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Biochemical reoccurrence with positive margins.

User
Posted 22 Apr 2024 at 14:41

Good afternoon all.

I would just like the views of you knowledgeable people regarding biochemical reoccurrence post surgery with positive margins/ extra prostatic extension.

My scores on the doors.

Pre surgery,  presenting psa 5  biopsy Gleason 3+4=7 mri  T2 N0 M0

Post surgery histology  Gleason 3+3=6 extra prostatic extension at the left apex small focus  (<1 high powered field). Focal Positive margin within the prostatic stroma at the posterior left apex. (2mm)

psa 2 months <0.1  psa 6 months <0.1  psa 12 months <0.1  psa 18 months <0.1  re test 24 months.

So ladies & gents is a relapse more likely / certain with positive margins or does other things like Gleason scores etc count favourably.

 Thanks in advance Jeff.

Good luck all.

User
Posted 25 Apr 2024 at 17:18

There is no such thing as internal or external margin. The margin is one: the point where the surgeon divides the prostate away of the surrounding connective tissue. If cancer cells are found at the peripheral edge of the specimen the margin is positive. The PSA should not significantly increase even in the presence of prostate tissue left behind. Oncologists do not deliver high dose radiotherapy on the suspicion of possible cancer cells. What is true is that (1) multifocality of the prostate cancer may have not been appreciated at the time of the prostatectomy and (2) once you have prostate cancer, your risk of developing further cancer in the potential remnant prostate tissue is higher than the 'normal' population.

Edited by member 25 Apr 2024 at 19:47  | Reason: Not specified

User
Posted 25 Apr 2024 at 20:44

With all your respect, there is some confusion here. Extraprostatic extension means the tumour has breached the capsule and spread to adjacent tissue. Intraprostatic incision means that the surgeon has cut through the tumour, either due to lack of a distinct plane between capsule and connective tissue or due to lack of expertise. They both result in cancer cells being left behind and the outlook is the same. 

A biochemical recurrence means that conventional imaging has not picked up significant volume of cancer because it's likely to be at the microscopic level, but oncologists believe the latter hence the offer of RT. The gents on the forum that had RT as a result of rising PSA had this on the knowledge they have residual disease in the prostate bed. There is little uncertainty that there is cancer when the PSA rises. Also even with a complete removal of the prostate there are prostate cells left behind in the bladder neck and urethra. Prostate doesn't stop at a specific point where the urethra starts, there is a transition region. 

I didn't want to disclose this, but I am in fact an oncologist, who has recent had a prostatectomy, so I hope I have a fair understanding of the biology :)

Have a good evening.

User
Posted 25 Apr 2024 at 20:23
Google extraprostatic extension v intraprostatic incision - the two types of positive margin with lots of research on the difference and how each relates to risk of BCR

"Oncologists do not deliver high dose radiotherapy on the suspicion of possible cancer cells." I am not sure that is right - as demonstrated on this forum on a fairly regular basis, if a man's PSA rises to a detectable level post-surgery but there is no sign of cancer on the scans, oncologists often recommend RT to the prostate bed. This is particularly true if the pathology was not great - e.g. EPE, positive margin, SVI, local lymph node affected, etc.

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

User
Posted 25 Apr 2024 at 21:35

Originally Posted by: Online Community Member

I didn't want to disclose this, but I am in fact an oncologist, who has recent had a prostatectomy, so I hope I have a fair understanding of the biology :)

Wow! 😲

That revelation was like an episode of Undercover Boss. 😁

Your inbox has just exploded.💥

Edited by member 25 Apr 2024 at 21:43  | Reason: Emoji

User
Posted 26 Apr 2024 at 12:02

The risk is made up by more than one factor as you know. It's obviously good that your margins were clear. EPE raise the chance of biochemical recurrence but as I said it's all about figures/risk. 

User
Posted 22 Apr 2024 at 17:28

My impression is from reading various bits of research is that positive marginas do increase the chance of recurrence, especially in the early years. However, the other factors do count, e.g. a Gleason 3+3 is "good".

