Pt3b N0 Help

@dave27

Unfortunately everybody needs to check PSA for many, many years, no matter what were findings after surgery. At the beginning they will check his PSA every 3 months, than every 6 months , than if there is no change after a couple of years once a year and that is protocol for everybody. That shows you that no matter how good or how troubling findings are nobody is in "clear" for many years after either RP or RT . That is the nature of PC, unfortunately. It can be dormant for 20 years and than pop up again but one can only take one step at a time.
The most important thing is that your father does not have aggressive cancer to begin with and even if it comes back it will most probably be treated successfully. I know that this all is so hard to hear and I wish I can tell you with certainty anything, but unfortunately nobody can. There are statistics and there are "probabilities" but everybody is different.

The one thing that is kind of important predictive factor is PSA level. If it comes undetectable and stays that for a year or more, that would be very good sign. Sometimes it is very low but not undetectable, still, if it grows over time in a very slow manner, that is again good sign and he may have couple of years before deciding to go into additional "clean-up" treatment. If it comes up fast, it just means that treatment should be administered VERY soon.

I know that this all sounds overwhelming and it IS. Just make sure that your father has the best doctor that there is and also never shy of asking for a second opinion. It is common thing to do with any kind of cancer treatment and doctors completely understand that and many even encourage patients to do that.

@jeffmarc How can non focal extraprostatic extension and ‘negative margins’ be consistent? They seem almost contradictory in nature.
I had negative margins and a ‘tiny break’ (my urologist’s words) in my capsule and even then I thought it was odd to put the two on the same page.
I wonder what the limit is on how much tissue surrounding the capsule can really be removed in order to get negative margins…?
I get the sense from some posters that they feel ‘positive margins’ is the fault of the surgeon not being diligent; however, I think anatomical considerations (bladder, eg) limit how much a surgeon can excise without causing additional damage.
I think the best policy would be for surgeons to be forthright and say ‘I wasn’t able to get it all’ rather than soft peddling the fact that cancer is still inside your body. JMO,
Phil

Dave, you did not mention your dad's health otherwise, but both diet and exercise recommendations have been demonstrated to reduce the chance of recurrence and disease-specific survival.

@heavyphil
That’s why I thought that he should talk to his doctor about that EPE issue. It sure seems that the way it was described in the biopsy, it had spread a lot. You could be right that they Really can’t completely remove something like EPE If it is spread as much as the biopsy reports.

The positive margins people get can be the fault of the doctor not having a pathologist available to check the margins as surgery is going on. Then again it could be because it was not possible to get clean margins without damaging other important tissue.

It’s a difficult situation when having surgery is already difficult.

You have pointed out a real conundrum.

Before my Husbands surgery I asked the Doctor if he would check for negative margins and he said the pathology report would have that info. So I took it that he would not be cutting till negative margin during surgery. Like you say Jeff surgery is already a difficult process and somehow i was uncomfortable with the surgeon checking and cutting etc. So I was ok with our Surgeon not doing that. I hear that even with negative margins things happen so why take that extra risk. Just my opinion.

@heavyphil

Negative margin means : no cancerous cells seen beyond line of cutting - it is actually cauterization that they use, not scissors or scalpels. (at least it was case in our surgery)

They cut away from the gland, as much as they can, so - when you look at the slide you see the whole section of a gland (gland is sliced like using egg mandolin on an egg) - one whole horizontal slice at a time. I was lucky in a sense that surgeon arranged us having a zoom call with pathologist and we went over slides together.
Since I am biologist and worked with microscope extensively it was easy for me to follow but my hubby saw things clearly also because pathologist was very patient and very good at showing and explaining findings.
We had one single EPE, that kind of EPE is called unifocal (one focus/ spot). They actually measure EPE size - it's width and also how much it is peeking out of the gland. BEYOND that EPE is a tissue (usually fat tissue) and than there is line - that is line of cutting. Line of cutting is dyed very clearly and in different ways and colors so they can know what is up, left, right, down.
To make the story short - it is very visible where that line passes AROUND the specimen. If it cuts too close to the gland or nicks a gland - it is positive, if the whole gland is intact and than some other tissue is BEFORE the line - it is negative. Negative means - no glandular or cancerous tissue is beyond the excision line.
They do not cut out only the gland, they cut out some fatty tissue around it for examination and also sometimes some nodes.

So - can you have EPE and negative margins - absolutely !!!

It means that line of excision is above and beyond visible EPE. Since we are talking about MICROSCOPIC examination, idea is that even microscopic bad cells would be seen if they are beyond EPE , but of course, one can not 100% examine every single cell in a gland ! That is why EPE is a red flag, no matter if margin is negative. BUT, if it is inside margin, it is a small red flag. If it is unifocal, it is even smaller red flag, if it is 3+3 EPE it is the tiniest "flaglet", etc.

