Predictive Factors for Ipsilateral Recurrence After Nephron-sparing Surgery in Renal Cell Carcinoma

Relevance of Positive Surgical Margins in Localized Renal Cell Carcinoma After Surgical Resection: Predictive Factors and Survival Implications

INTRODUCTION

The implications of positive surgical margins (PSM) after surgery for renal cell carcinoma (RCC) remain subject of discussion. This study aimed to identify risk factors for PSM, assess its effect on overall survival (OS), and determine predictors of OS.

PATIENTS AND METHODS

Data from RCC surgeries at Mannheim University Medical Center between 2010 and 2023 was analyzed. Propensity score matching balanced PSM and control groups using age, surgical approach, tumor stage, histological subtype, and American Association of Anesthesiologists (ASA) score. Logistic and cox regression models predict PSM and OS, respectively. Kaplan-Meier analysis compared OS of PSM patients and controls.

RESULTS

A total of 1066 RCC patients were included. Propensity score matching yielded 32 PSM patients and 96 controls. Multivariable logistic regression identified tumor stage ≥ T3a (odds ratio [OR] = 2.74, 95% confidence interval [CI] = 1.0-6.8, P = .04) and chromophobe, compared to clear cell, RCC (OR = 3.19, 95% CI = 1.0-8.7, P = .03) as independent predictors of PSM. Multivariable cox regression found age > 65 years (hazard ratio [HR] = 2.65, 95% CI = 1.7-4.2, P < .01) and tumor stage ≥ T3a (HR = 2.25, 95% CI = 1.4-3.7, P < .01) to predict shorter OS. Partial vs. radical nephrectomy was associated with improved OS (HR = 0.49, 95% CI = 0.3-0.9, P = .02). Kaplan-Meier analysis revealed no OS difference between PSM patients and controls (P = .49) over a 45-month median follow-up.

CONCLUSION

PSM is not a primary determinant of inferior survival, while age and tumor stage play a more prominent role. A well-calibrated follow-up protocol for PSM patients, combining PSM with coinciding factors such as tumor stage, grade, size, or PSM extent, is crucial for adequate surveillance while preventing excessive interventions.

[Nephron sparing in the management of localized solid renal mass]

Managing a malignant renal tumor requires, first of all, a reflection on the necessity of its treatment. It must consider the renal function, altered at the time of diagnosis in 50% of cases. The treatment method chosen depends on many factors, in particular, the predicted residual renal function, the risk of chronic kidney disease, the need for temporary or long-term dialysis, and overall long-term survival. Other factors include the size, position, and number of tumors and a hereditary tumor background. When a renal-sparing management alternative is available, total nephrectomy should no longer be performed in patients with small malignant renal masses (cT1a). This may consist of surgery (partial nephrectomy or lumpectomy), percutaneous thermo-ablation (by radiofrequency, microwave, or cryotherapy). In patients with limited life expectancy, imaging-based surveillance may be proposed to suggest treatment in case of local progression. Good coordination between urologist, radiologist, nephrologist, and sometimes radiotherapist should allow optimal management of patients with a malignant renal tumor with or without underlying renal failure.

Role of clinicopathological variables in predicting recurrence and survival outcomes after surgery for non-metastatic renal cell carcinoma: Systematic review and meta-analysis

Renal cell carcinoma (RCC) represents 2% of all diagnosed malignancies worldwide, with disease recurrence affecting 20% to 40% of patients. Existing prognostic recurrence models based on clinicopathological features continue to be a subject of controversy. In this meta-analysis, we summarized research findings that explored the correlation between clinicopathological characteristics and post-surgery survival outcomes in non-metastatic RCC patients. Our analysis incorporates 99 publications spanning 140 568 patients. The study's main findings indicate that the following clinicopathological characteristics were associated with unfavorable survival outcomes: T stage, tumor grade, tumor size, lymph node involvement, tumor necrosis, sarcomatoid features, positive surgical margins (PSM), lymphovascular invasion (LVI), early recurrence, constitutional symptoms, poor performance status (PS), low hemoglobin level, high body-mass index (BMI), diabetes mellitus (DM) and hypertension. All of which emerged as predictors for poor recurrence-free survival (RFS) and cancer-specific survival. Clear cell (CC) subtype, urinary collecting system invasion (UCSI), capsular penetration, perinephric fat invasion, renal vein invasion (RVI) and increased C-reactive protein (CRP) were all associated with poor RFS. In contrast, age, sex, tumor laterality, nephrectomy type and approach had no impact on survival outcomes. As part of an additional analysis, we attempted to assess the association between these characteristics and late recurrences (relapses occurring more than 5 years after surgery). Nevertheless, we did not find any prediction capabilities for late disease recurrences among any of the features examined. Our findings highlight the prognostic significance of various clinicopathological characteristics potentially aiding in the identification of high-risk RCC patients and enhancing the development of more precise prediction models.

Recognizing pathology of renal tumor from macroscopic cross-section image by deep learning

OBJECTIVES

This study aims to develop and evaluate the deep learning-based classification model for recognizing the pathology of renal tumor from macroscopic cross-section image.

METHODS

A total of 467 pathology-confirmed patients who received radical nephrectomy or partial nephrectomy were retrospectively enrolled. The experiment of distinguishing malignant and benign renal tumor are conducted followed by performing the multi-subtypes classification models for recognizing four subtypes of benign tumor and four subtypes of malignant tumors, respectively. The classification models used the same backbone networks which are based on the convolutional neural network (CNN), including EfficientNet-B4, ResNet-18, and VGG-16. The performance of the classification models was evaluated by area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and accuracy. Besides, we performed the quantitative comparison among these CNN models.

