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Thread: The utility of frozen sections during surgery

  1. #11
    I had a positive margin on frozen section, which was converted to a negative margin with additional resection. At the end of the day it didn’t really matter, as I experienced BCR a few years later. I sometimes wonder whether the additional resection might have released cancer cells into the bloodstream or elsewhere. But will never know
    Diagnosed at age 64 (in November, 2014), PSA 4.3
    Nov 2014 BX 3 of 12 cores positive original pathology G8. Johns Hopkins second opinion, G6
    Surgery with Dr Ash Tewari Jan 6, 2015
    Post surgical pathology, stage T2c, bilateral disease, upstaged to G7(3+4)
    5% of Prostate involved in Tumor. Organ confined, Margins, SV, lymph nodes (9) all negative, PNI positive
    PSA <.02 until (uh-oh), 2/17 .02. Then 5/17-.033, 8/17-.033, 11/17-.046, 4/18-.060, 6/18-.068, 7/18- .082, 8/18-. 078.
    Decipher score low risk, .37
    ADT/Firmagon started August 2018. SRT SEPT 2018. Finished SRT November 2018, Finished ADT Feb 2019
    T=7, PSA <.05, 5/19 T=48 PSA <.05, 10/19 T=97 PSA=<.05

  2. #12
    Quote Originally Posted by Pratoman View Post
    I had a positive margin on frozen section, which was converted to a negative margin with additional resection. At the end of the day it didn’t really matter, as I experienced BCR a few years later. I sometimes wonder whether the additional resection might have released cancer cells into the bloodstream or elsewhere. But will never know
    I think research has shown that many men have CTC, Circulating Tumor Cells, long before primary treatment. The issue may be whether these cells have metastatic potential and can become established elsewhere. Most can not.

    Djin

  3. #13
    Top User garyi's Avatar
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    Quote Originally Posted by Pratoman View Post
    ..... I experienced BCR a few years later....
    Not to belabor a point that has been discussed ad nauseam, I really don't believe a 0.078 PSA almost four years after surgery can be labelled BCR....bu if it makes you feel better, so be it.
    72...LUTS for the past 7 years
    TURP 2/16,
    G3+4 discovered
    3T MRI 5/16
    MRI fusion guided biopsy 6/16
    14 cores; four G 3+3, one G3+4,
    CIPRO antibiotic = C. Diff infection 7/16
    Cured with Vanco for 14 days
    Second 3T MRI 1/17
    Worsened bulging of posterior capsule
    Oncotype DX GPS 3/17, LFP risk 63%, Likelihood of Low
    Grade Disease 81%, Likelihood of Organ Confined 80%
    RALP 7/13/17 Dr. Gonzaglo @ Univ of Miami
    G3+4 Confirmed, Organ confined
    pT2 pNO pMn/a Grade Group 2
    PSA 0.32 to .54 over 3 months
    DCFPyl PET & ercMRI Scans - 11/17
    A one inch tumor still in prostate bed = failed surgery
    All met scans clear
    SRT, 2ADT, IMGT 70.2 Gys @1.8 per, completed 5/18
    Radiation Procitis, and Ulcerative Colitis flaired after 20 years
    PSA <.006 9/18, .054 11/18, .070 12/18, .067 2/19, .078 5/19, .074 7/19, .081 9/19, .116 11/19
    We'll see....what is not known dwarfs what is thought to be fact

  4. #14
    As everyone knows, the definition of BCR has changed over the years, and the .2 parameter, is old school. There is enough evidence out there, including the Fang study, that show that two consecutive rises above .03 after RALP are PREDICTIVE of BCR. So choose your red line. Mine was .08 and i crossed it at .083. The point of my previous post was that i needed treatment. with 8 rises over 10 PSA tests, it was pretty clear, and i believe, important enough for this discussion.
    Diagnosed at age 64 (in November, 2014), PSA 4.3
    Nov 2014 BX 3 of 12 cores positive original pathology G8. Johns Hopkins second opinion, G6
    Surgery with Dr Ash Tewari Jan 6, 2015
    Post surgical pathology, stage T2c, bilateral disease, upstaged to G7(3+4)
    5% of Prostate involved in Tumor. Organ confined, Margins, SV, lymph nodes (9) all negative, PNI positive
    PSA <.02 until (uh-oh), 2/17 .02. Then 5/17-.033, 8/17-.033, 11/17-.046, 4/18-.060, 6/18-.068, 7/18- .082, 8/18-. 078.
    Decipher score low risk, .37
    ADT/Firmagon started August 2018. SRT SEPT 2018. Finished SRT November 2018, Finished ADT Feb 2019
    T=7, PSA <.05, 5/19 T=48 PSA <.05, 10/19 T=97 PSA=<.05

