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Intraprostatic margin following RP?

User
Posted 24 Jul 2020 at 16:52

Hi - does anyone have any experience of the meaning of a 3mm intraprostatic margin following RP?  For the life of me I can't find much online about it.

My family member has PC - info as follows:

- age 53 

- gleason 3 + 4

- T2b at diagnosis

- RP 9 months ago

- upgraded to T3a, locally advanced, post op

- positive surgical margins following op (as described above)

- on 3 monthly PSA tests for life

- PSA thus far is undetectable.  Next test in 3 months

My understanding is that a margin can be extraprostatic (i.e. outside of the capsule?) or intraprostatic (has the surgeon made a slight mistake and accidentally cut into the capsule during surgery?  this seems to be what the internet is implying).

Has anyone heard of this type of margin, and any info about the likelihood of recurrence with such a margin?

 

Thank you!

 

 

User
Posted 24 Jul 2020 at 23:32
It means the surgeon accidentally left some of the prostate behind and the pathology suggests that the left behind bit will have some cancer cells. This makes recurrence more likely but not an absolute certainty - the fact that your relative has had low post-op PSA results is good.

Assuming the op was supposed to be nerve-sparing, imagine the surgeon was trying to remove the apple but leave the peel in place

- an extraprostatic margin is when the path lab says 'ooops - you left a bit of cancer with the peel'

- an intraprostatic margin is 'ooops - you left a bit of the apple behind and it was right where the bruise was'

Time (& PSA levels) will tell whether the bruise all came out or a tiny bit was left.

You won't find much about it on the internet, I think, as it is not a common situation - most often an error by a surgeon who is inexperienced or developing a new technique.

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

User
Posted 24 Jul 2020 at 20:55

Sorry to hear that, not the best news.

No direct experience, so I'm not certain what I'm saying is correct.

I think extraprostatic positive margin would always mean some cancer has been left behind, because only cancer grows outside the capsule.

This is not the case with intraprostatic positive margins, where the material left behind is not necessarily cancerous. I'm guessing it would increase your baseline PSA though, which would need to be taken into account with subsequent PSA monitoring. Still it would be an increase in PSA which you are watching for though.

You probably should ask for more information, such as if the intraprostatic positive margins is near any of the known cancer. I would imagine histology should be able to tell if there's cancer at the cut edge.

User
Posted 25 Jul 2020 at 07:24

Are you using the supersensitive assay for PSA Tests?

This is probably a scenario where you definitely should because it will give you early visibility of a recurrence.

If you got a "less than" with a supersensitive test that is s really good sign, even with a positive margin there is a good chance the trauma of the removal will have killed any cancer that may have been left behind. Hence most positive margins don't result in a later recurrence.

You can put your figures in here and compare the figures for positive and negative margins and the likely impact on survival and BCR risk.

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

 

Edited by member 25 Jul 2020 at 07:35  | Reason: Not specified

User
Posted 27 Jul 2020 at 15:51

Well Lyn isn't one to blow her own trumpet so I will do so on her behalf.

First I would just like to make a distinction between Professional and Amateur, well Professional means you get paid for it. Amateur comes from the Latin Amare = to love. So if someone is an amateur astronomer for example they love astronomy.

To call someone an amateur is often used pejoratively, but really it should be a compliment. A professional has the luxury of being paid so can devote their working time to their profession but may not actually be very interested in it. An amateur will often devote as much time as possible, though sadly has to devote some time to earning money to put food on the table. Some people are lucky enough to be professionals in the field they love, which is wonderful for them. 

So no Lyn isn't a professional in this field she is an amateur and that is a good thing not a bad thing. As she has a keen interest in this topic she seems to have filed away a mass of useful information. There are quite a few other amateurs on here who have their own specialities, some know all the latest trials, some can explain the biochemistry quite well, some would give you a good philosophical debate on Quality Of Life.

I hope Lyn isn't offended by anything I have said here. Matron (that's what we call her, when she isn't looking) will tell me off if I have.

 

Dave

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User
Posted 24 Jul 2020 at 20:55

Sorry to hear that, not the best news.

No direct experience, so I'm not certain what I'm saying is correct.

I think extraprostatic positive margin would always mean some cancer has been left behind, because only cancer grows outside the capsule.

