Positive Surgical Margins Increase Risk of Recurrence after Partial Nephrectomy for High Risk Renal Tumors

No AccessJournal of UrologyAdult Urology1 Aug 2016Positive Surgical Margins Increase Risk of Recurrence after Partial Nephrectomy for High Risk Renal Tumors Paras H. Shah, Daniel M. Moreira, Zhamshid Okhunov, Vinay R. Patel, Sameer Chopra, Aria A. Razmaria, Manaf Alom, Arvin K. George, Oksana Yaskiv, Michael J. Schwartz, Mihir Desai, Manish A. Vira, Lee Richstone, Jaime Landman, Arieh L. Shalhav, Inderbir Gill, and Louis R. Kavoussi Paras H. ShahParas H. Shah Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York , Daniel M. MoreiraDaniel M. Moreira Department of Urology, Mayo Clinic, Rochester, Minnesota , Zhamshid OkhunovZhamshid Okhunov Department of Urology, University of California, Irvine, California , Vinay R. PatelVinay R. Patel Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York , Sameer ChopraSameer Chopra USC Institute of Urology, University of Southern California, Los Angeles, California , Aria A. RazmariaAria A. Razmaria Department of Urology, University of Chicago, Chicago, Illinois , Manaf AlomManaf Alom Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York , Arvin K. GeorgeArvin K. George Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland , Oksana YaskivOksana Yaskiv Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York , Michael J. SchwartzMichael J. Schwartz Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York , Mihir DesaiMihir Desai USC Institute of Urology, University of Southern California, Los Angeles, California , Manish A. ViraManish A. Vira Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York , Lee RichstoneLee Richstone Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York , Jaime LandmanJaime Landman Department of Urology, University of California, Irvine, California , Arieh L. ShalhavArieh L. Shalhav Department of Urology, University of Chicago, Chicago, Illinois , Inderbir GillInderbir Gill USC Institute of Urology, University of Southern California, Los Angeles, California , and Louis R. KavoussiLouis R. Kavoussi Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.075AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: The clinical significance of a positive surgical margin after partial nephrectomy remains controversial. The association between positive margin and risk of disease recurrence in patients with clinically localized renal neoplasms undergoing partial nephrectomy was evaluated. Materials and Methods: A retrospective multi-institutional review of 1,240 patients undergoing partial nephrectomy for clinically localized renal cell carcinoma between 2006 and 2013 was performed. Recurrence-free survival was estimated using the Kaplan-Meier method and evaluated as a function of positive surgical margin with the log rank test and Cox models adjusting for tumor size, grade, histology, pathological stage, focality and laterality. The relationship between positive margin and risk of relapse was evaluated independently for pathological high risk (pT2-3a or Fuhrman grades III-IV) and low risk (pT1 and Fuhrman grades I-II) groups. Results: A positive surgical margin was encountered in 97 (7.8%) patients. Recurrence developed in 69 (5.6%) patients during a median followup of 33 months, including 37 (10.3%) with high risk disease (eg pT2-pT3a or Fuhrman grade III-IV). A positive margin was associated with an increased risk of relapse on multivariable analysis (HR 2.08, 95% CI 1.09–3.97, p=0.03) but not with site of recurrence. In a stratified analysis based on pathological features, a positive surgical margin was significantly associated with a higher risk of recurrence in cases considered high risk (HR 7.48, 95% CI 2.75–20.34, p <0.001) but not low risk (HR 0.62, 95% CI 0.08–4.75, p=0.647). Conclusions: Positive surgical margins after partial nephrectomy increase the risk of disease recurrence, primarily in patients with adverse pathological features. References 1 : Guideline for management of the clinical T1 renal mass. J Urol2009; 182: 