Prognostic importance of resection margin width after nephron-sparing surgery for renal cell carcinoma

doi:10.1016/S0090-4295(02)01983-0

Urology

Volume 60, Issue 6, December 2002, Pages 993-997

https://doi.org/10.1016/S0090-4295(02)01983-0 Get rights and content

Abstract

Objectives

To examine the relationship between the width of the resection margin and disease progression in renal cell carcinoma (RCC) after nephron-sparing surgery (NSS). During NSS for RCC, it is standard practice to excise the tumor along with a surrounding margin of normal parenchyma (margin of resection) to ensure complete resection of the neoplasm. However, no agreement has been reached on how wide the margin of resection should be.

Methods

We retrospectively reviewed the histopathologic sections and medical records of 69 patients with localized RCC who had undergone NSS between 1976 and 1988 to determine whether the resection margin, tumor size, TNM stage, and Fuhrman nuclear grade were associated with disease progression (defined as local tumor recurrence or metastasis). The mean postoperative follow-up interval was 8.5 years.

Results

No association was found between the width of the resection margin and disease progression (P = 0.98, log-rank test). Both TNM stage and Fuhrman nuclear grade correlated with disease progression. Patients with T1-T2 tumors had lower progression (P <0.001, log-rank test), and increased Fuhrman nuclear grade correlated with more disease progression (P <0.001, log-rank test).

Conclusions

The width of the resection margin after NSS for RCC does not correlate with long-term disease progression. A histologic tumor-free margin of resection, irrespective of the width of the margin is sufficient to achieve complete local excision of RCC.

Section snippets

Patient selection

We identified 107 patients who underwent NSS for localized sporadic RCC at the Cleveland Clinic Foundation from January 1976 through December 1988. These patients were the subject of a previous report.5 In the present study, we included only the 69 patients for whom a permanent frozen section slide of the tumor showing the margin of resection was available for study. The slides of the remaining 38 patients were absent from the pathology archives. None of these patients had von Hippel-Lindau

Results

The mean age at surgery was 61 years (range 36 to 85). The average tumor size was 4.4 cm (range 1 to 11.3). The other clinical and pathologic characteristics of the 69 study patients are summarized in Table I. RCC was unilateral in 34 patients (49%), bilateral synchronous in 14 patients (20%), and bilateral asynchronous in 21 patients (30%). NSS was performed in 6 patients (9%) because of a history of calculus disease, diabetes mellitus, renal artery disease, or hypertension. In the remaining

Comment

NSS is a surgical option for the treatment of RCC in selected patients.9 In addition to traditional indications for NSS in solitary kidneys or bilateral renal tumors, increasing evidence supports its elective use for small, solitary RCCs with a normal opposite kidney.11, 18 Although multiple surgical techniques have been fully described for use in NSS,9, 10 the recommendation of a determined minimal margin of surgical resection remains ill-defined.9, 10

The complete excision of the renal mass is

Conclusions

When performing NSS for RCC, if the tumor is completely excised with a surrounding margin of normal renal tissue, the width of the resection margin does not correlate with long-term disease progression. Traditional prognostic factors such as TNM stage, FNG, and tumor size remain the most significant predictors of disease progression.

Acknowledgements

To Amy Moore for helpful advice in the editing of this document.

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We reviewed studies on robotic surgery for partial kidney removal using different techniques to cut away the kidney tumor. We found that a technique called “enucleation” was associated with similar cancer control outcomes in comparison to the standard technique and had fewer complications, better kidney function after surgery, and a shorter hospital stay.
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Systematic pathology reviews in patients who experienced a clinical “recurrence” after partial nephrectomy for renal cell carcinoma (RCC) are anecdotal; therefore, definitions of “recurrence” varies considerably. We aimed to better define local recurrence by re-evaluation of surgical specimens of patients who experienced “recurrences” after partial nephrectomy at our institution.
Retrospective analysis of our institutional partial nephrectomy data set was performed. Patients who were clinically diagnosed with a local recurrence during the oncological follow-up after primary intervention for RCC were considered (January 2007 to December 2017, institutional review board number 5065, 15-1593). Re-evaluation of specimens coming from either primary treatment or management of the diagnosed recurrent disease was performed by 2 dedicated urologic pathologists. According to the findings of the pathology review, patients were assigned to 3 groups of disease event: (1) local recurrence of RCC; (2) new occurrence of RCC; and (3) micrometastatic RCC. Patient demographic characteristics, tumor pathological characteristics, oncological outcomes, disease treatment, and follow-up were reported for each patient. Cancer-specific survival was compared using the Kaplan–Meier method.
Of 1994 cases recorded in the institutional database, data on 30 patients who were clinically diagnosed with a local recurrence were extracted. After pathology review, 9 patients were found who truly developed a local recurrence (group 1). Positive surgical margin status was poorly related to the likelihood of a true local recurrence as defined herein. Twelve patients were assessed with a new occurrence of RCC (group 2). Nine were diagnosed with micrometastatic RCC (group 3). With comparable follow-up lengths among the groups (39 [interquartile range (IQR), 32-45] versus 51.5 [IQR, 35-90.5] versus 42 [IQR, 13-65], group 1 versus 2 versus 3, respectively; P = .4), patients classified in group 1 and 3 had comparable cancer-specific survival (P = .5). Conversely, patients in group 2 were less likely to die of disease compared with group 1 and 3 patients (P = .02).
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Adult urologyPrognostic importance of resection margin width after nephron-sparing surgery for renal cell carcinoma

Abstract

Objectives

Methods

Results

Conclusions

Section snippets

Patient selection

Results

Comment

Conclusions

Acknowledgements

J Urol

J Urol

Urol Clin North Am

J Urol

J Urol

J Urol

J Urol

J Urol

J Urol

Urology

Cancer statistics

Cancer J Clin

Adult urology
Prognostic importance of resection margin width after nephron-sparing surgery for renal cell carcinoma