RESULTS

For the model to differentiate the malignant tumor from the benign tumor, three CNN models all obtained relatively satisfactory performance and the highest AUC was achieved by the ResNet-18 model (AUC = 0.9226). There is not statistically significance between EfficientNet-B4 and ResNet-18 architectures and both of them are significantly statistically better than the VGG-16 model. The micro-averaged AUC, macro-averaged sensitivity, macro-averaged specificity, and micro-averaged accuracy for the VGG-16 model to distinguish the malignant tumor subtypes achieved 0.9398, 0.5774, 0.8660, and 0.7917, respectively. The performance of the EfficientNet-B4 is not better than that of VGG-16 in terms of micro-averaged AUC except for other metrics. For the models to recognize the benign tumor subtypes, the EfficientNet-B4 ranked the best performance, but had no significantly statistical difference with other two models with respect to micro-averaged AUC.

CONCLUSIONS

The classification results were relatively satisfactory, which showed the potential for clinical application when analyzing the renal tumor macroscopic cross-section images. Automatically distinguishing the malignant tumor from benign tumor and identifying the subtypes pathology of renal tumor could make the patient-management process more efficient.

Markers of local kidney cancer recurrence: A surgeon's mistake or a pattern? Review

The influence of various morphological, anatomical, genetic and other factors on the local recurrence-free survival of patients who have undergone different renal cell cancer (RCC) treatment is still a rather complex, ambiguous and controversial issue for practicing oncourologists. This review evaluates the effect of several factors on both recurrence-free survival and local recurrence-free survival. The review includes articles, clinical cases, literature reviews, and meta-analyses highlighting the analysis of independent and interrelated predisposing factors for developing local recurrence of RCC from 1984 to 2020. The PubMed, Web of Science, and Scopus databases were searched in English, Spanish, and German. A review of the literature showed the role of the following indices in the local recurrence RCC: microvascular invasion (p = 0.001), tumor necrosis (p = 0.0001), high malignancy (Fuhrman III or IV) (HR = 38.3, 95% CI 3.1-467, p = 0.004) as histological factors, tumor size as an anatomical factor. Thus, the authors state that every centimeter of the tumor increases the risk of local recurrence (p < 0.05). A group from the Mayo Clinic showed the equivalence of different treatment methods in local RCC recurrence. Thus, in the group of patients with cT1a stage kidney cancer, the 5-year local recurrence-free survival rates were 97.7% (96.7-98.6), 95.9% (92.3-99.6), and 95.9% (92.3-99.6) for renal resection, RFA, and cryoablation, respectively. Surgical margin status is the most studied and controversial marker of local renal cell carcinoma recurrence. Researchers found a direct effect of PSM on the risk of local RCC recurrence (p < 0.01). The personalized approach with the search and evaluation of predisposing factors for the local recurrence, as well as further selection of the most optimal treatment, will allow oncourologists to improve both the effectiveness of primary treatment and the recurrence-free survival of patients.

Comparative Analysis of Trifecta Outcomes in Robot-Assisted Partial Nephrectomy for cT1a Versus cT1b + Renal Tumours-a Single-Centre Study

Robotic assistance is being increasingly utilised for nephron-sparing surgery for complex renal masses. We evaluated the outcomes of robot-assisted partial nephrectomy (RAPN) for cT1a versus cT1b + renal masses by a comparative analysis of trifecta outcomes between these two groups of patients. We utilised our prospectively maintained database to identify patients undergoing RAPN for cT1a (group 1, n = 41) and cT1b + (group 2, n = 37) renal masses from April 2016 to March 2020. The oncological and trifecta outcomes were analysed using appropriate statistical methods. Out of 78 patients, trifecta was achieved in 30 (38.4%) patients. There was no statistically significant difference in trifecta between cT1a and cT1b + tumours (p = 0.152). We found a statistically significant difference between the two groups in terms of RENAL scores (p = 0.0005), PADUA score (p = 0.0002), and robotic console time (133.8 ± 42.8 Vs 170 ± 54.8 min for cT1a versus cT1b + , respectively) (p = 0.002). On multivariate analysis, warm ischemia time (p = 0.069), blood loss (p = 0.345), UCS repair (p = 0.691) and GFR reduction (p = 0.152) were not statistically different. There was no statistically significant difference in intraoperative and post-operative complications (p = 0.9317) or length of hospital stay (p = 0.112). Although recurrences were observed in two patients (5.4%) of the cT1b group, there was no statistical difference in the recurrence-free survival at 12 and 24 months. Our study shows that RAPN can be safely done for cT1b + renal tumours. These findings reinforce the view that RAPN should be considered a viable option for cT1b + lesions whenever technically feasible.

Positive surgical margin's impact on short-term oncological prognosis after robot-assisted partial nephrectomy (MARGINS study: UroCCR no 96)

The oncological impact of positive surgical margins (PSM) after robot-assisted partial nephrectomy (RAPN) is still under debate. We compared PSM and Negative Surgical Margins (NSM) in terms of recurrence-free survival (RFS), metastasis-free survival (MFS) and overall survival (OS) after RAPN, and we identified predictive factors of PSM. Multi-institutional study using the UroCCR database, which prospectively included 2166 RAPN between April 2010 and February 2021 (CNIL DR 2013-206; NCT03293563). Two groups were retrospectively compared: PSM versus NSM. Prognostic factors were assessed using Kaplan-Meyer curves with log-Rank test, cox hazard proportional risk model and logistic regression after univariate comparison. 136 patients had PSM (6.3%) and 2030 (93.7%) had NSM. During a median follow-up of 19 (9-36) months after RAPN, 160 (7.4%) recurrences were reported. Kaplan-Meier curves and analysis suggested that RFS, MFS and OS were not affected by a PSM (p = 0.68; 0.71; 0.88, respectively). In multivariate analysis predictors of PSM were a lower RENAL score (p = 0.001), longer warm ischemia time (WIT) (p = 0.003) and Chromophobe Renal Cell Carcinoma (chrRCC) (p = 0.043). This study found no impact of PSM on RFS, MFS or OS, and predictors of PSM were the RENAL score, WIT and chrRCC.

Positive surgical margins may not affect the survival of patients with renal cell carcinoma after partial nephrectomy: A meta-analysis based on 39 studies

Background

So far, whether positive surgical margin(PSM) has adverse effects on the prognosis of patients is still controversial, so we designed this study to systematically evaluate the effect of PSM on the prognosis of patients with renal cell carcinoma (RCC) after partial nephrectomy (PN).

