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Dec 7, 2013 • 12:56 PM
What is the most common location for microscopic capsule penetration that causes cancer cells to be left behind after radical prostatectomy?
Answer:
Microscopic capsule penetration can occur at any location around the prostate and result in radical prostatectomy failure. However, the most common location for cell leakage is at the bottom of the prostate (the apex). For any of the three techniques, the most critical and difficult part of a radical prostatectomy is removing the apex of the prostate, where the urethra is also cut across. There are several reasons for this difficulty.
First, it is common for prostate cancer to be located at the bottom of the prostate. According to Radiotherapy Clinics of Georgia database, 67% of men on biopsy have cancer at the bottom of the prostate. The second reason is that there is no capsule to contain prostate cancer at the apex, which means that prostate cancer can easily leak out of the prostate in this area (see Question 33 and Figure 6). Third, one of the large muscles that controls urination, the external sphincter muscle, is located at the apex of the prostate. A surgeon has a difficult decision when dissecting the apex. If the surgeon tries to cure a man of his prostate cancer, the procedure may remove too much of the muscle that controls urination, causing a man to leak urine. On the other hand, if the surgeon tries to ensure that the man will not leak, he can leave cancer cells behind.
To further complicate the procedure, the right and left sex nerves converge at the apex of the prostate. As with the muscles that control urination, if the surgeon tries to preserve these sex nerves, he may leave cancer behind; conversely, the surgeon may also leave the man without sexual function if he removes too much tissue in his attempt to cure the cancer. Although cancer cells can be left at any location, leaving cancer cells behind at the apex is the most common reason for surgery to fail to cure men with prostate cancer.
Despite this problem, it is remarkable that highly experienced surgeons can successfully dissect the apical area and cure many men with microscopic capsule penetration, if it is a small amount.
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Dec 8, 2013 • 7:31 AM
Dave205: do you have a reference for this statement? I have had a recurrence of PCa post RP and it seems like this is as good of an answer as any.
Regards
Dec 8, 2013 • 12:56 PM
My prostate cancer was in the apex and I copied this information and saved it as a Word document a year ago. I looked for where I found this information it is from question 88 from this link.
http://www.prostrcision.com/qa/radical-prostatectomy
The references they give are:
34. Smith JA, Chan RC, Chang SS, Herrell SD, Clark PE, Baumgartner R, and Cookson MS.: A Comparison Of The Incidence And Location Of Positive Surgical Margins In Robotic Assisted Laparoscopic Radical Prostatectomy And Open Retropubic Radical Prostatectomy. J Urol 178: 2385-2390, 2007.
35. Trock BJ, Gui CC, Tamas EF, and Epstein, JI.: Prognostic Significance Of Positive Surgical Margins In Radical Prostatectomies: An Analysis Based On Their Anatomic Locations. J Urol 179 (4) Supplement: 197, 2008.
36. Masieri L, Serni S, Lanciotti M, Minervini A, Lapini A, and Carini M.: Prostatic Apex Involvement In The Specimen Of Radical Prostatectomy Is An Independent Prognostic Factor Of Tumor Progression. J Urol 179 (4) Supplement: 495, 2008.
Dec 8, 2013 • 4:18 PM
Thanks Dave. Exactly what we are dealing with. Will provide update soon. We have been all over the place lately. Dr Wheeler in Sarasota, now Toronto with Dr Tractenberg (FLA TRIAL), and via phone with Dr. Scionti. Just did CT scan and bone scan tomorrow. Fingers and toes crossed.
The more information we get, the more confused we are...
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Dec 8, 2013 • 5:00 PM
Another fact; 51% of all positive margins happen in the apex.
0 ReactionsDec 8, 2013 • 5:21 PM
Frankpickard:
Since you are in Canada you may want to speak with Laurence Klotz, M.D.
And look at his approach to Focal Therapy.
Dec 20, 2013 • 4:27 PM
Dave 205:
I had low volume GL 9 PCa in prostate, and on pathology had SVI and 4mm positive margin (GL7) at the base, near EPE . Is this unusual? Is my prognosis better or worse than having pos. margin and EPE at the apex?
Bob
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Dec 20, 2013 • 8:24 PM
I am not a doctor and not qualified to answer your question. I can only refer you to the statements in my original post.
0 ReactionsDec 20, 2013 • 11:34 PM
Dave
I found the answer. Positive margin at base is the worst place to have it! Another bad day for me,
Bob
Dec 21, 2013 • 1:57 AM
break60, Why is that the case?
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Dec 21, 2013 • 8:42 PM
Dave 205
It's bad because according to a study I read, guys who had positive margin at the base had one of the highest chances of biochemical recurrence (BCR) in 5 years. But other studies say there is no difference where the positive margin occurred. So who the heck knows? Other studies on PT3b cases like mine show that there is a more than 50% chance of no recurrence. I just hope I'm one of the lucky ones.
Bob