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Biopsy results and question

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Posted 9/7/2014 10:30 AM (GMT -5)
So, my husband had two positive spots out of 12 in his prostate biopsy. I wondered what margins mean as I've read a lot about that. It did say that the tumor involves the prostate bilaterally. That seems potentially bad to me.
Summary:
Adenocarcinoma, Gleason Score 7, (4+3) in the right lateral base. involving 5% of the biopsy.
Other spot positive was the left lateral base, Gleason Score 6 ( 3+3) involving 5% of the biopsy.
I think lateral is close to the margins, am I correct?
The urologist we saw in our home town said he had the option of surgery or radiation. Of course, from what we've been told by family members who've had this, is that it's hard to remove the prostate after radiation.
We consulted the closest cyberknife treatment center at a major teaching hospital University of Florida, Gainesville and they said he was not a candidate for cyberknife but they'd recommend radiation and anti-androgen therapy.
We have an appt at Mayo Clinic in a few weeks about surgery. I think my husband wants to get this out.
I was just worried that the tumor could be at the margins but I am not sure what that means. Can anyone tell me? Thanks so much in advance.
Posted 9/7/2014 11:00 AM (GMT -5)
The only way you can confirm any real margins and involvement is to have it removed...get it out, then radiation is always an option later if anything escaped the prostate.

I just wanted to get mine out....the choice is certainly personal but there is some reasoning also behind that decision.

Good luck for your husband moving forward !!!

Cheers,

Curt
Posted 9/7/2014 11:12 AM (GMT -5)
Thanks for your quick response Curt! Yea, I was doing fine with this but today just got worried for some reason. What you said makes total sense. Thanks so much, again!!! These forums have really been such a lifesaver me through my health issues and now for my husband's.
Posted 9/7/2014 11:35 AM (GMT -5)
jeanneac,

Welcome to the prostate cancer forum. Sorry your situation brings you to our part of HealingWell but hope we can help.

You might read through our sticky thread at the top of our forum. Newly diagnosed with PC? – read this thread first.. It has a lot of useful information.

You asked about the word "lateral" on his biopsy report. I think you are reading too much into it. It just means "side" so left lateral refers to the left side of the prostate, right lateral is the right side, posterior and anterior are the back and front sides. "Lateral" doesn't mean close to the margin. It just tells tells which side the cancer was found. "Bilateral" means "on both sides" and it is mildly bad news -- it is slightly better if the cancer is only on one side or the other, but it's not a big deal.

His cancer all seems to be in the "base" of the prostate. That is usually good in terms of side effects from treatments. The "base" is the big end of the prostate right up next to the bladder. The other end is called the "apex". The apex is jammed in amongst lots of tissues that can cause side effects when damaged while the base has a bit more room. Cancer in the apex has significantly more side effects after surgery than in the base. The side effects of radiation and seeds are also a bit worse with cancer in the apex but not as much. His seems to be all in the base. So that's good.

Not so good is the fact that the pathology report put the four in front of the three in the Gleason score -- 7(4+3) -- since that mean that there are a lot of more-aggressive type-4 cells present which bumps him up a risk category. In the sticky thread it talks about getting a second opinion on the biopsy slides. That would probably be a good idea since the gleason score will make a big difference in selecting his treatments.
Posted 9/7/2014 12:11 PM (GMT -5)
"Margins" refer to the edge of the removed gland. A positive margin would mean that the tumor, or at least a portion of it, has reached that edge. Here's a link to an article that does an excellent job of explaining what a surgical margin refers to, and the implications of a positive margin.

I don't see anything in your original post that would indicate one way or the other if there might be a positive margin, and that's probably not knowable at this point. Every surgical patient looks forward to hearing that the margins were clear when the post-surgery pathology report comes in.