Methods

On the basis of three electronic databases (PubMed, Embase and the Cochrane Library) up to May 2022, all case-control studies (CCSs) comparing the effects of PSM and negative surgical margin (NSM) after PN on the oncological results of RCC patients were included. Two evaluators independently conducted a systematic literature search and extracted the data we needed. The methodological quality of all studies was evaluated by the modified Newcastle-Ottawa scale. The odds ratio (OR) was used to describe the results for dichotomous variables, and the meta-analysis was conducted using Cochrane Review Manager 5.2 and Stata 14.2.

Results

A total of 39 studies involving 21461 patients were included in our meta-analysis. The pooled results showed that the rates of tumor recurrence (OR 3.93, 95% CI 2.95-5.24; p < 0.00001) and metastasis (OR 4.63, 95% CI 3.11-6.88; p < 0.00001) in the PSM group were significantly higher than those in the NSM group. However, there were no significant differences in the rates of all-cause death (OR 1.35, 95% CI 0.92-1.99; p = 0.13) or cancer-specific death (OR 0.99, 95% CI 0.51-1.94; p = 0.99) between the two groups. In addition, subgroup analyses were carried out according to different average follow-ups, which revealed similar results.

Conclusion

Insignificant differences in survival between the PSM and NSM groups were observed, although significant differences in recurrence and metastasis in the PSM group were reported. Our study supported that close monitoring might be another effective choice for patients with PSM after PN. Considering the possible limitations, we recommended cautious interpretation of our results.

Surgical margins after partial nephrectomy as prognostic factor for the risk of local recurrence in pT1 RCC: a systematic review and narrative synthesis

Purpose

To systematically review the published literature on surgical margins as a risk factor for local recurrence (LR) in patients undergoing partial nephrectomy (PN) for pT1 renal cell carcinomas (RCC).

Evidence acquisition

A systematic literature search of relevant databases (MEDLINE, Embase and the Cochrane Library) was performed according to the PRISMA criteria up to February 2022. The hypothesis was developed using the PPO method (Patients = patients with pT1 RCC undergoing PN, Prognostic factor = positive surgical margins (PSM) detected on final pathology versus negative surgical margins (NSM) and Outcome = LR diagnosed on follow-up imaging). The primary outcome was the rate of PSM and LR. The risk of bias was assessed by the QUIPS tool.

Evidence synthesis

After assessing 1525 abstracts and 409 full-text articles, eight studies met the inclusion criteria. The percentage of PSM ranged between 0 and 34.3%. In these patients with PSM, LR varied between 0 and 9.1%, whereas only 0–1.5% of LR were found in the NSM-group. The calculated odds ratio (95% confident intervals) varied between 0.04 [0.00–0.79] and 0.27 [0.01–4.76] and was statistically significant in two studies (0.14 [0.02–0.80] and 0.04 [0.00–0.79]). The quality analysis of the included studies resulted in an overall intermediate to high risk of bias and the level of evidence was overall very low. A meta-analysis was considered unsuitable due to the high heterogeneity between the included studies.

Conclusion

PSM after PN in patients with pT1 RCC is associated with a higher risk of LR. However, the evidence has significant limitations and caution should be taken with the interpretation of this data.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-022-04016-0.

Prognostic factors for surgical margin status and recurrence in partial nephrectomy

PURPOSE

To evaluate the prognostic factors affecting the surgical margin and recurrence in patients who underwent partial nephrectomy (PN) for renal masses.

MATERIALS AND METHODS

Data of 125 patients who underwent open or laparoscopic PN because of renal mass between January 2006 and January 2019 were analysed retrospectively. Demographic data, habits, additional diseases, clinical and laboratory findings, operational data, the morphology of the tumour in computerised tomography or magnetic-resonance imaging and follow-up data were scanned and acquired via our hospital's system and archive.

RESULTS

Average age was 54.4, male-female ratio was 1.55 and average tumour size was 3.31 cm. One hundred and four patients had malignant pathology and 21 were benign. Positive surgical margin (PSM) rate was 5.6% and recurrence rate was 3.2%. Average follow-up was 47.4 months. Pathological size of the tumour was larger (P = .006), warm-ischemia period was lower (P = .003) and PADUA score was higher (P = .015) in open technique. Tumour size and tumour stage were statistically higher in patients with recurrence (P = .009, P < .001, respectively). There was a significantly higher PSM ratio in mandatory indication group than elective indication group (P = .025). No statistically significant difference was observed between surgical margin positivity and tumour size, Fuhrman grades, PADUA scores, RENAL scores and C-index. (P > .05).

CONCLUSION

Surgical margin positivity after PN is not significantly associated with tumour characteristics and anatomical scoring systems. Surgical indication for PN has a direct influence on PSM rates. Tumour size and stage after PN are valuable parameters in evaluating the recurrence risk.

Local Recurrence Following Resection of Intermediate-High Risk Nonmetastatic Renal Cell Carcinoma: An Anatomical Classification and Analysis of the ASSURE (ECOG-ACRIN E2805) Adjuvant Trial

PURPOSE

We describe what is to our knowledge a novel classification system for local recurrence after surgery of renal cell carcinoma. We assessed its prognostic implications using prospective, randomized controlled data.

MATERIALS AND METHODS

We queried the ASSURE (Sunitinib Malate or Sorafenib Tosylate in Treating Patients With Kidney Cancer That Was Removed By Surgery) (ECOG-ACRIN [Eastern Cooperative Oncology Group-American College of Radiology Imaging Network] E2805) trial data for patients with fully resected, intermediate-high risk, nonmetastatic renal cell carcinoma with local recurrence. We used certain definitions, including type I-single recurrence in a remnant kidney or ipsilateral renal fossa, type II-single recurrence in the ipsilateral vasculature, the ipsilateral adrenal gland or a lymph node, type III-single recurrence in other intra-abdominal soft tissues or organs and type IV-any combination of types I-III or multiple recurrences of a single type. Multivariable logistic regression and the log rank test were performed to identify clinicopathological predictors and compare survival, respectively.