You could try inputting your numbers into the Kattan post-prostatectomy nomogram which aims to estimate your probability of recurrence at intervals up to 10 years after surgery. One interesting feature of it is that it aims to take account of how long you have had an undetectable PSA. Here is  a link if it sounds of interest:

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

This can also let you see what the effect of the positive margins might be in various circumstances. For example, I tried inputting some numbers similar to yours and it came up with  25% chance of recurrence at 10 years with positive margins, compared with about 11% without positive margins. But you need to put in as much detail as you can to get their best estimate. And of course it only gives a rough idea of the statistical probabilities based on historic results from people with characteristics similar to yours. It does not give a definite yes or no.

User
Posted 22 Apr 2024 at 18:15

Hi Jeff.

I'm delighted that your PSA is still undetectable, long may it continue. I'm afraid I'm useless at what margins mean and how relevant EPE is.

To tell you the truth, I've packed in exploring the chances of having BCR. I was Gleason 9 (4+5) with EPE, not certain about margins. I've been told I've got a 60% chance of recurrence but I don't know over what time span.

I'm now over a year post op,  and happily find my PSA is still undetectable.

It's taken me ages, but I've eventually began to believe in 'what will be will be.'

Best of luck mate.

Edited by member 22 Apr 2024 at 18:22  | Reason: Typo

User
Posted 22 Apr 2024 at 19:14

Hi Adrian.

congratulations on the undetectable psa long may it continue, I agree with you on what will be will be, with this disease we have to be prepared for what is thrown at us, my main incentive was to ask you knowledgeable people if any other factors like Gleason scores or number of positive margins would be a indication of reoccurrence.

Thanks for your opinion.

Jeff.

User
Posted 22 Apr 2024 at 19:43

Jeff, I had positive margins and extraprostatic extension and was 4+3, my staging was upgraded after histology. I was told there was a 30 percent chance of recurrence. 

I was fortunate to have more sensitive testing, my post op PSA was 0.03 which would have been reported as <0.1 in your hospital. At 23 months my PSA was 0.07, again still below the so called undetectable range. I was told the consultant had many patients who levelled off at 0.1. 

At 26 months I reached 0.13 and was brought back under urology for monitoring. 

At 33 months I hit 0.2 ,at 35 months I was 0.27. I started salvage RT at 36 months. 

We are all different and you may be absolutely fine. 

Thanks Chris 

User
Posted 23 Apr 2024 at 09:02

Thanks for the reply Chris.

I guess all we can do is wait for our next psa tests, as with your undetectable levels at 2 years I suppose a reoccurrence could happen at any time.

All the very best with your treatment. 
Jeff.

User
Posted 23 Apr 2024 at 10:29

Exactly right Kevin, all we can do is keep up with our psa testing, I see you are into your 4 th year undetectable  post surgery, long may it continue.

Jeff.

User
Posted 25 Apr 2024 at 20:30

Originally Posted by: Online Community Member
Under these circumstances do you think as this tissue repairs there is a possibility that this could lead to a rise in PSA that was just created by extraneous prostate tissue rather than cancer? If so how might we be able to tell this (eg through the readings?).

That is why the definition of BCR is as it is - traditional view is that benign prostate material could account for a reading of up to 0.2 but in reality is very unlikely to lead to a PSA of more than 0.1 - hence BCR is generally defined as (and referral to oncology should be considered at)

- 0.2 or

- three successive rises above 0.1 or

- PSA started as undetectable post-op and is still below 0.1 but demonstrates steady increases and the pathology was of concern 

Doctors will also take account of the possibility of minute amounts of PSA being generated elsewhere in the body - prostate specific antigen is not prostate-specific! 

