Positive margins - Now what?

Let me be clear that I am not an oncologist and therefore I am not an expert in that field. But, I practiced Radiology for 40+ years and have learned a lot about prostate cancer that I didn't know since I was diagnosed almost 4 years ago. Unless there is clear evidence of residual disease/ positive nodes on PSMA PET, I don't believe most docs would treat unless the PSA is rising and goes above a certain level (().1-0.2). I don't believe the G score is relevant in that regard. Radiation can have shorter and longer term side effects. I think they would hold that in abeyance until/if needed.

I had surgery last Wednesday and received my Pathology report yesterday. Came here and saw this thread. My report seems very similar to mayolink's. I am older (72 next month) and my PSA before surgery was 12.1. I haven't talked to anyone yet about my pathology, but I expect I'll be receiving a call this week. Catheter comes out tomorrow and my next appointment with surgeon is in first week of May. Pathology:
SPECIMEN

Procedure: Radical prostatectomy

Prostate Size:

Prostate Weight (Grams): 83.7 g

Prostate Greatest Dimension (Centimeters): 5.5 cm

Additional Prostate Dimension (Centimeters): 5.6 cm

Additional Prostate Dimension (Centimeters): 4.5 cm

TUMOR

Histologic Type: Acinar adenocarcinoma, conventional (usual)

Histologic Grade:

Grade: Grade group 2 (Gleason Score 3 + 4 = 7)

Percentage of Pattern 4: 6 - 10%

Intraductal Carcinoma (IDC): Not identified

Cribriform Glands: Not identified

Treatment Effect: No known presurgical therapy

TUMOR QUANTITATION:

Estimated Percentage of Prostate Involved by Tumor: 1 - 5%

Extraprostatic Extension (EPE): Not identified

Urinary Bladder Neck Invasion: Not identified

Seminal Vesicle Invasion: Not identified

Lymphatic and / or Vascular Invasion: Not Identified

Perineural Invasion: Present

MARGINS

Margin Status: Invasive carcinoma present at margin

Linear Length of Margin(s) Involved by Carcinoma: Less than 3 mm (limited)

Focality of Margin Involvement: Unifocal

Margin(s) Involved by Invasive Carcinoma: Left apical

Margin Involvement by Invasive Carcinoma in Area of Extraprostatic Extension (EPE): Not identified

Gleason Pattern at Margin(s) Involved by Carcinoma: Pattern 3

REGIONAL LYMPH NODES

Regional Lymph Node Status:

: All regional lymph nodes negative for tumor

Number of Lymph Nodes Examined: 8

pTNM CLASSIFICATION (AJCC 8th Edition)

Reporting of pT, pN, and (when applicable) pM categories is based on information available to the pathologist at the time the report is issued. As per the AJCC (Chapter 1, 8th Ed.) it is the managing physician’s responsibility to establish the final pathologic stage based upon all pertinent information, including but potentially not limited to this pathology report.

pT Category: pT2

pN Category: pN0

Like mayolink, I'm a little concerned about the small positive margin, but reading this helpful thread has calmed me down a bit. Can anyone comment on the per

I had surgery this past Wednesday and received my pathology report in MyChart yesterday. Came here and found this thread. It looks like my situation is very similar to mayolink's. reading this helpful thread has calmed me down somewhat, but still am anxious to talk with my medical team. Pathology:
SPECIMEN
Procedure: Radical prostatectomy
Prostate Size:
Prostate Weight (Grams): 83.7 g
Prostate Greatest Dimension (Centimeters): 5.5 cm
Additional Prostate Dimension (Centimeters): 5.6 cm
Additional Prostate Dimension (Centimeters): 4.5 cm

TUMOR

Histologic Type: Acinar adenocarcinoma, conventional (usual)

Histologic Grade:
Grade: Grade group 2 (Gleason Score 3 + 4 = 7)
Percentage of Pattern 4: 6 - 10%
Intraductal Carcinoma (IDC): Not identified
Cribriform Glands: Not identified
Treatment Effect: No known presurgical therapy

TUMOR QUANTITATION:

Estimated Percentage of Prostate Involved by Tumor: 1 - 5%
Extraprostatic Extension (EPE): Not identified
Urinary Bladder Neck Invasion: Not identified
Seminal Vesicle Invasion: Not identified
Lymphatic and / or Vascular Invasion: Not Identified
Perineural Invasion: Present