RESULTS

Of the 1,943 patients 300 (15.4%) had local recurrence, which was type I, II, III and IV in 66 (22.0%), 97 (32.3%), 87 (29.0%) and 50 (16.7%), respectively. Surgical modality (minimally invasive vs open) and type of surgery (partial vs radical) did not predict any local recurrence. Five-year cancer specific survival and overall survival were worse in patients with type IV recurrence (each p <0.001). There was no difference in survival among patients with types I to III recurrence.

CONCLUSIONS

In patients with intermediate-high risk nonmetastatic renal cell carcinoma local recurrence appears to be a function of biology more than of surgical modality or surgery type. The prognosis for solitary intra-abdominal local recurrences appear similar regardless of location (types I-III). Local recurrences involving multiple sites and/or subdivisions are associated with worse survival (type IV).

The Correlation of Clinicopathological Features With the Status of Surgical Margins in Renal Cell Cancer Patients Following Nephron-Sparing Surgery: A Systematic Review and Meta-Analysis

Objectives: The aim of this study was to evaluate the correlation of various clinicopathological variables with positive surgical margins (PSMs) in renal cell cancer (RCC) patients after nephron-sparing surgery (NSS). Methods: A systematic search of PubMed, EMBASE, Web of Science, and China National Knowledge Infrastructure (CNKI) was performed to identify studies that compared PSMs with negative surgical margins (NSMs) and were published up to December 2018. Outcomes of interest included perioperative and postoperative variables, and the data were pooled by odds ratios (ORs)/standard mean differences (SMD) with 95% confidence intervals (CIs) to evaluate the strength of such associations. STATA 12.0 software was used for all statistical analyses. Results: Based on the inclusion and exclusion criteria, 13 studies including 47,499 patients with RCC were analyzed. The results showed that higher Furhman grade (pooled OR = 1.25; 95% CI: 1.14-1.37; P < 0.001), higher pathological stage (pooled OR = 2.67; 95% CI: 2.05-3.50; P < 0.001), non-clear cell RCC (non-ccRCC) histology (pooled OR = 0.78; 95% CI: 0.72-0.84; P < 0.001), and non-white race (pooled OR = 0.90; 95% CI: 0.82-0.99; P = 0.026) were significantly associated with high risk of PSMs. However, age (pooled SMD = 0.09; 95% CI: -0.01-0.20; P = 0.078), gender (female vs. male) (pooled OR = 1.04; 95% CI: 0.96-1.12; P = 0.377), tumor laterality (left vs. right) (pooled OR = 1.09; 95% CI: 0.84-1.42; P = 0.501), tumor focality (unifocal vs. multifocal) (pooled OR = 0.67; 95% CI: 0.23-1.90; P = 0.445), tumor size (pooled SMD = 0.03; 95% CI: -0.10-0.15; P = 0.685), and surgical approach (open vs. non-open) (pooled OR = 0.94; 95% CI: 0.62-1.42; P = 0.763) had no relationship with PSMs. Sensitivity analysis showed that all models were stable, and no publication bias was observed in our study. Conclusions: The present findings demonstrate that the presence of PSMs was associated with higher Furhman grade and higher pathological stage. Additionally, non-white patients with non-ccRCC histology had a high risk of PSMs after NSS. Further multicenter and long-term follow-up studies are required to verify these findings.

Outcomes of Nephron Sparing in a Specialist Cancer Hospital of a Developing Country

Introduction

Nephron-sparing surgery in the form of partial nephrectomy (PN) is currently considered the standard treatment for relatively small localized renal cell tumors.

Objectives

This study aimed to determine outcomes of PN regarding complications, recurrence, and survival rates at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan.

Methods

We assessed the data of patients older than 18 years undergoing PN from January 2010 to June 2017 who met our inclusion criteria. Data were analyzed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY).

Results

A total of 35 patients were studied, with a male to female ratio of 2.5:1 with median age of 50 years. The median hospital stay was four days (range: 3-7), and the median RENAL (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, anterior/posterior location relative to polar lines) Score was five (range: 4-10). The most common pathological tumor stage was T1 (94%), and the median size was 3.5 cm. On histopathology, clear-cell carcinoma was the most common tumor (incidence, 71%). The median Fuhrman’s grade was two. On final histopathology, four patients had positive margins. Among them, two patients showed a progressive deterioration in renal functions and were found to have residual disease six months later. Only one patient developed metastasis in the lung. Wound infection was observed in one patient while another had wound dehiscence. Urine leakage was noted in two patients. The median follow-up duration was 18 months (range: 3-84). Mean cancer-free survival was 78.6 months, and overall survival was 79.2 months. The projected three-year and five-year disease-free and overall survival was 96% and 94%, respectively.

Conclusion

PN is a viable option with excellent outcomes regarding the complication profile, recurrence-free, and overall survival in patients with relatively small localized renal tumors.

Predictors of positive surgical margins in patients undergoing partial nephrectomy: A large single-center experience

OBJECTIVE

To identify preoperative factors that predict positive surgical margins in partial nephrectomy.

MATERIAL AND METHODS

Using our institutional partial nephrectomy database, we investigated the patients who underwent partial nephrectomy for malignant tumors between January 2011 and December 2015. Patient, tumor, surgeon characteristics were compared by surgical margin status. Multivariable logistic regression was used to identify independent predictors of positive surgical margins.

RESULTS

A total of 1025 cases were available for analysis, of which 65 and 960 had positive and negative surgical margins, respectively. On univariate analysis, positive margins were associated with older age (64.3 vs. 59.6, p<0.01), history of prior ipsilateral kidney surgery (13.8% vs. 5.6%, p<0.01), lower preoperative eGFR (74.7 mL/min/1.73 m² vs. 81.2 mL/min/1.73 m², p=0.01), high tumor complexity (31.8% vs. 19.0%, p=0.03), hilar tumor location (23.1% vs. 12.5%, p=0.01), and lower surgeon volume (p<0.01). Robotic versus open approach was not associated with the risk of positive margins (p=0.79). On multivariable analysis, lower preoperative eGFR, p=0.01), hilar tumor location (p=0.01), and lower surgeon volume (p<0.01) were found to be independent predictors of positive margins.