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

User
Posted 25 Apr 2024 at 22:19

It’s a good thing then that I can’t respond to personal messages being a new member! 😂 

User
Posted 26 Apr 2024 at 11:09

Not at all, we are talking about risks; If there was EPE which was not resected (removed) at surgery, then you are not clear of cancer and should have radiation treatment. If it is removed, then you are talking about having an increased risk of relapse but this is far from definite. Risk is a difficult concept to swallow and live with. But there is always risk that the disease reappears even with the best prognostic indicators; it's just that the number varies. Learning to live with that knowledge is the most important thing, in my view. 

I met with my own surgeon last night and debated at length the value is supersensitive PSA vs 2 decimal point PSA my hospital offers. The reality is the outcome doesn't change, as the intervention doesn't change with picking up slow rising (3 decimal point) PSA. All the supersensitive PSA does is to increase my anxiety with a potentially slow rising PSA which I may not need treatment for, for years. I haven't decided yet which one I'll have next week! 

User
Posted 26 Apr 2024 at 14:55

Thank you Lyn,

As always your replies are so helpful and appreciated. You and a number of others provide such valuable experience and insight.

It made me chuckle your comment that "prostate specific antigen is not prostate-specific!" as it really sums up my experience of nothing quite being what you think it is with PC.

Have a lovely weekend

Many thanks

Show Most Thanked Posts
User
Posted 22 Apr 2024 at 17:28

My impression is from reading various bits of research is that positive marginas do increase the chance of recurrence, especially in the early years. However, the other factors do count, e.g. a Gleason 3+3 is "good".

You could try inputting your numbers into the Kattan post-prostatectomy nomogram which aims to estimate your probability of recurrence at intervals up to 10 years after surgery. One interesting feature of it is that it aims to take account of how long you have had an undetectable PSA. Here is  a link if it sounds of interest:

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

This can also let you see what the effect of the positive margins might be in various circumstances. For example, I tried inputting some numbers similar to yours and it came up with  25% chance of recurrence at 10 years with positive margins, compared with about 11% without positive margins. But you need to put in as much detail as you can to get their best estimate. And of course it only gives a rough idea of the statistical probabilities based on historic results from people with characteristics similar to yours. It does not give a definite yes or no.

User
Posted 22 Apr 2024 at 17:49

HI,

I'd think 3+3 Gleason is a good factor.   Some say 3+3 is only marginally cancer.

Also I've read that positive margins at the apex are better than near the bladder.

Having a positive margin increases the risk that at some stage it might come back but you've gone a decent time at under <0.1.   

In my opinion, and there are those who won't agree, you should be having psa tests down to <0.03.  Especially with the positive margins giving a higher risk.   It will be better to get a heads up on any change coming down the line.   If you were in the US they'd likely be considering RT a lot earlier than here.  Although I admit I'm a neurotic and wanting immediate action whereas others are OK to sit back to the specified limits are crossed.   All the best, Peter

User
Posted 22 Apr 2024 at 18:15

Hi Jeff.

I'm delighted that your PSA is still undetectable, long may it continue. I'm afraid I'm useless at what margins mean and how relevant EPE is.

To tell you the truth, I've packed in exploring the chances of having BCR. I was Gleason 9 (4+5) with EPE, not certain about margins. I've been told I've got a 60% chance of recurrence but I don't know over what time span.

I'm now over a year post op,  and happily find my PSA is still undetectable.

It's taken me ages, but I've eventually began to believe in 'what will be will be.'

Best of luck mate.

Edited by member 22 Apr 2024 at 18:22  | Reason: Typo

User
Posted 22 Apr 2024 at 19:02

Thank you  Kevin & thanks for the nomogram very interesting results.

all the best Jeff.

User
Posted 22 Apr 2024 at 19:08

Thank you for the reply Peter.

Yes I understand the point on the psa  going down <0.03 unfortunately the <0.1 is the lowest my gp goes down to.

Best of luck Jeff.

User
Posted 22 Apr 2024 at 19:14

Hi Adrian.

congratulations on the undetectable psa long may it continue, I agree with you on what will be will be, with this disease we have to be prepared for what is thrown at us, my main incentive was to ask you knowledgeable people if any other factors like Gleason scores or number of positive margins would be a indication of reoccurrence.

