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Biochemical reoccurrence with positive margins.

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.πŸ’₯

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! πŸ˜‚ 

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

User
Posted 29 May 2025 at 09:15

Originally Posted by: Online Community Member
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


Could the slight disagreement between Lyn and Andy1504 be simply due to confusing how margins can be created with what they are called? Two names for how they're created but just one name for what's they create....a margin?


A positive margin may be created in two ways: failure of the surgeon to fully excise the extraprostatic extension of the neoplasm in a tumor that is locally advanced (at least pT3a) and intraprostatic incision of a T2 tumor. 


The above exert was taken from this research, which I found quite informative. If you're into margins. 😁


https://pmc.ncbi.nlm.nih.gov/articles/PMC8749855/


 

Edited by member 29 May 2025 at 09:25  | Reason: Add link

User
Posted 29 May 2025 at 10:10
Thanks Adrian I will have a good look at the link. PS I now see why I got the 2 Andy’s mixed up.
User
Posted 29 May 2025 at 10:16

Originally Posted by: Online Community Member
Thanks Adrian I will have a good look at the link. PS I now see why I got the 2 Andy’s mixed up.


No problem, mate. I was going to pm you with the cause of your confusion, but it would have taken three hours to send with this damn 502 site error. 😁

User
Posted 29 May 2025 at 14:33
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