CONCLUSION

In our large institutional series of partial nephrectomy cases, patient, tumor, and surgeon factors influence the risk of positive margins. Of these, surgeon volume is the single most important predictor of surgical margin status, indicating that optimal oncological outcomes are best achieved by high-volume surgeons.

Classification of positive surgical margins and tumor recurrence after nephron-sparing surgery for small renal masses

BACKGROUND

The association of positive margin and local recurrence after nephron-sparing surgery (NSS) remains a notably controversial issue. The aim of the present study was to investigate the relationship between classification of positive surgical margins (PSMs) and tumor recurrence based pathological findings.

METHODS

Clinical, pathological, and follow-up data of 600 small renal cancer patients who underwent NSS between November 2007 and November 2017 at four hospitals in China were analyzed retrospectively.

RESULTS

Of the 600 reviewed patients, 20 had positive margins. During the follow-up period of 56 months, only three cases of tumor recurrence were identified. Pathological examination was performed, and subsequently a new classification criteria were proposed: 1) False PSMs, which could be further divided into three subtypes: i) no standard processing performed on pathological specimens (seven patients); ii) incidental incision into the tumor during operation, with the tumor bed free of tumor residues (four patients); iii) part of the tumor pseudocapsule was noted to be remained in the tumor bed, with no signs of tumor residue (four patients). 2) True PSMs with two subtypes: i) a large number of residual tumor cells at the surgical margin (three patients); ii) incision of satellite tumor nodules detected around a large tumor (two patients).

CONCLUSION

Taken together, PSMs in NSS were rarely found. Based on the pathological examination findings, PSMs can be divided into false positive and true positive. This being said, PSMs were determined to be poor predictors for local recurrence, with no predominant association with true tumor remnants in the majority of our evaluated cases. Through the key findings of our study, we concluded that PSMs should be carefully analyzed and treated on a case-by-case basis.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU – Actualisation 2018–2020 : prise en charge du cancer du reinFrench ccAFU guidelines – Update 2018–2020: Management of kidney cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: DOI:10.1016/j.purol.2019.01.004. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the DOI:10.1016/j.purol.2019.01.004. That newer version of the text should be used when citing the article.

[Partial nephrectomy for renal masses >7cm: Morbidity, oncological and functional outcomes (UroCCR-7 study)]

OBJECTIVES

To describe the morbidity, mortality, oncological and functional results of Partial nephrectomy (PN) for the treatment of renal tumors of more than 7cm.

MATERIAL AND METHODS

Thirty-seven partial nephrectomies for tumors larger than 7cm operated in a single center between 1987 and 2016 were analyzed retrospectively. The pre, per and postoperative clinico-biological data were collected within the UroCCR database. The GFR was assessed at day 5, 1 month and last follow-up. Intraoperative and postoperative surgical complications, the recurrence rate and the overall and specific mortality were collected.

RESULTS

The mean age of the patients was 57 years (44-68). The preoperative GFR and the median tumor size were 80mL/min and 8cm, respectively. The indication for surgery was elective in 21 cases (60%) and 19 tumors (54%) were malignant. Postoperative complications occurred in 24,3 cases (24.3%). The median post-operative GFR was respectively 77mL/min, 80mL/min and 77mL/min at day 5, 1month and at last follow-up. With a median follow up of 31 months [1-168], 5 patients (26,3%) had metastatic progression of whom 1 (5.3%) had a concomitant local recurrence and 3 (15.8%) had died from cancer.

CONCLUSION

This study confirms the feasibility of PN for large tumors with acceptable morbidity, limited risk of local recurrence and excellent functional results.

LEVEL OF EVIDENCE

4.

Long-term oncological outcomes after robotic partial nephrectomy for renal cell carcinoma: a prospective multicentre study

PURPOSE

This study aimed at reporting the long-term oncological outcomes of robotic partial nephrectomy (RPN) for renal cell carcinoma (RCC).

METHODS

Data from all consecutive patients who underwent RAPN for RCC from July 2009 to January 2012 in three departments of urology were prospectively collected. Overall survival (OS), cancer-specific survival (CSS) and disease free-survival (DFS) were estimated using the Kaplan-Meier method. Prognostic factors associated with CSS were sought in univariate analysis. The log-rank test was used for categorical variables and the Cox model for continuous variables.

RESULTS

110 patients were included with a median follow-up of 64.4 months [95% CI = (61.0-66.7)]. Median age was 61 years (29-83) with 62.7% of men and 37.3% of women. Median RENAL score was 6 (4-10) with elective indications accounting for 95% of cases. Out of 27 patients (24.5%) who experienced peri-operative complication, 12 patients (10.9%) had a major complication (Clavien-Dindo grade ≥ 3). The TRIFECTA achievement rate was 52.7%. Three patients (2.7%) experienced local recurrence and seven patients (6.4%) progressed to a metastatic disease. 5-year OS, CSS, DFS were 94.9, 96.8, 86.4%, respectively. In univariate analysis, no pre/peri-operative characteristic was associated with DFS. No port-site metastasis was observed and there was one case of peritoneal carcinomatosis.

CONCLUSION

In this multicenter series, long-term OS, DFS and CSS after RPN appeared comparable to large series of open partial nephrectomy, with no port-site metastasis and one case of peritoneal carcinomatosis.

Positive surgical margin following radical nephrectomy is an independent predictor of local recurrence and disease-specific survival

Background

Positive surgical margins (PSM) are recognized as an adverse prognostic sign and are often associated with higher rates of local and systemic disease recurrence. The data regarding the oncological outcome for PSM following radical nephrectomy (RN) is limited. We examined the predictive factors for PSM and its influence on survival and site of recurrence in patients treated with RN for renal cell carcinoma (RCC).

Methods

Clinical, pathologic and follow-up data on 714 patients undergoing RN for kidney cancer were analyzed. Secondary analysis included 44 patients with metastatic RCC upon diagnosis who underwent cytoreductive nephrectomy (CRN). Univariate and multivariable logistic regression models were fit to determine clinicopathologic features associated with PSM. A Cox proportional-hazards regression model was used to test the independent effects of clinical and pathologic variables on survival.