Thanks for your opinion.

Jeff.

User
Posted 22 Apr 2024 at 19:43

Jeff, I had positive margins and extraprostatic extension and was 4+3, my staging was upgraded after histology. I was told there was a 30 percent chance of recurrence. 

I was fortunate to have more sensitive testing, my post op PSA was 0.03 which would have been reported as <0.1 in your hospital. At 23 months my PSA was 0.07, again still below the so called undetectable range. I was told the consultant had many patients who levelled off at 0.1. 

At 26 months I reached 0.13 and was brought back under urology for monitoring. 

At 33 months I hit 0.2 ,at 35 months I was 0.27. I started salvage RT at 36 months. 

We are all different and you may be absolutely fine. 

Thanks Chris 

User
Posted 22 Apr 2024 at 23:25
While you are less than 0.1 with a G3+3 especially after 2 years I would relax and stop worrying.

Keep up the PSA testing though and make sure you get your actual results, do not rely on GPs to interpret your results! If you ever lose the < insist on a referral to oncology.

User
Posted 22 Apr 2024 at 23:42

Originally Posted by: Online Community Member
So ladies & gents is a relapse more likely / certain with positive margins or does other things like Gleason scores etc count favourably.

Not all positive margins are equal. Research says that an external positive margin does not increase the risk of BCR at all but an internal positive margin does increase the risk. Technically, the Gleason score makes very little difference unless you had a 5 in the mix. 

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

User
Posted 23 Apr 2024 at 00:04

Originally Posted by: Online Community Member

Technically, the Gleason score makes very little difference unless you had a 5 in the mix. 

Thanks for that Lyn. You know I already have trouble sleeping. 😁

Edited by member 23 Apr 2024 at 00:05  | Reason: Typo

User
Posted 23 Apr 2024 at 09:02

Thanks for the reply Chris.

I guess all we can do is wait for our next psa tests, as with your undetectable levels at 2 years I suppose a reoccurrence could happen at any time.

All the very best with your treatment. 
Jeff.

User
Posted 23 Apr 2024 at 09:09

Thanks for the advice Jonathan, I get the results direct from my gp with the system online which shows the < on the reports. 
Really grateful. Jeff.

User
Posted 23 Apr 2024 at 09:16

Lyn.

Thank you for your knowledgeable advice, would you know the reason why internal & external margins differ. I also thought I had read where focal margins at the apex were hard to distinguish.

Your input is truly valued.

Jeff.

User
Posted 23 Apr 2024 at 09:41

On the effect of Gleason score, this must be another one of those topics on which the research varies.

On the Kattan nomogram it seems to make a huge difference even going from 3+3 up to 4+3.

If I put in a hypothetical man with positive margins as the only adverse feature and a Gleason 3+3 it shows the 10 year risk of recurrence as only 16%.

If I then change the Gleason score to 4+3 the risk goes up to 63%.

The Kattan nomogram does not seem to allow you to investigate the effect of Gleason 5 because it groups Gleason 8-10s together.

I must stress that I have no expertise with which to judge how reliable this nomogram might be, but it claims to be based on thousands of cases and is quite widely used.

Of course, at the end of the day, none of these percentages really matter because que sera sera and we just have to deal with whatever turns up. Even being in a 1% risk group would be no comfort if you turned out to be the 1% !

 

User
Posted 23 Apr 2024 at 10:29

Exactly right Kevin, all we can do is keep up with our psa testing, I see you are into your 4 th year undetectable  post surgery, long may it continue.

Jeff.

User
Posted 24 Apr 2024 at 14:20

Originally Posted by: Online Community Member

Lyn.

Thank you for your knowledgeable advice, would you know the reason why internal & external margins differ. I also thought I had read where focal margins at the apex were hard to distinguish.

Your input is truly valued.

Jeff.

It is possible to have an external positive margin without any cancer being left behind - the remaining sliver of cancer may have been right on the cutting edge or could have been burnt away at the end of the op when they were sealing blood vessels, etc. 