Here's the link: http://urology.jhu.edu/newsletter/prostate_cancer410.php
Posted 9/7/2014 3:56 PM (GMT -5)
jeanneac,

I can't think why he wouldn't be a good candidate for CyberKnife, other than his history of colitis - but that makes any kind of radiation risky. I suggest you talk to Debra Freeman in Tampa or Constantine Mantz in Naples (whichever is closer) for an opinion from someone who may have a lot more experience with that sort of thing. It's true that it is hard to remove the prostate after radiation, so if there is a (rare) local recurrence after radiation, salvage usually consists of more radiation (especially if it was CyberKnife) rather than surgery. Recurrences are more usually from remote mets, however.

Because of the colitis concerns, pencil beam proton monotherapy at UF Jacksonville may be a good option - it has extremely low rectal side effects. It may also be possible to use a hydrogel spacer with any kind of radiation.

The major consideration with surgery when there is cancer near the base is whether the bladder neck can be spared, which is a concern for continence.

- Allen
Posted 9/7/2014 4:43 PM (GMT -5)
jeanneac,

Sorry to hear about the diagnosis. But as my oncology urologist said, it isn't pancreatic cancer; which means you have time. Margins as in positive surgical margins (PSM) can only be determined when the prostate is removed, stained with ink and then viewed under a microscope. The base is up top adjacent to the bladder while the apex is down below. As for positive surgical margins, usually PSM at the apex has a lower risk of biological failure than PSM at the base.
Posted 9/7/2014 6:51 PM (GMT -5)
Lapilot, Why does PSM at the apex have lower chances of biological failure than at the base? I thought it was the other way around?
Posted 9/7/2014 8:17 PM (GMT -5)
There has been several papers published discussing sites of positive surgical margins influences biochemical recurrence after radical prostatectomy, here is one.

http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2009.08688.x/abstract;jsessionid=9EC4B30617AAFB5A086B17B7CE10017C.f02t04?deniedAccessCustomisedMessage=&userIsAuthenticated=false
Posted 9/7/2014 9:37 PM (GMT -5)
So much to learn about all this, it's pretty complicated and I have a medical background. Didn't know much about prostate though.

Yes, we did hear that the Gleason score was not such good news. That worries me. His father had aggressive prostate cancer but I don't think it was discovered so soon. Also worries me that it's not just in one area.

We are going to see if Mayo wants us to get the slides for them to have a look.

Thank you so much for all the superb information!
Posted 9/7/2014 11:27 PM (GMT -5)
There are two different questions -
(1) where is a PSM most likely to occur? the answer is clearly the apex:58%, base:19%, anterior 11% according the this study:

Anatomic site-specific positive margins in organ-confined prostate cancer and its impact on outcome after radical prostatectomy.

So apex PSM are vastly more common - 3x more common than at the base- owing to anatomical difficulties of getting it all there, and the ease of penetration into the prostate fossa.

The other question: (2) Which PSM site is associated with higher rates of BCR? The answer is more often the base (according to lapilot's reference, but not all others). This is because a PSM is far less likely to occur there, but when it does, it may reflect a more serious disease. Others have found site of PSM far less important than extent and GS.

- Allen
Posted 9/8/2014 7:24 AM (GMT -5)
BTW, the medical history down at the bottom of the posts is my information, not my husband's. I am a member of healing well for a few years now.
Posted 9/8/2014 7:31 AM (GMT -5)
http://training.seer.cancer.gov/prostate/anatomy/

This gives a nice picture of the prostate anatomy for those of us who need visuals-:)
Posted 9/8/2014 11:27 AM (GMT -5)
Jeannesac,

Thanks for clearing that up about your signature - many women come to this forum and post about their husband, father, etc. Maybe you can sign in under a different name and include his info in your signature.

So that leaves it even more of a question mark why he'd be turned down down for CyberKnife. It's been used for a long time for low and intermediate risk cases, and is even being used for high risk now (see link in my signature). There's a forum devoted just to CyberKnife that has a couple of doctors who answer questions, if you are interested: www.cyberknife.com/Forum.aspx?g=topics&f=2586
Posted 9/8/2014 11:34 AM (GMT -5)
Yea, it worried me a little bit that they turned him down for the cyberknife. They said it was b/c of his Gleason score. This was UF Shands in Gainesville.

Thanks, I'll check out that website.
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