  5. #15
    Quote Originally Posted by Pratoman View Post
    As everyone knows, the definition of BCR has changed over the years, and the .2 parameter, is old school. There is enough evidence out there, including the Fang study, that show that two consecutive rises above .03 after RALP are PREDICTIVE of BCR. So choose your red line. Mine was .08 and i crossed it at .083. The point of my previous post was that i needed treatment. with 8 rises over 10 PSA tests, it was pretty clear, and i believe, important enough for this discussion.
    There are two separate but related issues, IMO. The "official" or most common definition of BCR has not changed. It is still 0.2, as is cited in research studies and is printed at the bottom of every Labcorp uPSA result:

    According to the American Urological Association, Serum PSA should decrease and remain at undetectable levels after radical prostatectomy. The AUA defines biochemical recurrence as an initial PSA value 0.200 ng/mL or greater followed by a subsequent confirmatory PSA value 0.200 ng/mL or greater.
    Yes, there have been several studies that different lower post-op values are predictive of BCR, as you mention, such as 0.03 and even 0.01. Clearly guys with high-grade lesions, adverse RP features, and/or genomic risk for mets are free to start salvage treatment whenever they like, and the jury is still out on the advantages of starting treatment at this or that PSA value after RP.

    So I think it's just a question of defining terms. As you state, Pratoman, you exceeded the limit you set for yourself. But also keep in mind that there are many, many guys (usually low-risk), who are chugging along happily with their <0.1 PSA results, who are only one tick away (0.1) from a result of 0.2. Keep in mind that contemporary studies still call treatment at 0.2 (and even higher) "early SRT" !

    Djin
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg., then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%, 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 wk) PSA <0.1
    LabCorp uPSA, Roche ECLIA:
    11-28-17 (3 m ) 0.010
    02-26-18 (6 m ) 0.009
    05-30-18 (9 m ) 0.007
    08-27-18 (1 yr.) 0.018 (?)
    09-26-18 (13 m) 0.013 (30-day retest)
    11-26-18 (15 m) 0.012
    02-25-19 (18 m) 0.015
    05-22-19 (21 m) 0.015
    08-28-19 (2 yr. ) 0.016
    12-18-19 (24 m)
    Avg. = 0.013

  6. #16
    Djin, yes, i know that the "official" definition of BCR remains at .2, per AUA. I felt that i was well on my way, due to the slow but VERY steady rise. I followed the lead of two top RO's at MSKCC and Cleveland Clinic (Fl) who both told me to pull the trigger at .06, due to my POSITIVE MARGIN ON FROZEN SECTION.

    I posted my comments only because i thought my experience would be valuable to the group, especially other guys who are going through this. i didn't expect it to be derailed into a discussion on the definition of BCR, that was not my intent.
    Diagnosed at age 64 (in November, 2014), PSA 4.3
    Nov 2014 BX 3 of 12 cores positive original pathology G8. Johns Hopkins second opinion, G6
    Surgery with Dr Ash Tewari Jan 6, 2015
    Post surgical pathology, stage T2c, bilateral disease, upstaged to G7(3+4)
    5% of Prostate involved in Tumor. Organ confined, Margins, SV, lymph nodes (9) all negative, PNI positive
    PSA <.02 until (uh-oh), 2/17 .02. Then 5/17-.033, 8/17-.033, 11/17-.046, 4/18-.060, 6/18-.068, 7/18- .082, 8/18-. 078.
    Decipher score low risk, .37
    ADT/Firmagon started August 2018. SRT SEPT 2018. Finished SRT November 2018, Finished ADT Feb 2019
    T=7, PSA <.05, 5/19 T=48 PSA <.05, 10/19 T=97 PSA=<.05

  7. #17
    Quote Originally Posted by Pratoman View Post
    Djin, yes, i know that the "official" definition of BCR remains at .2, per AUA. I felt that i was well on my way, due to the slow but VERY steady rise. I followed the lead of two top RO's at MSKCC and Cleveland Clinic (Fl) who both told me to pull the trigger at .06, due to my POSITIVE MARGIN ON FROZEN SECTION.