MARGINS
Margin Status: Invasive carcinoma present at margin
Linear Length of Margin(s) Involved by Carcinoma: Less than 3 mm (limited)
Focality of Margin Involvement: Unifocal
Margin(s) Involved by Invasive Carcinoma: Left apical
Margin Involvement by Invasive Carcinoma in Area of Extraprostatic Extension (EPE): Not identified
Gleason Pattern at Margin(s) Involved by Carcinoma: Pattern 3

REGIONAL LYMPH NODES
Regional Lymph Node Status:
: All regional lymph nodes negative for tumor
Number of Lymph Nodes Examined: 8

pTNM CLASSIFICATION (AJCC 8th Edition)

Reporting of pT, pN, and (when applicable) pM categories is based on information available to the pathologist at the time the report is issued. As per the AJCC (Chapter 1, 8th Ed.) it is the managing physician’s responsibility to establish the final pathologic stage based upon all pertinent information, including but potentially not limited to this pathology report.

pT Category: pT2
pN Category: pN0

Besides the small positive margin, I'm a little concerned with the perineurial invasion being present; not sure of the significance of that. This is a great resource and I appreciate all of the helpful members here. TIA.

Your results look real good. You might be one of the people that’s able to be cured rather than have a chronic disease.

Only 20 to 30% of prostate cancer patients have reoccurrences, You are very likely among the group that doesn’t have one.

Have you had hereditary genetic testing?

See below comments, I missed the fact that the margins were not clear.

I have not had hereditary genetic testing done, but my maternal grandfather had prostate cancer and one uncle also had it. I appreciate your input Jeff; I've read a lot of your comments here and you've obviously "been around the block" with this. Any insight regarding perineural invasion you might be able to offer would be appreciated. Thanks.

Your margins are like mine, very similar. I just had a meeting with my urologist yesterday about this very thing, he said that there is some pattern 3 left behind, because it's not really considered cancer, and that taking it with wider margins meant greater risk for both ED and incontinence and there was no reason to take them. I asked him what he felt the likelihood of this being a future problem and he said "likely not more than 10%" and that he felt good that I would not have any recurrence in my lifetime or, if I did, it wouldn't be for many years.

He felt I addressed this in time, and even though I did have an EPE, it was just a bulge and did not appear to impact anything else (benefit of a small prostate perhaps).

Only time will tell, but like @jeffmarc mentioned, recurrence is fairly low, and the better your Gleason going in then the higher chance that you might be cured (as hopefully am I).

I'm supposed to get my hereditary test done soon to see what's what, but I feel fairly good about everything at the moment.

While perennial invasion makes the cancer more aggressive most of the time it is caught before it leaves the prostate and a prostatectomy removes it. I must admit, I missed the fact that your margins do show an issue.

With cancer showing up in the margins, they may want to do salvage radiation sooner rather than later. That should take care of the problem long-term. In some cases, I know they wait to see if the PSA rises after surgery to confirm that there is a problem due to margins.

Perineural invasion is a frequent finding; it used to be thought that it indicated a more aggressive tumor - similar to cribriform/intra-ductal findings.
However, research has shown that it simply quantifies the spread of malignant cells laterally toward the nerves. I had it in almost every core in my biopsy. I did wind up with salvage radiation 5 yrs after surgery but not all men do.
What’s strange to me is how low your tumor volume is - yet it shows PNI and positive margins. The tumor formed in just the right place (wrong, actually) to put you in a possible salvage radiation situation.
It would be helpful to know your Decipher - or similar - Score to give you an idea of what path you should take.
But it’s also been shown that men who have radiation years after surgery (provided they’ve been closely monitored) have the same outcomes as those radiated right after surgery.
So you DO have plenty of time to heal, relax and monitor PSA’s going forward before you really need to do anything. Best,
Phil

Thank you, Phil; that's very helpful. I had my catheter out yesterday, and the PA at that meeting indicated that they don't think it's a big concern. I'll discuss this with my urologist when I meet with him in the first week of May. I feel very fortunate the way things turned out in that the volume of cancer in my prostate was low and that positive margin is grade 3. I did read a study where they compared adjuvant radiation therapy with salvage radiation at a later date, and, as you stated, outcomes are similar. I resolve to remain vigilant, but I'll compartmentalize this and not allow this disease to define my life going forward. Prayers and well wishes for everyone here and stay strong!