Prostate Cancer Expert Forum
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This forum is for questions about: Advanced or Metastatic Prostate Cancer, Biopsy, Bone Scan, Blood in Urine or Semen, Benign Prostatic Hyperplasia (BPH), CT Scan, Cystoscopy, Erectile Dysfunction, Hormone Therapy, Incontinence, Pain (abdomen, low back or hip), PSA Test, Prostatitis , Radiation Therapy, Rectal Exam, Recurrent Cancer, Risk Factors, Screening, Staging (Tumor size; Metastasis), Surgery, Transrectal Ultrasound, Urinary Difficulty or Burning, Urinary Urgency (Leaking), Watchful Waiting.

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Need advice

My husband was diagnosed with prostate cancer in November of 2009.  He had a PSA of 50 and a Gleason of 8 (4+4).
Radical prostatectomy was performed on January 4, 2010.  Surgery went well with no incidence.  He's home recuperating.  One week later, the catheter was removed. Nodes were clean during surgical biopsy.  
Just got results of capsular biopsy.  The biopsy showed cellular penetration of prostate capsule and invasion of seminal vesicles with positive margins.  Doctor's recommendation was to wait 3 months and repeat PSA.  
Very worried about this "wait and see" period.  Is there something we can be doing in the meantime that may be proactive?  What about a PET scan.  Would it show anything this early?   Can metastatic cancer be seen on a cellular level on PET scan?
I'd appreciate any input anyone may have or advice from someone with a similar situation.  
thank you, in advance, for your advice.

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Thank you for your question. Followup PSA after radical prostatectomy usually occurs between 6 to 12 weeks after surgery. During this time followup therapy would not be ideal as radiation would greatly diminish the return of urinary continence and erectile functioning.

With Gleason 8 disease and a preoperative PSA of 50 ng/mL and seminal vesicle involvement your husband is a candidate for adjuvant radiation therapy. A recent study in 2008 showed that patients with pT3 disease had a lower risk of biochemical recurrence when treated with radiation following their prostatectomy.

In the early 1990s, 425 men were enrolled in SWOG (Southwest Oncology Group) 8794 with aggressive prostate cancer. They were randomly assigned within 16 weeks after prostatectomy into groups of adjuvant radiation or observation. Immediate radiation following the removal of the prostate significantly reduced recurrence (biochemical, local failure and metastatic disease) and increased metastatic disease-free and overall survival.

The Fifteen-year metastasis-free survival was 46 percent with radiation and 38 percent for observation respectively. The overall survival was 47 percent and 37 percent, respectively. Radiation therapy also significantly reduced biochemical and local failure as well as the need for androgen ablation (or hormone therapy).

A PSA rise at this point would not necessarily mean metastatic disease. It is not clear if distant micrometastases would evolve before PSA elevation. It could mean prostate tissue was left in the body (not necessarily a positive surgical margin but a capsular invasion) or micrometastases. It may be prudent for urinary function to return prior to starting radiation.

Best of luck

Ashutosh (Ash) K. Tewari, MD

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I had a similar situation (radical prostatectomy in August, seminal vesicle invasion, penetration of prostate capsule, Gleason 9) but no positive margins (although close, at less than 1mm).  After seeking several opinions, the concensus was that this was an aggressive cancer and adjuvant therapy (both hormone and radiation)should begin as soon as I had recovered from the operation in about 2-3 months (I haven't done this yet because my PSA has been undetectable, but I'm not sure that was the right choice.)  Get a second opinion (Dr. Tewari gives sound advice).  I'm no expert, but "positive margins" means there is a chance that the surgery did not get all of the cancer (locally).  Good luck.
thanks for your response about our situation.  I had read your post and found it extremely similar to my husbands.  Yes, his margins were positive, so we're aware that the surgery did not get all of the cancer cells.  We have about 2-3 more weeks before next PSA.  I suppose, at this point, we'll wait for that and decide what the next step is based on the findings.  I'm glad to hear your PSA is currently undetectable.  I hope it remains that way for you.  Best of luck and thanks again.
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