This is not the case with intraprostatic positive margins, where the material left behind is not necessarily cancerous. I'm guessing it would increase your baseline PSA though, which would need to be taken into account with subsequent PSA monitoring. Still it would be an increase in PSA which you are watching for though.

You probably should ask for more information, such as if the intraprostatic positive margins is near any of the known cancer. I would imagine histology should be able to tell if there's cancer at the cut edge.

User
Posted 24 Jul 2020 at 23:32
It means the surgeon accidentally left some of the prostate behind and the pathology suggests that the left behind bit will have some cancer cells. This makes recurrence more likely but not an absolute certainty - the fact that your relative has had low post-op PSA results is good.

Assuming the op was supposed to be nerve-sparing, imagine the surgeon was trying to remove the apple but leave the peel in place

- an extraprostatic margin is when the path lab says 'ooops - you left a bit of cancer with the peel'

- an intraprostatic margin is 'ooops - you left a bit of the apple behind and it was right where the bruise was'

Time (& PSA levels) will tell whether the bruise all came out or a tiny bit was left.

You won't find much about it on the internet, I think, as it is not a common situation - most often an error by a surgeon who is inexperienced or developing a new technique.

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

User
Posted 25 Jul 2020 at 07:24

Are you using the supersensitive assay for PSA Tests?

This is probably a scenario where you definitely should because it will give you early visibility of a recurrence.

If you got a "less than" with a supersensitive test that is s really good sign, even with a positive margin there is a good chance the trauma of the removal will have killed any cancer that may have been left behind. Hence most positive margins don't result in a later recurrence.

You can put your figures in here and compare the figures for positive and negative margins and the likely impact on survival and BCR risk.

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

 

Edited by member 25 Jul 2020 at 07:35  | Reason: Not specified

User
Posted 25 Jul 2020 at 16:32
Thank you all so much for your replies - I've been looking for ages online and then ask on here and get some really decent replies straight away : )

I didn't think it was particularly good news and I was under the impression that perhaps the surgeon had made a mistake. I'll trawl through the community here and see if anybody else has a similar situation. I'm guessing that if his PSA rises at some point then he will be offered salvage RT on the prostate bed.....

Lyn - yes, it was a nerve sparing op. Your explanation is SO helpful to me I can't thank you enough. You seem really knowledgeable - I'll see if I can read your posts - I'm sure they're full of info!

francij1 - I'm guessing they're using the supersensitive as they give him a detailed reading - i.e. the first one post op was 0.013 - I'm guessing if they were using the non sensitive test they would have just said <0.1?

Andy - thank you, I'll try and approach the topic of asking about histology detail when I next see him. I guess there's no way of knowing whether the cells that have been left behind are cancerous - just got to keep an eye on the PSA like you say.

Is the 3mm measurement significant in terms of recurrence does anyone know? Everything I've read indicates that 3mm or more isn't great news. Is the mm literally the length of the bit the surgeon has left in/the distance from between the left in cells and the edge of the capsule?

Thank you.

User
Posted 25 Jul 2020 at 20:28
Yes 3 decimal places is supersensitive so good news indeed if it's a less than
User
Posted 25 Jul 2020 at 23:28

Originally Posted by: Online Community Member
. I'll trawl through the community here and see if anybody else has a similar situation. 

.

I have been here more than 10 years and can only think of one person who had an intraprostatic +ve margin, although there may be members who just haven't posted about it. 

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

User
Posted 26 Jul 2020 at 15:51
Thanks Lyn - I didn't realise his situation was so incredibly rare. It makes stats ref recurrence even harder to find. You know an awful lot about it - are you a prostate medical professional?! (I've read your profile and know your husband's journey - great to hear he's doing well). I wonder how that one person you remember got on. Thanks again.
User
Posted 27 Jul 2020 at 15:51

Well Lyn isn't one to blow her own trumpet so I will do so on her behalf.

First I would just like to make a distinction between Professional and Amateur, well Professional means you get paid for it. Amateur comes from the Latin Amare = to love. So if someone is an amateur astronomer for example they love astronomy.

To call someone an amateur is often used pejoratively, but really it should be a compliment. A professional has the luxury of being paid so can devote their working time to their profession but may not actually be very interested in it. An amateur will often devote as much time as possible, though sadly has to devote some time to earning money to put food on the table. Some people are lucky enough to be professionals in the field they love, which is wonderful for them. 

