Positive margins

Thank you for your insights. I am in Canada and actually received the pathology summary online, but have not yet spoken with the urologist who performed the robotic prostatectomy, so I have no clue what he will say, or when. The pathology report does not outline details of the positive margins, so the details you highlight are excellent as questions, so thank you. I have never had a PSMA scan. I had a contrast MRI, followed by a targeted biopsy and the robotic removal. Incontinence is improving, but not ED (low priority for me) but it has only been 4 weeks tomorrow. Best I can tell much reliance will be placed on a 6 week and 3 month PSA screen. Please comment if you feel this is reasonable timing. The availability of advanced screening and targeted radiation approaches in Canada is limited, so I will likely be heading to the US if additional steps need to be taken.

I did. All clear, no invasion of other aneas or lymph nodes, however 3 positive margins 4,4 and 5 mm. Not small, but surgeon seems fine with it. I am not so sure as they seem larger than others I have read about. As a result I am awaiting 1st PSA (6 weeks next week) to be see if it is undetectable as the surgeon as expects. If not, his view is to await 3 month PSA before considering additional work. My strategy will possibly be different. Others have recommended a PSMA PET scan to assess whether adjunct radiation of the remaining cancer makes sense. I would appreciate other’s views on strategy. My Gleason on pathology remained 3+4 so urologist is less concerned.

I did. All clear, no invasion of other aneas or lymph nodes, however 3 positive margins 4,4 and 5 mm. Not small, but surgeon seems fine with it. I am not so sure as they seem larger than others I have read about. As a result I am awaiting 1st PSA (6 weeks next week) to be see if it is undetectable as the surgeon as expects. If not, his view is to await 3 month PSA before considering additional work. My strategy will possibly be different. Others have recommended a PSMA PET scan to assess whether adjunct radiation of the remaining cancer makes sense. I would appreciate other’s views on strategy. My Gleason on pathology remained 3+4 so urologist is less concerned.

I had two positive surgical margins after my RARP in December 2018: 4mm at distal apical margin and 1mm at bladder neck margin. The former was in an area of Gleason pattern 4, which for me was cribriform architecture, and the latter had been cauterized. At that time, there was the option to wait to see if salvage radiation would be indicated by a future PSA rise or to elect to have immediate adjuvant RT (ART). Given that my Decipher Biopsy score was 0.94 and that cribriform PCA cells tend to be prolific, I chose ART to my prostatic bed (I think that they recommend some lymph nodes now). Perhaps having a Decipher test of your surgically removed prostate would give you more information for decision making?

I believe that current protocols would lean towards PSA monitoring to two digits after the decimal point and then to have early salvage RT (eSRT) to prostate bed and some local lymph nodes. That's what a friend was recommended and had last year. Probably delays experiencing side effects while still being effective -- quality of life factored in. Your surgeon should have more information and be able to offer options, and you can always seek a second opinion.

FWIW, I ended up with BCR about 2.5 years after the end of ART, but had a great 2.5 years where I ran a marathon and did a century ride on a recumbent road bike.

I did. All clear, no invasion of other aneas or lymph nodes, however 3 positive margins 4,4 and 5 mm. Not small, but surgeon seems fine with it. I am not so sure as they seem larger than others I have read about. As a result I am awaiting 1st PSA (6 weeks next week) to be see if it is undetectable as the surgeon as expects. If not, his view is to await 3 month PSA before considering additional work. My strategy will possibly be different. Others have recommended a PSMA PET scan to assess whether adjunct radiation of the remaining cancer makes sense. I would appreciate other’s views on strategy. My Gleason on pathology remained 3+4 so urologist is less concerned.

Like you, my path report showed several areas of positive margin, "linear length 3-4 mm". 60-70% Gleason grade 4, 34-40% grade 3. Like you, my surgeon "seemed fine with it", and wanted to wait for 6 week PSA before talking about further diagostic or treatment steps. I'm now 13 months out with all PSAs "undetectable" (< 0.02).

I am wary of getting Too Much Information. My opinion/feeling is that, until the PSA begins to rise, there is no reason for getting any other test. The PSA is molecular. Imaging studies are not as sensitive or precise.

"When keeping an open mind, be sure your brains don't fall out."