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jimschlemmer
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Joined: 28 Apr 2008
Posts: 22
Location: troy, ny
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 Posted: Fri Jun 06, 2008 9:44 am Post subject: Positive Margins |
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Hi.
I just had a robotic RP. The pathology that came back was not good. My gleason score moved from 3+4 and 4+3 (2 out of 12 samples) to an 8.
Seminal vesicles were negative. However, positive margins were identified in an area near the tumor. There was also a mention of "Lymphatic Invasion Present" at several points in the report but the urologist made no mention of that in talking to us. He did say that they didn't take any lymph nodes, based on nomogram statistics. Does anybody know if this is a term of art or whether it's more of a concern?
Anyway, I'm a little distressed. The urologist who gave us the news said we'd have to wait and see what happens with the PSA.
My first step is to have the results sent to Jonathan Epstein at Johns Hopkins.
I remember talking to a radiation oncologist who said that there was a recent double blind study that concluded that in the event of extra capular extension, hitting the area with radiation right away yielded better results than waiting.
Replicant, do you have any information or opinion on this? Your case seems very close to my own.
Thanks.
-jim |
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Replicant
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| Posted: Fri Jun 06, 2008 10:46 am Post subject: hi |
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I think your plan to send the tissue to Epstein is EXCELLENT.
I don't know the answer to your question about whether "lymphatic invasion present" is a term of art or something to be concerned about. Epstein will tell you in detail, I'm sure, everything you need to know.
Dr. Catalona says "Vascular/lymphatic invasion means that the pathologist identified cancer cells growing into blood vessels or lymphatic channels. This finding indicates a higher risk for cancer recurrence at a site distant from the prostate gland." I THINK that means that even without dissecting lymph nodes, the pathologist can see from the removed prostate that cancer had extended into the blood vessels and lymph channels surrounding the gland.
http://www.drcatalona.com/quest/quest_spring03_3.htm
A more technical explanation from two pathologists writing in the Internet Journal of Urology:
"The histology report should comment upon lymphatic invasion. The latter consists of tumor cells within endothelium lined spaces and has been reported in 35% of radical prostatectomies. The presence of lymphatic invasion indicates extra prostatic extension, (62%) and lymph node metastasis in many cases, (67%)."
http://www.ispub.com/ostia/index.php?xmlFilePath=journals/iju/vol3n1/biopsy.xml
As to hitting it now or later with radiation, I've seen studies that go both ways. See my blog--I just found some very recent articles on the topic of salvage. From my reading, my nonprofessional take on the matter is that whether you do it right away without waiting for PSA results (adjuvant therapy) or whether you wait until PSA confirms recurrence (salvage therapy) the key is getting started before PSA hits 1.0, and optimally, before it gets to 0.5.
If I were you, I would not only get a second pathology opinion from Epstein, but I would at least identify a radiation oncologist and set up an appointment.
A lot of the time in prostate cancer, it doesn't matter whether you do something now or several months from now, but this is not true with salvage or adjuvant radiation. If you and your doctors determine that you are a good candidate for radiation, time--in the form of rising PSA--is your enemy.
Gleason 8 is a high risk factor for recurrence. In the past, it was thought that men with a high risk factor--high Gleason, fast PSA doubling time, etc. were not good candidates for salvage radiation because of the probability that disease was already systemic and beyond the reach of local cure. However, Stephenson's research has shown that a large percentage of men who have a single high risk factor like Gleason 8-10 can have a durable benefit from salvage radiation if they have positive margins and if their pre-radiation PSA is low (again, optimally 0.5 or less--I got started at 0.7 for what it's worth).
Anyway, those are my layperson's thoughts on the matter. I wish you well.
_________________
Replicant
Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NXMX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 (and thereafter) <0.1
http://pcabefore50.blogspot.com |
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jimschlemmer
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Joined: 28 Apr 2008
Posts: 22
Location: troy, ny
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| Posted: Fri Jun 06, 2008 12:36 pm Post subject: Re: Positive Margins |
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Thanks, replicant.
You're a good man.
-jim |
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brainman
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Joined: 13 Oct 2005
Posts: 5617
Location: Tennessee
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jimschlemmer
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Joined: 28 Apr 2008
Posts: 22
Location: troy, ny
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| Posted: Fri Jun 06, 2008 2:33 pm Post subject: Re: Positive Margins |
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They have done no scans and the urologist is content to watch and wait. Maybe he knows more than what he was saying but he seemed very passive.
I've lost every contest with "the odds" so far, starting with the probability that a 45 year old man would have a PSA of 9, so I'm not inclined to twiddle my thumbs. Yet, it may still be the wisest tack.
Thanks.
-jim |
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jimschlemmer
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Joined: 28 Apr 2008
Posts: 22
Location: troy, ny
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| Posted: Wed Jun 11, 2008 1:50 pm Post subject: Re: Positive Margins |
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Hi.
I've been consuming papers and news articles about adjuvant radiotherapy and salvage radiotherapy.
Does anybody know of any studies that compared ART directly to SRT? It seems -- as replicant has pointed out -- that getting RT before your PSA gets back up to 0.5 is significant. My inkling is that hitting it before that can help. But this is the crux of the issue before me and my urologist. He's arguing for a wait 'n see approach but I'm leaning toward getting the radiation as soon as possible.
The one paper I've found that [i]seems[/i] to do this is titled:
"Adjuvant radiotherapy following radical prostatectomy for pathologic T3 or margin-positive prostate cancer: A systematic review and meta-analysis."
But I'm not quite clear if they're compaing ART to SRT or ART to observation. It's a long paper so maybe I missed it.
Thanks.
-jim |
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brainman
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Location: Tennessee
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Replicant
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Joined: 01 Nov 2006
Posts: 744
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| Posted: Wed Jun 11, 2008 6:44 pm Post subject: adjuvant vs. salvage |
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I don't think the matter has been resolved yet, meaning I don't think there's a clear consensus on adjuvant vs. salvage.
For example, in 2006, there was a point-counterpoint discussion about adjuvant vs. salvage with both sides having good points. In favor of adjuvant is that adjuvant seems to have an edge over salvage in terms of progression-free survival. However there was no reduction in risk of metastasis or mortality from prostate cancer.
In favor of waiting and doing salvage is the fact that only about half of men with positive margins will have recurrences, so with salvage you spare a lot of patients unnecessary radiation.
http://www.medicalnewstoday.com/articles/43871.php
Walsh sits astride this fence. In his 2007 book he talks about adjuvant radiation vs. observation. He cites two large studies, one in the U.S., one in Europe. Although adjuvant radiation in both studies delayed the time to PSA failure, it had no effect upon the risk of developing metastases or dying from prostate cancer. He then brings up salvage: "What if these men are followed carefully, with regular PSA measurements, and they undergo radiation therapy at the time when their PSA level begins to rise? Besides putting off the side effects of undergoing two aggressive treatments within a very short span of time in many men who would never go on to have symptoms of recurrent cancer, would the results be just as good? Unfortunately, it will take many patients and many years to answer this question, and no such study is currently underway." (p. 379).
What makes this question so hard to answer, I think, is that prostate cancer often moves so very slowly compared to other cancers, and at the same time radiation technology is rapidly improving. So even when you have finally have some data in hand, the patients in question had what would now be considered obsolete, primitive treatment.
_________________
Replicant
Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NXMX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 (and thereafter) <0.1
http://pcabefore50.blogspot.com |
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