Prostate cancer Surgery-positive surgical margins etc-Is adjuvant radiation recommended?

Welcome pkferino-

Could you please provide some more information:

1. What was the Gleason score at the positive margins?
2. How large were the positive margins?
3. Was there a positive margin at the established extraprostatic extension?
4. Were any lymph nodes sampled?

The reason I ask is because if the margins are small (focal) and low grade, you can wait for your 2 or 3 month ultrasensitive PSA test to decide. If they were large and high grade (Gleason 8-10), there is no point in waiting. If you had any positive lymph nodes, there is no point in waiting.

The other consideration is continence. If your continence seems to be recovering quickly, you may be able to start adjuvant radiation sooner. They probably would not start it before 3 months so as to allow for better recovery. If you have high grade PC, they can start you on hormone therapy now to give you more time.

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pkferino said...
I just had robotic prostate surgery and the pathology report came back with multiple positive margins and extraprostatic extension which is present and established (the tumor portruded outside of the prostate capsule). I'm strongly considering adjuvant radiation therapy to start in a couple of months or so as it increases the odds of the cancer not coming back, instead of waiting to see if/when the PSA level rises and then opt for salvage radiation.
Any advise would be greatly appreciated.
diagnosed with PC April 2017
Biopsy showed the cancer
Gleason-3+4 on one side of the prostate and 3+3 on the other side
had robotic surgery on 8/3/17
pathology report shows multiple positive margins (margins measure over 2mm)
extraprostatic extension is present and established
age 56
no lymph node or seminal vescicle invasion present
pathological staging pT3a, pN0-6 of 7 biopsy samples-
cancerous

Hi PK,
It is hard to say, and depending on the size and Gleason of the + margins. I bet most would have some salvage after some minimal time for healing. Although, maybe if the gleason is only a 6, maybe they would wait for PSA trends?

I certainly was expecting some salvage after my path report(G9, a single focal + margin, SV+), but I was very surprised when my well known surgeon said to do nothing until and if the numbers came up. I was very nervous about that advice, but lo and behold I have made it 3+ years without any additional treatment. Which I am obviously glad about, since I needed most of that time for healing, I had some pretty bad incontinence during the 1st year or so. I am mostly pad free now, so glad to have had all that extra time, since RT can halt healing, even if all else goes perfectly. So while I am glad I took his advice on that, I suspect I might be a bit of an outlier. Compared to you, I did not have multiple + margins, but I did have G9 and SV+, which I suspect more than makes up for that. I will let others advise you on which path you should take, I really don't know. I really did not know in my own case, just ended up taking my docs advice, though it made me nervous and I suspected I would have a rising PSA in just the 1st few months. But I was wrong.

I had an area of positive margin. My surgeon indicated that while the studies are not entirely conclusive, they indicate that life expectancy is not remarkably different for those who opt for adjunct radiation versus those who don't. I decided that I just wasn't up for another medical procedure and didn't want to risk a successful surgery outcome to potential further side-effects from radiation. Therefore, I decided on the "wait and see" approach especially since my surgeon was on board and said that was the approach he would take if it was him. So far, so good two years out but who knows what the future will bring. One thing that I try to keep in mind when I make these decisions is that we're not going to live forever no matter what we do.

I agree with Tall Allen the resident expert. Being GS 6, GS 7 (3+4), you have time to get a ultrasensitive PSA in 2 or 3 months after surgery, then if PSA is detectable you can decide on adjuvant radiation. It is always best if possible to delay radiation to regain continence. Radiation usually locks in your continence to the level you have or even a little worse.

You do what I do pkferino. I read studies...(some of which TA has provided)....study....listen to the doctors opinions....and if they have different opinions....I try to extrapolate some sort of direction in which they can mostly agree...weighing how much trust to put into each source of information I get.

From my memory...more margins equals a greater chance of having to have more treatment. The area the margin(s) are in and the size of the margin all have some impact on recurrence. The take away message for *me* in reading and information gathering on this topic is that the jury is still out of whether margins pose a significantly higher risk of dying from prostate cancer. That's not to say they do not....the jury just hasn't rendered it's verdict on this particular topic yet.. (Am I wrong? Someone correct me if they have better information...)

My urology group's protocol is ART for *any* margin after surgery. However...the more I read, listened, and pondered on the topic.....the more I felt comfortable with waiting to see where I stood, where I stand, what's going on with PSA, and seeing what's happening. There's a study or two I remembered looking at that suggested that waiting isn't dangerous and that my uro's group's protocols results in overtreatment.
(margins was all I cared about....the EPE I never looked at)

So....my thinking is....there's a lot of different takes and opinions on whether a pathology such as yours needs ART immediately. I do believe the (and here I'm just "winging it"...) EPE and surgical margins...having both....put's you in a higher risk for recurrence. But...HEY....that's a retired pilot LOL talking!!!

But since he likes to opine......I'll go ahead and say......I don't believe anyone would say your crazy for wanting ART with your path. It's not the best....but FAR from the worst. I"d want more information. Gene testing....John's Hopkins second opinions on slides...other opinions from other doctors.

But....*if* it were *me*......I *believe* I'd want to see what my first PSA is before going forward. If it's not undetectable.....I believe that would seal the deal for me. I'd probably do it.

That's my story....and I'm sticking to it.

Thanks island time. I'll be getting my first PSA before I do anything with ART.
I go to the Mayo Clinic in Phoenix AZ. Does anyone have a very reputable radiation oncologist and a medical oncologist that you can refer me to?

I wish you the best also randrball1

You mentioned your biopsy Gleason score but not the Gleason score of the actual tumors, and particularly at the positive margins, on your post-op pathology report. Also, what was the size of the largest positive margin? If the Gleason scores were all 3+3 at the margins, you may have little to worry about.

If you don't have a copy of your pathology report - be sure and get one for your records. If any of this info is not on your pathology report, it should be - so bug your urologist to answer them.

If your pathology (as opposed to your biopsy) Gleason scores were also no greater than 3+4, and there was no tertiary pattern 5, you may be OK just waiting for your first uPSA. If any were GS 8-10, or there was any tertiary pattern 5, you may want to start on hormone therapy sooner rather than later in preparation for ART. Cutting through high grade cancer may spread it, but cutting through low grade cancer will not.

In that case, waiting for a 3-month uPSA seems to be pretty much risk-free.