What is a Positive Margin After a Prostatectomy?

Dr. Bevan Thomas explains what a positive margin after a prostatectomy means

45109618711In an ideal world, after radical prostatectomy, the pathologist would send a triumphant report to the surgeon: “I’ve looked at the prostate tissue you removed from Mr. Jones, and all of the edges are clear. Congratulations! You’ve removed all the cancer!”

Most often, it happens that way. Sometimes, however, the pathologist’s report is more ambiguous: Either the margins — the edges of the removed tumor — are “positive,” meaning they show cancer cells, or they’re “close,” meaning cancer is just a hair’s breadth away from the edge of the specimen.

In this video, Dr. Bevan-Thomas breaks what a positive margin after prostatectomy means, and shares why obtaining a pathology report after surgery is so important for patients to do.

Video Transcript

Dr. Richard Bevan Thomas:  Hey folks, this is Dr. Richard Bevan Thomas from prostate cancer live and I want to talk a little bit about a recent paper that talked about in particular challenge that we see with patients who have actually had surgery for prostate cancer and most patients actually have had what we described as a robotic prostatectomy and in that robotic prostatectomy, we actually looked at specific aspects of that pathology to figure out where that cancer is located i.e. did the cancer get outside of the capsule of the prostate, do we have what’s called a positive margin or they invading in the seminal vesicles, so there are number of different things that we are looking at.  In this particular paper, we are looking at what’s called a positive surgical margin, so we are going to have a length that we are not actually explaining all the detail of your final pathology report and I recommend that every patient actually have and get a copy of their final pathology report when they walk out of doctor’s office after they have had surgery. 

This particular patient I am going to read of the name to you and we are going to create the link for this is called the use of early postoperative prostate specific antigen to stratify risk in patients with positive surgical margins after a radical prostatectomy.  Okay, that’s a mouthful let’s break this down what is this mean, so the prostate is like a golf ball.  It can be bigger than a golf ball or can be smaller than a golf ball, but we look at all of the aspects of that golf ball when we take it out and especially when we are actually tying to spare those nerves responsible for the erections what happens is that cancer can come right up against the edge and if it comes up right up against the edge that’s what we call a margin which make sense.  A margin is obviously right up against the margin or whatever that’s going to be and in particular in prostate cancer it’s called a positive surgical margin what we described as PSM again positive surgical margin when that cancer gets up to that surgical margin, we know that those patients unfortunately have an increase risk of the cancer coming back. 

Now, all patients unfortunately have some risk of it coming back which is why when a patient after we do surgery you know we much we loved to give them high five and say alright call me when you are 90 years old we cannot do that because there is always the risk of the cancer has already gotten outside even though everything looks great on the pathology, but if we see other adverse pathology aspects of this pathology report meaning that if that cancer has got up against that margin that increases the risk.  Well what we have done in the past is we either follow those very closely or you know and again it’s really a judgment call. 

There are some urologists that will say hey you know we are seeing the positive margin, we are going to see you after radiation immediately and make sure that this cancer doesn’t come back.  The problem we doing that is that unfortunately you are overtreating a significant number of those patients.  Well, there is different ways of handling this.  We can actually number one is look at the size of the margin and that you can imagine, the increase of the length, think about that golf ball right and I have got a little worry that this is going to coming out the side or coming right up against the edge there, the more cancer that’s ride up against the edge when we took that golf ball out and the cancer is right up against the edge of the potentially the nerve, but anywhere else on there the more volume there is the higher risk that we are seeing that risk of cancer can come back that being said this paper actually looked at the PSA alone and I have been a huge advocate as many of patients know of what we called the ultra-sensitive PSA. 

Well, it’s not a PSA that just gets very you know goes to the minute is amount, but it goes got to what we called second decimal point.  The ultra-sensitive PSA goes to 0.00.  A normal PSA will go to 0.1 okay lets go into detail, so you have the patient.  He has got a positive surgical margin.  We know on this paper, they actually look at the 30 days, but you know most of us as urology community will routinely get a PSA either its six weeks or in three months, but what we do know is that those patients who have a positive surgical margin and have a PSA that is detectable and that’s detectable either 0.01 or even at 0.03 or anything higher than that have the increase risk of having that cancer come back, so what is my advice to you, my advice to you is that if you have a positive surgical margin and these things happen unfortunately, we are not all genies and we don’t have all negative margins. 

These cancers can come right up against the edge.  The first question we want to ask ourselves is if that PSA and if that ultra-sensitive PSA is detectable, you want to have discussion with your doctor about is a time for us to consider radiation therapy or you know is it time when we consider other things or is a genetic risk etc.  This paper as told us that those patients who have some detectable PSA 0.01 or greater those of patients that are at increased risk of having that cancer come back.  Here what we also know, we know that the sooner we treat these patients, the better off we have a results and ideally it’s for that PSA is 0.2 not 0.02, but 0.2, so the takeaway, know your pathology report, do you have a positive margin, if you do have a positive margin what is your ultra-sensitive PSA, sit down with your doctor, ask him what this means, and do you think that you may potentially need an additional type of therapy which is usually radiation therapy that can potentially kill any potential cancer that may pop up in the future.  Okay guys.  This is Dr. Richard Bevan Thomas signing out.

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