Results

PSM was documented in 17 cases (2.4%). PSM were associated with tumour size, advanced pathologic stage (pT3 vs. ≤ pT2) and presence of necrosis. On multivariate analysis, cancer-specific survival (CSS) was associated with tumour stage, size, presence of necrosis and PSM. PSM was also associated with local recurrence but not distant metastasis or overall survival (OS). CSS and OS were comparable between the PSM and metastatic RCC groups, but significantly lower than the negative margin group.

Conclusions

The prevalence of PSM following RN is rare. Pathological data, including advanced stage (> pT2), tumour necrosis and tumour size, are associated with the presence of PSM. PSM is associated with tumour recurrence and CSS. Patients with PSM are a potential group for adjuvant therapy or for more careful and thorough follow-up following surgery.

Robot-Assisted Partial Nephrectomy for T1b Tumors: Strict Trifecta Outcomes

Background and Objectives:

“Trifecta” in partial nephrectomy consists of negative surgical margins, minimal renal function decrease and absence of complications. In the present article, our single-center robot-assisted partial nephrectomy (RAPN) experience in T1b renal masses is reported in terms of strict Trifecta outcomes.

Methods:

This is a retrospective analysis of patients with a tumor diameter between 4 and 7 cm (stage T1b), who underwent RAPN by a single surgeon. Preoperative, intraoperative, and postoperative data were recorded and analyzed to evaluate short-term functional and oncologic outcomes. Patients with absence of grade ≥ 2 Clavien-Dindo complications, warm ischemia time (WIT) ≤25 minutes, ≤15% postoperative estimated glomerular filtration rate (eGFR) decrease and negative surgical margins were reported to achieve strict Trifecta outcomes. P < .05 was indicated statistically significant.

Results:

A total of 150 patients underwent RAPN, and 50 patients were identified with tumor size between 4 and 7 cm. Mean WIT was 20.8 ± 6.2 minutes and mean estimated blood loss (EBL) was 269 ± 191 mL. Surgical margins were negative in all patients. Eleven patients (22%) had a >15% eGFR decrease after surgery. Nine patients (18%) had WIT longer than 25 minutes. Four patients (8%) had grade ≥2 Clavien-Dindo complications. Twenty-nine (58%) patients had strict Trifecta outcomes. Mean follow-up was 44.2 ± 27.2 months. Tumor recurrence was not observed in any patient.

Conclusions:

Robot-assisted laparoscopic partial nephrectomy for T1b renal masses can be safely performed in experienced hands. Optimal strict Trifecta outcomes and recurrence rates can be achieved.

The Diagnosis, Treatment, and Follow-up of Renal Cell Carcinoma

BACKGROUND

In 2014, 15 500 persons in Germany were given the diagnosis of renal cell carcinoma. This disease is the third most common cancer of the urogenital system. The mean age at diagnosis is 68 years in men and 71 in men.

METHODS

Pertinent publications up to 2014 were retrieved by a systematic literature search and reviewed in a moderated, formalized consensus process. Key questions were generated and answered by the adaptation of existing international guidelines, on the basis of an independent literature review, and by expert consensus. Representatives of 30 medical specialty societies, patient self-help groups, and other organizations participated in the process.

RESULTS

The search for guidelines yielded 80 hits, 23 of which were judged by DELBI to be potentially relevant; 7 were chosen for adaptation. Smoking, obesity, and hypertension increase the risk of renal cell carcinoma. Its 5-year survival rate is 75% for men and 77% for women. Renal cell carcinoma accounts for 2.6% of all deaths from cancer in men and 2.1% in women. Nephrectomy and partial nephrectomy are the standard treatments. Locally confined tumors in clinical stage T1 should be treated with kidney-preserving surgery. Minimally invasive surgery is often possible as long as the surgeon has the requisite experience. For patients with metastases, overall and progression-free survival can be prolonged with VEGF and mTOR inhibitors. The resection or irradiation of metastases can be a useful palliative treatment for patients with brain metastases or osseous metastases that are painful or increase the risk of fracture.

CONCLUSION

Minimally invasive surgery and new systemic drugs have expanded the therapeutic options for patients with renal cell carcinoma. The search for new predictive and prognostic markers is now in progress.

Standardized Reporting of Microscopic Renal Tumor Margins: Introduction of the Renal Tumor Capsule Invasion Scoring System

PURPOSE

Renal tumor enucleation allows for maximal parenchymal preservation. Identifying pseudocapsule integrity is critically important in nephron sparing surgery by enucleation. Tumor invasion into and through the capsule may have clinical implications, although it is not routinely commented on in standard pathological reporting. We describe a system to standardize the varying degrees of pseudocapsule invasion and identify predictors of invasion.

MATERIALS AND METHODS

We performed a multicenter retrospective review between 2002 and 2014 at Indiana University Hospital and Loyola University Medical Center. A total of 327 tumors were evaluated following removal via radical nephrectomy, standard margin partial nephrectomy or enucleation partial nephrectomy. Pathologists scored tumors using our i-Cap (invasion of pseudocapsule) scoring system. Multivariate analysis was done to determine predictors of higher score tumors.

RESULTS

Tumor characteristics were similar among surgical resection groups. Enucleated tumors tended to have thinner pseudocapsule rims but not higher i-Cap scores. Rates of complete capsular invasion, scored as i-Cap 3, were similar among the surgical techniques, comprising 22% of the overall cohort. Papillary histology along with increasing tumor grade was predictive of an i-Cap 3 score.

CONCLUSIONS

A capsule invasion scoring system is useful to classify renal cell carcinoma pseudocapsule integrity. i-Cap scores appear to be independent of surgical technique. Complete capsular invasion is most common in papillary and high grade tumors. Further work is warranted regarding the relevance of capsular invasion depth as it relates to the oncologic outcome for local recurrence and disease specific survival.