And this goes for every single finding !!! Determination of how adverse situation really is depends of margins, size, gleason , and extent of every adverse feature present.

@surftohealth88 You are bringing me back to my old histology/microbiology days… Such pretty colors for such nasty things!
In my cases the EPE was described as a ‘tiny’ break with negative margins- still needed SRT years later. But my Gleason 4+3 was high volume so I consider myself lucky…could have been a lot worse.
I should not have mixed oranges and apples in my post. What I was referring to are those cases (not simple EPE) in which the cancer extends way beyond the capsule and adipose tissue into the bladder or urethra or bowel. Now the ‘margin’ becomes something else completely.
Many times the surgeon will simply get as much as he can and leave it to the RO/medical Onco to finish the job…but sometimes they DO perform much more extensive removal.
I met a man a few years back who went in for RARP and came out of the OR missing his bladder as well. The PCa had invaded significantly and the surgeon knew that once the muscle layer is invaded, the bladder has to go.
Don’t know if this possibility was discussed beforehand or what diagnostic pre-op scans were done, but the procedure was done at Sloan so I am sure they didn’t go in blindly…
Phil

I am a pT3b who had slight left seminal vesicle invasion without tumor or nodules, and all cells were grade "3". My Gleason Score was 3 + 4 = 7 with only 6-10% of cells being "4", but it didn't matter. The key feature of being a pT3b is that despite both seminal vesicles and both vas deferens being removed with the prostate, the literature and my urologist said: "A pT3b cancer has an extremely high rate of recurrence within the first five years." My urologist even corrected me when I said: "so I can count on this coming back in five years?" He said: "No...'WITHIN' five years...It could be next year, or the second year, or might take four or five years, but it will likely return." This is particularly true if you add the features that I and many others have documented in their post-op surgical pathology report: Extraprostatic Extension ("EPE"); surgical margins (urologist left cancer tissue behind); Cribriform glands (sheets of prostate tissue with holes like Swiss cheese). There can be bladder neck invasion as well. I agree with one person's comments that it is contradictory to have surgical margins without EPE, or...EPE without surgical margins. EPE means that the tumor extended outside of the thin prostate membrane capsule. This usually means "surgical margins" will be present. If the urologist had a pathologist standing by doing frozen sections of prostate tissue while the patient was still on the table, and...the pathologist reported back that there are "surgical margins", the the urologist has the opportunity to continue removing tissue. But as another person wrote, the surgery includes cautery as part of the excision, so frozen sections may not be an option. Surgical margins most often occur because in the urologist's effort to preserve the neurovascular bundles that supply and innervate the penis, but (s)he can't remove "all" of the tissue without damaging that neurovascular bundle. So...cancerous tissue is left behind to slowly start growing over time until PSA is detected in your blood. BTW - for the first year, he will have a PSA test every 3 months. If he remains at < 0.1 ng/ml (essentially "zero"), he'll be fine. If after a year his PSA is still < 0.1 ng/ml, he will go to a PSA test every six months. But...anytime the PSA is >0.2 ng/ml, meaning a 100% or greater increase, the physician will start with additional therapy/treatment (radiation, hormonal, pharmaceuticals).
I asked my urologist what will happen "when", in all likelihood, my pT3b cancer returns? My urologist said that I would start 40-days-straight of radiation therapy. But even after radiation, your cancer can come back. This blog is full of guys who had various forms (grades/Classes) of prostate cancer, and after 10-15 years, their cancer returned. Frustrating to live your life with prostate cancer sitting on your shoulder just waiting to eventually say "I'm back." Good luck to you.

@heavyphil
“Negative margins” is obviously good but not definitive. The pathologist cannot look at ever tiny bit of capsule for extensions but looks at a lot of representative sections. Mine said “clear margins” but then said”tumor within 0.1mm (!) of the posterior capsule”. Had that been his prostate, I bet he would have. Looked a lot more and not called it clear. Also things like tumor along nerves and vessels (perivascular and perineural) and tumor in seminal vesicles and, of course, tumor in lymph nodes are all worrisome findings (and the surgeon can’t take out ALL the lymph nodes but only the ones available close by for sampling. All in all, there are a lot of factors other than the path report, mainly follow up for persistence or recurrence of tumor.

@tedbeemer Yes, I totally agree with all that. I literally leaped off the table when my urologist mentioned the ‘tiny’ break in the capsule.
He tried to reassure me that margins were negative, but at that moment I knew I was gonna be in trouble.
Just like your pathologist blithely called the all clear on a .1mm close call, I wondered what my urologist would have considered ‘tiny’ if my capsular break was HIS!! I just shake my head sometimes…
Phil