Is there a clinical role for frozen section analysis during partial nephrectomy? A multicenter experience over 10 years

BACKGROUND

Frozen section analysis (FSA) is frequently performed during partial nephrectomy (PN). We investigate the utility of intraoperative FSA by evaluating its impact on final surgical margin (SM) status.

METHODS

Between January 1995 and December 2005, a series of patients who were treated with open PN for renal cell carcinoma was prospectively analyzed. During PN, each patient underwent a FSA on renal parenchyma distal margin. If FSA was positive for infiltration a deeper excision was performed till obtaining a negative FSA. SM outcome of the FSA was compared with the final pathology report. Recurrence-free survival (RFS) and cost analysis on the FSA performed were analyzed.

RESULTS

A total number of 373 patients were enrolled. FSA was performed in all the patients considered for PN. Fifteen patients had a conversion to radical nephrectomy. Positive SMs at the definitive pathological outcome were found in 36 patients (9.6%). FSA was positive in eight patients (2.1%). In that eight cases after a deeper excision the definitive pathological outcome on SM was still positive in two cases. FSA revealed just 14.3% of the positive SM. Patients with positive SM had a worse follow up considering RFS (P<0.05). Kaplan-Meier analysis revealed that FSA did not considerably contribute to prevent recurrence (P=0.35). 1438 euros was the mean cost of performing a FSA during PN.

CONCLUSIONS

FSA during PN does not reduce the risk of positive SMs. The use of FSA has also a higher cost related to the procedure.

Diffuse minute clear cell proliferation in kidney: case report and review of literature

To our knowledge, diffuse involvement of renal parenchyma by multiple minute foci of clear cell proliferations has not been previously reported. We report such a case, found incidentally, in an 86-year-old woman who had undergone right ureteronephrectomy for pyeloureteral urothelial carcinoma. Macroscopy of the kidney showed numerous yellow dot-like cortical nodules less than 0.3 cm. Histologic examination of the kidney and nodules revealed innumerable foci of minute clear cell proliferations in a background of chronic pyelonephritis. The benign or malignant nature of those clear cell microtumors was investigated by immunohistochemistry and fluorescent in situ hybridization analysis of chromosome 3p.

Prospective study of safety margins in partial nephrectomy: Intraoperative assessment and contribution of frozen section analysis

OBJECTIVES

To evaluate prospectively a healthy parenchymal safety margin during conservative surgery for renal cell carcinoma.

METHODS

From 1997 to 2001, elective nephron-sparing surgery was performed through a flank incision in 61 consecutive patients (mean age 59.4 years, range 34.2 to 78.5). The mean tumor size was 32 mm (range 12 to 50). The tumor localization was juxtahilar in 10 and distant in 51. Prospective margin assessment used the following protocol. Margins were evaluated macroscopically by the surgeon, controlled by frozen section analysis, and subsequently measured during histologic examination. All patients were monitored with computed tomography scans, with a mean follow-up of 72.5 months (range 46 to 95).

RESULTS

The histologic type was clear cell in 42 patients, papillary in 17, and chromophobic cell in 2. Of the 61 patients, 57 had 1997 TNM Stage pT1 and 4 had Stage pT2. The Furhman grade was grade 1 in 16, grade 2 in 35, and grade 3 in 10. No tumor margin was positive. Frozen section analysis and routine histologic examination yielded 53 complete and 8 incomplete margins compared with 51 and 10, respectively, as assessed by the surgeons. The mean peritumoral margin was 7 mm (range 4 to 10) for the cortex and 2 mm (range 0 to 5) for the deep part. No patient developed locoregional or metastatic relapse.

CONCLUSIONS

No apparent relationship was observed between peritumoral margin width and the risk of disease progression, even for tumors abutting the hilum, rendering illusory a safety margin greater than 1 cm. Although the surgeons' macroscopic margin evaluations were accurate, frozen section analysis is mandatory when the margin status is in doubt. In all cases, margin negativity remains an oncologic imperative.

Análisis de las neoplasias renales en adultos menores de 40 años

OBJECTIVES

To analyze within our sample population the number of patients under 40 receiving surgery as a result of renal neoplasm; to describe the characteristics of these patients and compare them with those of adult patients over 40.

PATIENTS AND METHODS

We have revised the clinical history of the 379 patients with renal neoplasm who have undergone surgery in our Service from January 1986 through June 2003. Patients were divided into two groups. Group I, formed by 36 subjects (9.5%) < or = 40. Group II includes 343 patients (90.5%) over 40. Data were included in a database created using the software programme Access and were subsequently analysed using the statistical package SPSS. A descriptive analysis was performed and life expectancy was calculated for both groups using the Kaplan-Meier survival curve.

