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

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 significance of subclassifying stage pT3a renal tumors with fat invasion: a retrospective study of 99 patients

PURPOSE

To analyze the recurrence in patients with clinic stage T1 renal cell carcinoma (RCC) who were upstaged to stage T3a after partial nephrectomy (PN) using a new sub-classification criterion.

METHODS

A retrospective study of pathological characteristics was performed in patients who were upstaged to pT3a on the basis of fat invasion (FI).

RESULTS

After analyzing the pathological findings, we proposed the following new sub-classification criteria for pT3a RCC with FI: (1) renal tumor invades the pseudo-capsule and contacts the perinephric adipose tissue directly or the tumor protrudes into the perinephric adipose tissue like a tongue (Type A); and (2) tumor nodules are distributed in perinephric adipose tissues (Type B). A significant difference was observed in the recurrence rate between the two subtypes A and B. For Type B, the recurrence rate after radical nephrectomy (RN) and PN was 15.79% and 63.64%, respectively. The recurrence rates for Types A and B after PN were 11.11% and 63.64%, respectively.

CONCLUSIONS

T3a RCC with tumor nodules in perinephric adipose and/or an irregular tumor protruding into the adipose tissues lead to a higher recurrence rate. We recommend that T3a RCC be carefully analyzed and patients be treated on an individual basis.

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.