Surgical margin does not influence recurrence rate in pT1 clear cell renal cell carcinoma after partial nephrectomy: A multicenter study

PURPOSE

To assess the risk factors of positive surgical margins (PSM) and the influence of margin status on recurrence in pT1 clear cell renal cell carcinoma (RCC) following partial nephrectomy (PN).

MATERIALS AND METHODS

Patients (1,831) with pathologically confirmed stage T1 clear cell RCC were retrospectively analyzed following PN at eight institutions in Korea between 1999 and 2011. Demographics, operative data, pathological margin status, and site of recurrence were analyzed.

RESULTS

Resection margins were positive in 31 patients (1.7% of the cohort) on final pathology. None of the clinicopathological parameters were significantly related to the marginal status (all P > 0.05). During a median follow-up of 32.5 months, local recurrences were observed in 0.4% of negative surgical margins. There was no local recurrence in any of the cases with PSM. Distant recurrences developed in 1.7% of negative surgical margins and 3.2% of PSM. There were no significant differences in recurrence-free survival by margin status (P = 0.566).

CONCLUSIONS

Our multi-institutional data suggest that marginal status does not influence tumor recurrence risk in pT1 clear cell RCC after PN. Careful surveillance seems to be a sufficient strategy in this clinical scenario. J. Surg. Oncol. 2016;114:70-74. © 2016 Wiley Periodicals, Inc.

Self-assessment of surgical technique leads to reduction of positive surgical margins in partial nephrectomy

The background of the study was to examine potential causes for a positive surgical margin (PSM) and develop strategies to improve surgical outcomes. A retrospective review of consecutive partial nephrectomy cases for renal cell carcinoma was performed. We divided the patients into 2 groups. The first group consisted of the first 67 renal tumors in 65 patients that underwent our early surgical technique. The second group consisted of the next 45 renal tumors in 39 patients that underwent the revised surgical technique which included wider resections and robotically controlled ultrasound. Our primary outcome was margin status and secondary outcome was disease recurrence. Univariate and multivariate analyses were performed to determine factors that resulted in a PSM. Positive margins were detected in 19 out of 67 (28 %) renal tumors in the early technique group compared to 1 out of 45 (2 %) positive margins in the revised technique group (p < 0.001). On multivariate analysis, only technique modification (OR 0.04, p = 0.003) and larger tumor size (OR 0.41, p = 0.01) were significant predictors of a lower rate of PSM. Smaller tumors were more common in robotic assisted partial nephrectomies which had a higher rate of PSM on univariate analysis (OR 3.51, p = 0.04). Only one patient with a PSM experienced a systemic disease recurrence. In our experience, self-assessment and technique modification resulted in a dramatic PSM improvement. Smaller tumors were associated with PSM. It is important for all surgeons to periodically look at their own surgical outcomes and modify their surgical technique accordingly.

Predictors of trifecta outcomes in laparoscopic partial nephrectomy for clinical T1a renal masses

OBJECTIVES

To assess trifecta outcomes for laparoscopic partial nephrectomy for clinical T1a renal masses.

METHODS

A total of 63 patients who underwent laparoscopic partial nephrectomy for clinical T1a renal masses by a single surgeon between January 2007 and December 2012 were evaluated. Demographic and perioperative data were collected and statistically analyzed. We retrospectively evaluated trifecta outcomes. Multivariable logistic regression models were used to analyze predictors of trifecta outcomes. Trifecta outcomes were defined as the combination of total ischemia time <25 min, negative surgical margins and no surgical complications.

RESULTS

Of the 63 patients, 39 (62%) achieved trifecta. A total of 21 patients had total ischemia time ≥25 min, four patients had positive surgical margins and two patients had surgical complications. Tumor size (P < 0.001), distance from the urine collecting system or sinus (P < 0.001) and surgeon's learning curve (P < 0.01) were significantly different between the trifecta and no-trifecta group. Multivariate analysis showed tumor size and surgeon's learning curve to be independent predictors of trifecta outcomes.

CONCLUSIONS

Tumor size and surgeon's learning curve seems to be strong predictors of trifecta outcomes after laparoscopic partial nephrectomy in T1a renal masses.

Positive surgical margins in nephron-sparing surgery: risk factors and therapeutic consequences

The increased use of nephron-sparing surgery to treat localized renal cell carcinoma (RCC) lends weight to the question of the value of microscopically positive surgical margins (PSM) in cases with a tumor bed macroscopically free of residual tumor. The aim of this article is to highlight the data available on risk factors for PSM, their clinical relevance, and possible therapeutic consequences. For this purpose, publications on the incidence and relevance of PSM after partial nephrectomy from the last 15 years were examined and evaluated. We summarize that PSM are generally rare, regardless of the surgical procedure, and are seen more often in connection with an imperative indication for nephron-sparing surgery as well as a central tumor location. Most studies describe that PSM lead to a moderate increase in the rate of local relapses, but no study has thus far been able to demonstrate an association with shorter tumor-specific overall survival. Intraoperative frozen section analysis had no positive influence on the risk of definite PSM in most trials. Therefore, we conclude that PSM should definitely be avoided. However, in cases with a macroscopically tumor-free intraoperative resection bed, they should lead to close surveillance of the affected kidney and not to immediate (re)intervention.

[Positive surgical margins in nephron sparing surgery for renal cell carcinoma]

Nephron sparing surgery (NSS) with a minimal tumor-free margin is considered the cornerstone in the contemporary management of renal cell carcinoma (RCC) stage T1. The aim of this study is to review incidence, predictive risk factors, clinical significance and oncologic outcomes of positive surgical margins (PSM) in NSS. English articles published before March 2014 have been searched in Medline Databank.PSM are present in 0-7% of patients in all surgical approaches considered. Some predictive factors,such as tumor size, localization, and histology have been identified in the past. Other topics concerning surgical technique and approach are discussed.The majority of patients with PSM do not experience disease recurrence and PSM impact on overall survival and cancer-specific survival seems to be irrelevant. These results lead to more conservative clinical strategies. However, an active surveillance is mandatory for all patients with PSM and especially for those with high risk disease. Generalization of these results is limited by the low level of evidence of available studies. Further efforts are necessary to avoid PSM intraoperatively and to provide prospective information in order to standardize the postoperative management.