An internal positive margin means that the surgeon accidentally left a bit of the prostate inside the patient. 

Statistically, a man with a tiny bit of prostate left behind is more likely to have small rises in PSA leading to a recommendation of salvage RT ... the difference is because a biochemical recurrence is defined as a PSA over 0.2 or 3 rises above 0.1. Biochemical recurrence doesn't need any evidence that there is actually active cancer present. 

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

User
Posted 25 Apr 2024 at 07:52

Ah that makes sense now Lyn, thanks for your easy to understand explanation.

Jeff.

User
Posted 25 Apr 2024 at 15:57

Thanks Lynn,

This is very interesting. Under these circumstances do you think as this tissue repairs there is a possibility that this could lead to a rise in PSA that was just created by extraneous prostate tissue rather than cancer? If so how might we be able to tell this (eg through the readings?). I wouldn't want unnecessary salvage treatment nor using a significant part of my armoury if it wasn't in all likelihood cancerous but equally wouldn't want to ignore it if it was. A potential conundrum. Many thanks

User
Posted 25 Apr 2024 at 17:18

There is no such thing as internal or external margin. The margin is one: the point where the surgeon divides the prostate away of the surrounding connective tissue. If cancer cells are found at the peripheral edge of the specimen the margin is positive. The PSA should not significantly increase even in the presence of prostate tissue left behind. Oncologists do not deliver high dose radiotherapy on the suspicion of possible cancer cells. What is true is that (1) multifocality of the prostate cancer may have not been appreciated at the time of the prostatectomy and (2) once you have prostate cancer, your risk of developing further cancer in the potential remnant prostate tissue is higher than the 'normal' population.

Edited by member 25 Apr 2024 at 19:47  | Reason: Not specified

User
Posted 25 Apr 2024 at 20:23
Google extraprostatic extension v intraprostatic incision - the two types of positive margin with lots of research on the difference and how each relates to risk of BCR

"Oncologists do not deliver high dose radiotherapy on the suspicion of possible cancer cells." I am not sure that is right - as demonstrated on this forum on a fairly regular basis, if a man's PSA rises to a detectable level post-surgery but there is no sign of cancer on the scans, oncologists often recommend RT to the prostate bed. This is particularly true if the pathology was not great - e.g. EPE, positive margin, SVI, local lymph node affected, etc.

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

User
Posted 25 Apr 2024 at 20:30

Originally Posted by: Online Community Member
Under these circumstances do you think as this tissue repairs there is a possibility that this could lead to a rise in PSA that was just created by extraneous prostate tissue rather than cancer? If so how might we be able to tell this (eg through the readings?).

That is why the definition of BCR is as it is - traditional view is that benign prostate material could account for a reading of up to 0.2 but in reality is very unlikely to lead to a PSA of more than 0.1 - hence BCR is generally defined as (and referral to oncology should be considered at)

- 0.2 or

- three successive rises above 0.1 or

- PSA started as undetectable post-op and is still below 0.1 but demonstrates steady increases and the pathology was of concern 

Doctors will also take account of the possibility of minute amounts of PSA being generated elsewhere in the body - prostate specific antigen is not prostate-specific! 

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

User
Posted 25 Apr 2024 at 20:44

With all your respect, there is some confusion here. Extraprostatic extension means the tumour has breached the capsule and spread to adjacent tissue. Intraprostatic incision means that the surgeon has cut through the tumour, either due to lack of a distinct plane between capsule and connective tissue or due to lack of expertise. They both result in cancer cells being left behind and the outlook is the same. 

A biochemical recurrence means that conventional imaging has not picked up significant volume of cancer because it's likely to be at the microscopic level, but oncologists believe the latter hence the offer of RT. The gents on the forum that had RT as a result of rising PSA had this on the knowledge they have residual disease in the prostate bed. There is little uncertainty that there is cancer when the PSA rises. Also even with a complete removal of the prostate there are prostate cells left behind in the bladder neck and urethra. Prostate doesn't stop at a specific point where the urethra starts, there is a transition region. 