    I posted my comments only because i thought my experience would be valuable to the group, especially other guys who are going through this. i didn't expect it to be derailed into a discussion on the definition of BCR, that was not my intent.
    Not a problem at all. I was just trying to remove any friction between your and garyi's comments. Of course your input and experience is greatly valued! This discussion only highlights the current uncertainty about who should do what and when with a rising post-op PSA. Please see also the other thread I started with the recent review paper on BCR that discusses current efforts to use genomics to aid in risk assessment. Rather than a derailment, let's call it a speed bump

    I would point out that the Subforum topic on BCR and adjuvant/salvage therapies is by far the largest topic there, with the most number of papers. In part this is because the topic is big, but it is also of central importance to the PCa story. Just as a PCa diagnosis marks a major decision point (whether to treat, and what treatment?), the return of a rising PSA is another decision point, and perhaps an even more difficult one.

    Djin
    Last edited by DjinTonic; 10-25-2019 at 02:27 PM.

  8. #18
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    I'll also throw in that protocols and definitions are the last to change when change happens.

  9. #19
    Top User garyi's Avatar
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    Good discussion and valuable input.

    My clarification was that the anticipation of future BCR, due to a low but rising PSA pattern, while potentially predictive of BCR, and probably frightening, is very clearly not clinically experiencing BCR, as was stated.

    Stay vigilant brother's, and as my signature says, 'what is not known dwarfs what is thought to be fact.'
    72...LUTS for the past 7 years
    TURP 2/16,
    G3+4 discovered
    3T MRI 5/16
    MRI fusion guided biopsy 6/16
    14 cores; four G 3+3, one G3+4,
    CIPRO antibiotic = C. Diff infection 7/16
    Cured with Vanco for 14 days
    Second 3T MRI 1/17
    Worsened bulging of posterior capsule
    Oncotype DX GPS 3/17, LFP risk 63%, Likelihood of Low
    Grade Disease 81%, Likelihood of Organ Confined 80%
    RALP 7/13/17 Dr. Gonzaglo @ Univ of Miami
    G3+4 Confirmed, Organ confined
    pT2 pNO pMn/a Grade Group 2
    PSA 0.32 to .54 over 3 months
    DCFPyl PET & ercMRI Scans - 11/17
    A one inch tumor still in prostate bed = failed surgery
    All met scans clear
    SRT, 2ADT, IMGT 70.2 Gys @1.8 per, completed 5/18
    Radiation Procitis, and Ulcerative Colitis flaired after 20 years
    PSA <.006 9/18, .054 11/18, .070 12/18, .067 2/19, .078 5/19, .074 7/19, .081 9/19, .116 11/19
    We'll see....what is not known dwarfs what is thought to be fact

  10. #20
    Moderator Top User HighlanderCFH's Avatar
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    Posts
    7,302
    Quote Originally Posted by garyi View Post
    Not to belabor a point that has been discussed ad nauseam, I really don't believe a 0.078 PSA almost four years after surgery can be labelled BCR....bu if it makes you feel better, so be it.

    No need to be so snotty to Prato, Gary. This forum is for the discussion of such topics, so there is no such thing as "ad nauseam" around here.

    Thanks,
    Chuck
    July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA 9/ 2011 = 5.7.
    Local uro DRE revealed significant BPH, no lumps.
    PCa Dx Aug. 2011 age of 61.
    Biopsy DXd adenocarcinoma in 3/20 cores (one 5%, two 20%). T2C.
    Gleason 3+3=6. CT abdomen, bone scan negative.
    DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
    Surgeon was Dr. Matthew Tollefson, who I highly recommend.
    Final pathology shows tumor confined to prostate.
    5 lymph nodes, seminal vesicules, extraprostatic soft tissue all negative.
    1.0 x 0.6 x 0.6 cm mass involving right posterior inferior, right posterior apex & left
    mid posterior prostate. Right posterior apex margin involved by tumor over 0.2 cm length,
    doctor says this is insignificant.
    Prostate 98 grams, tumor 2 grams.
    Catheter out in 7 days. No incontinence, minor dripping for a few weeks.
    Eight annual post-op exams 2012 through 2019: PSA <0.1
    Semi-firm erections without "training wheels," usable erections with 100mg Sildenafil.
    NOTE: ED caused by BPH, not the surgery.

 

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