1271. Link, Google Scholar 2 : Positive surgical margins after nephron-sparing surgery for renal cell carcinoma: incidence, clinical impact, and management. Clin Genitourin Cancer2013; 11: 5. Google Scholar 3 : Prediction of progression following radical prostatectomy. A multivariate analysis of 721 men with long-term follow-up. Am J Surg Pathol1996; 20: 286. Crossref, Medline, Google Scholar 4 : Factors influencing post-recurrence survival in bladder cancer following radical cystectomy. BJU Int2012; 109: 846. Google Scholar 5 : Association of positive transection margins with gastric cancer survival and local recurrence. Ann Surg Oncol2013; 20: 2663. Google Scholar 6 : The association of surgical margins and local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy: a meta-analysis. Ann Surg Oncol2014; 21: 717. Google Scholar 7 : Impact of positive surgical margins in patients undergoing partial nephrectomy for renal cortical tumours. BJU Int2007; 99: 286. Google Scholar 8 : Positive surgical margin appears to have negligible impact on survival of renal cell carcinomas treated by nephron-sparing surgery. Eur Urol2010; 57: 466. Google Scholar 9 : Positive surgical margins in robot-assisted partial nephrectomy: a multi-institutional analysis of oncologic outcomes (leave no tumor behind). J Urol2013; 190: 1674. Link, Google Scholar 10 : Positive surgical parenchymal margin after laparoscopic partial nephrectomy for renal cell carcinoma: oncological outcomes. J Urol2006; 176: 2401. Link, Google Scholar 11 : Positive surgical margins at partial nephrectomy: predictors and oncological outcomes. J Urol2008; 179: 2158. Link, Google Scholar 12 : Clinical practice. Small renal mass. N Engl J Med2010; 362: 624. Google Scholar 13 : Outcomes of active surveillance for the management of clinically localized prostate cancer in the prospective, multi-institutional Canary PASS cohort. J Urol2016; 195: 313. Link, Google Scholar 14 : Intermediate and longer-term outcomes from a prospective active-surveillance program for favorable-risk prostate cancer. J Clin Oncol2015; 33: 3379. Google Scholar 15 : Five-year analysis of a multi-institutional prospective clinical trial of delayed intervention and surveillance for small renal masses: the DISSRM Registry. Eur Urol2015; 68: 408. Google Scholar 16 : Prognostic models and algorithms in renal cell carcinoma. Urol Clin North Am2008; 35: 613. Google Scholar 17 : A review of prognostic pathologic features and algorithms for patients treated surgically for renal cell carcinoma. Clin Lab Med2005; 25: 433. Google Scholar 18 : Nephron sparing surgery for renal tumors: indications, techniques and outcomes. J Urol2001; 166: 6. Link, Google Scholar 19 : Laparoscopic partial nephrectomy for renal tumor: duplicating open surgical techniques. J Urol2002; 167: 469. Link, Google Scholar 20 : Robotic-assisted partial nephrectomy. BJU Int2009; 103: 1296. Google Scholar 21 : Prognostic factors in metastatic renal carcinoma. J Urol1986; 136: 376. Link, Google Scholar 22 : Renal cell carcinoma recurrence after nephrectomy for localized disease: predicting survival from time of recurrence. J Clin Oncol2006; 24: 3101. Google Scholar 23 : Surgical management of local retroperitoneal recurrence of renal cell carcinoma after radical nephrectomy. J Urol2015; 194: 316. Link, Google Scholar 24 : Local treatments for metastases of renal cell carcinoma: a systematic review. Lancet Oncol2014; 15: e549. Google Scholar 25 : Overall survival and updated results for sunitinib compared with interferon alfa in patients with metastatic renal cell carcinoma. J Clin Oncol2009; 27: 3584. Google Scholar 26 : Survival after complete surgical resection of multiple metastases from renal cell carcinoma. Cancer2011; 117: 2873. Google Scholar 27 : Axitinib versus sorafenib in advanced renal cell carcinoma: subanalyses by prior therapy from a randomised phase III trial. Br J Cancer2014; 110: 2821. Google Scholar 28 : Prevalence and impact on survival of positive surgical margins in partial nephrectomy for renal cell