RESULTS

7.3% of the total number of renal cell carcinomas included in our series occurs in patients of or under 40. No significant differences have been observed as regards the distribution per sexes, laterality, size, incidental occurrence, clinical symptoms, anatomopathology, staging or surgical technique employed. However, we have observed differences as regards cancer-specific survival rate after 5 years, being 94.74% in the case of group I and 68.64% in group II (log-rank 0.0338).

CONCLUSIONS

The number of patients < or = 40 undergoing surgery as a result of renal cell carcinoma in the sample under study matches other series already published. No statistically significant difference has been observed as regards staging among patients under and over 40. Differences do exist as regards cancer-specific survival rate. In the case of our patients, irrespective of the age group to which they were ascribed, it is more common to diagnose a renal neoplasm incidentally than through the clinical manifestations.

Long-term results of nephron-sparing surgery for renal cell carcinoma in 114 patients: risk factors for progressive disease

OBJECTIVES

To evaluate risk factors for metastatic disease after nephron-sparing surgery (NSS) for renal cell carcinoma (RCC).

PATIENTS AND METHODS

NSS for RCC was used 117 times in 114 patients at our institution; 61 had a normal contralateral kidney and were selected for elective NSS, and in 56 cases (53 patients) the indication for NSS was imperative. Univariate and multiple regression analysis was used to evaluate the risk factors for metastatic disease.

RESULTS

After a mean follow-up of 80 months, there was tumour progression in 17 of the 114 patients (15%). In the univariate analysis, the tumour diameter (P = 0.03) and imperative indication (P = 0.009), and in multiple regression analysis only imperative indication, were significant risk factors for metastatic disease (P = 0.016).

CONCLUSIONS

Elective NSS for RCC provides excellent long-term results in selected patients, whereas those undergoing NSS imperatively are at a significantly higher risk of metastatic disease and require a close follow-up.

The role of partial nephrectomy for renal cell carcinoma in contemporary practice

Partial nephrectomy has proved to be a safe and effective treatment modality, even for patients with normal contralateral kidneys. The indications for elective partial nephrectomy continue to evolve as contemporary series demonstrate low morbidity approaching that of radical nephrectomy. Furthermore, patients who undergo partial nephrectomy have a significantly decreased risk of future renal insufficiency. As such, a rationale exists for expanding indications in an era of excellent technical outcomes and increased patient longevity. Characterization of newer diagnostic (three-dimensional imaging) and treatment (laparoscopic partial nephrectomy, cryosurgery) modalities will allow continued evolution of nephron-sparing techniques.

Subclassification of renal cell neoplasms: an update for the practising pathologist

The classification of renal cell neoplasms has been extensively studied in the last decade, and a standardized nomenclature adopted. Although this system is based on a combination of genetic, histological and immunohistological features, in most cases accurate classification can be based on histological features alone. This review summarizes the key features of the tumours included in this system, and then focuses on diagnostic difficulties that can arise when using this system, as well as reviewing several recently characterized tumours that are not yet included.

Incidental renal cell carcinoma and nephron sparing surgery

The role of nephron sparing surgery in patients with a solitary kidney, bilateral kidney tumors or an impaired renal function has been widely accepted. Partial nephrectomy in patients with a normal contralateral kidney is still under discussion. Nevertheless, more and more surgeons perform nephron sparing surgery in these patients with good results. From historical comparisons there seems to be no statistically significant difference in five-year survival between radical nephrectomy and nephron sparing surgery when the tumor diameter is four centimeters or less. The most common problem is the risk of tumor recurrence due to the multifocality. However, multifocality is more frequent than kidney recurrence, questioning the spontaneous evolution of satellite lesions. Further investigations are necessary to optimize patient selection. Therefore, a randomized prospective multicenter study with long-term follow-up might add to the excellent results published by several authors during the last two years in order to confirm that nephron sparing surgery is an excellent alternative to radical nephrectomy in small asymptomatic renal cell carcinoma.

Nephron-sparing surgery

The curative management of renal cell carcinoma remains surgical. Recent advances in imaging and increased use of cross-sectional imaging modalities have led to an increased detection of incidental renal cell carcinomas. There is little debate regarding the role of nephron-sparing surgery (NSS) when absolutely indicated. Radical nephrectomy is still considered by many as the treatment of choice for localized renal cell carcinoma in the setting of a normal contralateral kidney. However, there is growing evidence that in the correct patient, the use of NSS in this setting is justified. Therefore, the indications of NSS have evolved in the past decade. Recent data indicate that radical nephrectomy and NSS provide effective and equivalent curative treatment for most renal cell carcinomas, especially those 4 cm or smaller. These data, along with new, refined surgical techniques, new studies regarding the biology of renal cell carcinoma and true incidence of occult multifocality, and earlier diagnosis make NSS an attractive consideration for the practicing urologist.