's good to be able to have RT after surgery.  It was my own prejudices and investigation that formed those thoughts and the doctors let me follow my own choices.  Although two doctors said I'd made the right choice after I'd made it and I've no regrets.

I had quite a few fears about 3 months of hormones as I had been led to believe there was a risk of the tumour coming out, I had images of it spreading and then being denied RT.   Cut it out sounded great and no going back.

It sounds like your John had the same thoughts as myself.  It's unfortunate that you become more expert after the event but we're not sure it would change anything.   I'm sure there are thousands who have the op and just go home and not learn any more about it anyway. So perhaps lucky them.

User
Posted 09 Mar 2019 at 06:36
My surgeon said I had microscopic negative margins. Is that the same as close margins? I'd have thought a microscope was used to identify all margins?

Cheers

Bill

User
Posted 17 Mar 2019 at 17:12
Sounds like a very small margin
 
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