carcinoma: a population-based study. BJU Int2013; 111: E300. Google Scholar 29 : A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol2011; 59: 543. Google Scholar 30 : Anatomic features of enhancing renal masses predict malignant and high-grade pathology: a preoperative nomogram using the RENAL Nephrometry score. Eur Urol2011; 60: 241. Google Scholar © 2016 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byCadeddu J (2019) Re: Surgical Approach Does Not Impact Margin Status after Partial Nephrectomy for Large Renal MassesJournal of Urology, VOL. 202, NO. 2, (192-193), Online publication date: 1-Aug-2019.Laguna M (2018) Re: Oncologic Outcomes of Patients with Positive Surgical Margin after Partial Nephrectomy: A 25-Year Single Institution ExperienceJournal of Urology, VOL. 201, NO. 1, (27-28), Online publication date: 1-Jan-2019.Campbell S, Uzzo R, Allaf M, Bass E, Cadeddu J, Chang A, Clark P, Davis B, Derweesh I, Giambarresi L, Gervais D, Hu S, Lane B, Leibovich B and Pierorazio P (2017) Renal Mass and Localized Renal Cancer: AUA GuidelineJournal of Urology, VOL. 198, NO. 3, (520-529), Online publication date: 1-Sep-2017.Mouracade P, Kara O, Maurice M, Dagenais J, Malkoc E, Nelson R and Kaouk J (2016) Patterns and Predictors of Recurrence after Partial Nephrectomy for Kidney TumorsJournal of Urology, VOL. 197, NO. 6, (1403-1409), Online publication date: 1-Jun-2017.Cotter K and Dahm P (2016) Re: The Prognostic Impact of a Positive Vascular Margin on pT3 Clear Cell Renal Cell CarcinomaJournal of Urology, VOL. 196, NO. 4, (1317-1318), Online publication date: 1-Oct-2016.Kim S and Abouassaly R (2016) Treatment of Patients with Positive Margins after Partial NephrectomyJournal of Urology, VOL. 196, NO. 2, (301-302), Online publication date: 1-Aug-2016.Smith J (2016) This Month in Adult UrologyJournal of Urology, VOL. 196, NO. 2, (295-296), Online publication date: 1-Aug-2016. Volume 196Issue 2August 2016Page: 327-334 Advertisement Copyright & Permissions© 2016 by American Urological Association Education and Research, Inc.Keywordslaparoscopycarcinoma, renal cellnephrectomykidney neoplasmsMetricsAuthor Information Paras H. Shah Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York More articles by this author Daniel M. Moreira Department of Urology, Mayo Clinic, Rochester, Minnesota More articles by this author Zhamshid Okhunov Department of Urology, University of California, Irvine, California More articles by this author Vinay R. Patel Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York More articles by this author Sameer Chopra USC Institute of Urology, University of Southern California, Los Angeles, California More articles by this author Aria A. Razmaria Department of Urology, University of Chicago, Chicago, Illinois More articles by this author Manaf Alom Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York More articles by this author Arvin K. George Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland More articles by this author Oksana Yaskiv Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York More articles by this author Michael J. Schwartz Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York More articles by this author Mihir Desai USC Institute of Urology, University of Southern California, Los Angeles, California More articles by this author Manish A. Vira Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York More articles by this author Lee Richstone Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York More articles by this author Jaime Landman Department of Urology, University of California, Irvine, California More articles by this author Arieh L. Shalhav Department of Urology, University of Chicago, Chicago, Illinois More articles by this author Inderbir Gill USC Institute of Urology, University of Southern California, Los Angeles, California More articles by this author Louis R. Kavoussi Department of Urology, Smith Institute for Urology, North Shore LIJ, New Hyde Park, New York More articles by this author Expand All Advertisement PDF downloadLoading ...