I didn't want to disclose this, but I am in fact an oncologist, who has recent had a prostatectomy, so I hope I have a fair understanding of the biology :)

Have a good evening.

User
Posted 25 Apr 2024 at 21:35

Originally Posted by: Online Community Member

I didn't want to disclose this, but I am in fact an oncologist, who has recent had a prostatectomy, so I hope I have a fair understanding of the biology :)

Wow! 😲

That revelation was like an episode of Undercover Boss. 😁

Your inbox has just exploded.💥

Edited by member 25 Apr 2024 at 21:43  | Reason: Emoji

User
Posted 25 Apr 2024 at 22:19

It’s a good thing then that I can’t respond to personal messages being a new member! 😂 

User
Posted 26 Apr 2024 at 09:59

Andy thanks for your input, so are you saying that extra prostatic extension “ie breached the prostrate” means a definite reoccurrence at some time in the future.

 Thanks Jeff.

User
Posted 26 Apr 2024 at 10:44

Originally Posted by: Online Community Member
Andy thanks for your input, so are you saying that extra prostatic extension “ie breached the prostrate” means a definite reoccurrence at some time in the future.

I'm not an oncologist.

I've got EPE only 1mm and  Gleason 9 (4+5), apparently both increase the risk of BCR.

It is also known that both extraprostatic extension (EPE) and positive surgical margin (PSM) can offer prognostic information. EPE usually increases BCR risk 1.5-fold over confined disease. 

https://www.sciencedirect.com/science/article/pii/S2287888221000039

There are several posters on here, that had EPE, and have not had BCR. 

 

Edited by member 26 Apr 2024 at 10:50  | Reason: Not specified

User
Posted 26 Apr 2024 at 11:09

Not at all, we are talking about risks; If there was EPE which was not resected (removed) at surgery, then you are not clear of cancer and should have radiation treatment. If it is removed, then you are talking about having an increased risk of relapse but this is far from definite. Risk is a difficult concept to swallow and live with. But there is always risk that the disease reappears even with the best prognostic indicators; it's just that the number varies. Learning to live with that knowledge is the most important thing, in my view. 

I met with my own surgeon last night and debated at length the value is supersensitive PSA vs 2 decimal point PSA my hospital offers. The reality is the outcome doesn't change, as the intervention doesn't change with picking up slow rising (3 decimal point) PSA. All the supersensitive PSA does is to increase my anxiety with a potentially slow rising PSA which I may not need treatment for, for years. I haven't decided yet which one I'll have next week! 

User
Posted 26 Apr 2024 at 11:54

Originally Posted by: Online Community Member
Not at all, we are talking about risks; If there was EPE which was not resected (removed) at surgery, then you are not clear of cancer and should have radiation treatment. If it is removed, then you are talking about having an increased risk of relapse but this is far from definite. Risk is a difficult concept to swallow and live with. But there is always risk that the disease reappears even with the best prognostic indicators; it's just that the number varies.

Although I had EPE my Apical, Basal and  Circumferential margins were all negative. Presumably that's good news?

Although I had a high Gleason, if all the cancer was removed, which at this stage it appears to have been, is it relevant anymore?

 

Edited by member 26 Apr 2024 at 14:18  | Reason: Typo

User
Posted 26 Apr 2024 at 12:02

The risk is made up by more than one factor as you know. It's obviously good that your margins were clear. EPE raise the chance of biochemical recurrence but as I said it's all about figures/risk. 

User
Posted 26 Apr 2024 at 14:04

Andy.

 Thanks for the reply & clear explanation, the best of luck to you & everyone on this excellent site.

Jeff.

User
Posted 26 Apr 2024 at 14:55

Thank you Lyn,

As always your replies are so helpful and appreciated. You and a number of others provide such valuable experience and insight.

It made me chuckle your comment that "prostate specific antigen is not prostate-specific!" as it really sums up my experience of nothing quite being what you think it is with PC.

Have a lovely weekend

Many thanks

 
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