Inferior vena cava tumor thrombus after partial nephrectomy for renal cell carcinoma

Background

Partial nephrectomy is now the gold standard treatment for small renal tumors. Local recurrence is a major problem after partial nephrectomy, and local recurrence in the remnant kidney after partial nephrectomy is common.

Case presentation

A 77-year-old man underwent right partial nephrectomy for a T1 right renal cell carcinoma. Microscopic examination revealed a clear cell renal carcinoma, grade 2, stage pT3a. Although the surgical margin was negative, the carcinoma invaded the perirenal fat, and vascular involvement was strongly positive. Thirty months after partial nephrectomy, an enhanced computed tomographic scan showed local recurrence of the renal cell carcinoma extending into the inferior vena cava without renal mass. Hence, we performed right radical nephrectomy and intracaval thrombectomy. Microscopic examination revealed a clear cell carcinoma grade 2, stage pT3a + b. The patient is still alive with no evidence of recurrence 10 months post-procedure.

Conclusion

To our knowledge, local recurrence of renal cell carcinoma extending into the inferior vena cava after partial nephrectomy has not been reported in the literature. Our case report emphasizes the importance of strict surveillance of patients after partial nephrectomy, especially for those with renal cell carcinoma positive for microvessel involvement.

Current management considerations for the incidentally detected small renal mass

BACKGROUND

Nephron-sparing treatments remain underutilized for the management of small renal masses despite a rise in incidentally detected renal cell carcinoma and a downward stage migration.

METHODS

Historical publications representative of currently accepted paradigms were reviewed, and the results of a contemporary scientific literature search conducted in PubMed focusing on studies involving humans, published in English, and inclusive of clinical trials, meta-analyses, randomized controlled trials, and practice guidelines are included. Results from contemporary retrospective trials augment the data when level I or II evidence is absent.

RESULTS

Phase III clinical trial results substantiate the long-held tenet that partial nephrectomy is equivalent to radical nephrectomy with respect to safety and oncologic efficacy. Further, minimally invasive techniques using laparoscopy and robotic assistance to achieve partial nephrectomy appear equally effective to traditional open techniques. Although no prospective randomized studies are available, large retrospective studies support the notion that active surveillance and thermal ablative techniques are viable options for carefully selected patients.

CONCLUSIONS

The management of small renal masses encompasses a host of therapeutic options, all of which must be considered and discussed with the individual patient.

Positive surgical margins after nephron-sparing surgery for renal cell carcinoma: incidence, clinical impact, and management

Nephron-sparing surgery (NSS) for renal cell carcinoma (RCC) offers comparable oncologic results but a lower risk of chronic kidney disease when compared with radical nephrectomy; however it can result in positive surgical margins (PSMs) and consequently to a possible risk of oncologic failure. The aim of this review is to evaluate the incidence of PSMs after nephron-sparing surgery, to assess their clinical and oncologic impact, and to provide an overview of the possible therapeutic management. We performed a nonsystematic review of the literature in the MEDLINE database using the following keywords: partial nephrectomy, nephron-sparing surgery, and positive margin. We reviewed articles published only in English from January 2002 to May 2012. The overall incidence of PSMs after NSS ranges from 0% to 7%, with no significant differences in open, laparoscopic, and robot-assisted techniques. Smaller tumor size could result in a higher risk of PSMs. Even if there is not a clear agreement in the clinical evidence, local recurrence seems to be more likely in patients with PSMs, especially in those with high-grade tumors. Development of metastases and cancer-specific survival, as seen in midterm follow-up studies, seems to be comparable to those in patients with negative surgical margins. Considering the globally low risk of local recurrence, development of metastasis, or cancer-specific mortality, careful surveillance could be the best management option for most patients with PSMs after NSS.

Advancements in laparoscopic partial nephrectomy: expanding the feasibility of nephron-sparing

Partial nephrectomy (PN) offers equivalent oncologic outcomes to radical nephrectomy (RN) but has greater preservation of renal function and less risk of chronic kidney disease and cardiovascular disease. Laparoscopic PN remains underutilized likely because it is a technically challenging operation with higher rates of perioperative complications compared to open PN and laparoscopic RN. A review of the latest PN literature demonstrates that recent advancements in laparoscopic approaches, imaging modalities, ischemic mitigating strategies, renorrhaphy techniques, and hemostatic agents will likely allow greater utilization of LPN and expand its usage to increasingly more complex tumors.

Positive surgical margins after nephron-sparing surgery

CONTEXT

Little is known on the natural history of positive surgical margins (PSMs) in partial nephrectomy (PN). Accumulating data suggest that secondary nephrectomy might not be necessary in all patients with PSMs after PN.

OBJECTIVE

Provide an overview on incidence and risk factors for PSMs after partial nephrectomy and on the rate of local and distant disease recurrence related to PSMs. We also provide recommendations on how to avoid and how to treat PSMs after PN.

EVIDENCE ACQUISITION

A nonsystematic literature research was based on Medline, Scopus, and Web of Science queries on these keywords: nephron-sparing surgery, partial nephrectomy/ies, and margin. Only human studies (original research) published in English were included.

EVIDENCE SYNTHESIS

PSMs are present in 0-7% of patients after open PN, in 0.7-4% after laparoscopic PN, and in 3.9-5.7% after robot-assisted PN. The thickness of healthy parenchyma surrounding the tumour is irrelevant as long as complete tumour removal is achieved. The coincidence of a highly malignant tumour and PSM increases the risk of local recurrence. Intermediate follow-up data indicate that the vast majority of patients with PSMs will not experience local or distant tumour recurrence. Frozen-section analysis for evaluation of resection margins during PN is of minor clinical significance, as the surgeon's gross assessment of macroscopically negative margins provides reliable results.

CONCLUSIONS

PSMs in PN are rare. As indicated by intermediate follow-up data, the majority of patients with PSMs after PN remain without disease recurrence, and a surveillance strategy seems preferable to surgical reintervention.