So no Lyn isn't a professional in this field she is an amateur and that is a good thing not a bad thing. As she has a keen interest in this topic she seems to have filed away a mass of useful information. There are quite a few other amateurs on here who have their own specialities, some know all the latest trials, some can explain the biochemistry quite well, some would give you a good philosophical debate on Quality Of Life.

I hope Lyn isn't offended by anything I have said here. Matron (that's what we call her, when she isn't looking) will tell me off if I have.

 

Dave

User
Posted 27 Jul 2020 at 18:06

Originally Posted by: Online Community Member

I hope Lyn isn't offended by anything I have said here. Matron (that's what we call her, when she isn't looking) will tell me off if I have.

Extra blanket baths scheduled for you now. πŸ˜‚

_____

Two cannibals named Ectomy and Prost, all alone on a Desert island.

Prost was the strongest, so Prost ate Ectomy.

User
Posted 27 Jul 2020 at 18:19
πŸ™„

Bollinge has a lot to answer for.

Sorry, Lou - I missed your question. No, not a medical professional but my dad and father-in-law both had PCa before my husband so you get to know quite a lot from different perspectives and I have been here more than 10 years now so tend to remember who has had unusual situations, been on trials, etc.

I believe that there are a few medical professionals who are members of this forum but none of them post openly.

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

User
Posted 27 Jul 2020 at 22:44

Now Lyn, if you worked at my place, you’d be called Matron Lyn, or Matron Eyre.  I’m glad I’m not within hearing or slapping distance lol

User
Posted 28 Jul 2020 at 07:35
I am an β€œamateur” of Champagne, but not a lover of prostate cancer...

Cheers, John.

User
Posted 06 Aug 2020 at 19:48

That’s what *you* call her.

I’m waiting for someone to tag you “Captain Mainwaring” 😈😈😈

User
Posted 08 Aug 2020 at 07:10
Defo not Captain Mainwaring more like the shifty Private Walker! πŸ˜‚πŸ˜‚πŸ˜‚

BTW do you know what 😈 means??

User
Posted 08 Aug 2020 at 08:24

Ahah! I was watching the first episode a few days ago and I could not remember that character’s name. You saved me a google πŸ˜‚

I use 😈 for devilish impish banter emoticons. If it has another meaning do tell because I use it a lot and I hate to think I’ve left random marriage proposals or worse everywhere πŸ˜±πŸ˜±πŸ˜‚πŸ˜‚

User
Posted 09 Aug 2020 at 09:00
My kids tell me if means you are feeling horny!
User
Posted 09 Aug 2020 at 09:19

Kids today, what do they know?.... everything. 

Dave

User
Posted 24 Jul 2021 at 12:18

I a very have similar situation, so following this thread with interest.

Also 53, 3+4, grade 2, T2a going in to nerve-sparing. Had op 1st June and follow up call 21st July after chasing hard. Then got a slot but no chance to get PSA beforehand. Good job we are not in a hurry, eh?

Consultant informed of ‘free upgrade’ to 4+3, described as ‘touching margin’ (whatever that means) but that could be a tear during nerve sparing. He didn’t mention multiple margins on the call. Get PSA done 3 monthly, speak in 6 weeks.

Received report today, 4+3, grade 3 with tertiary grade 5 (worrying), pT2c, and…

Margin status:

- Circumferential margin left posterior/lateral, intraprostatic, <3mm. Earlier in report it states surgical incisions: Absent, so assume this margin can’t be down to that.

- Apical margin: <3mm. (I assume from this that Apical margin was extraprostatic?)

So blood Wednesday then waiting for first PSA. More anxiety. And more questions for next Consultant call 1st Sept.

 

User
Posted 24 Jul 2021 at 20:06
A positive margin at the apex is quite common and doesn't necessarily mean that you will have problems going forward. The intraprostatic margin is a surgical error and the risk of recurrence is higher than would be for extraprostatic margin but even so, your PSA will be a good marker. I am not sure why you haven't had your first post-op PSA yet?

The tertiary 5 is a bit of a blow but isn't a problem if it is all in the petrie dish!

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

 
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