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Renal cell carcinoma: histological findings on surgical margins after nephron sparing surgery1
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A.C. Novick / Urologic Oncology: Seminars and Original Investigations 22 (2004) 71– 84
Recent data suggest that retroperitoneal lymphadenopathy may be a significant independent negative prognostic variable in patients with metastatic RCC. A recent study from the National Cancer Institute evaluated 154 patients with metastatic RCC who underwent cytoreductive nephrectomy and interleukin-2-based systemic therapy [1]. Patients with no preoperative retroperitoneal lymphadenopathy had significantly longer survival than those with lymphadenopathy. A multi-variate analysis indicated that lymphadenopathy was more closely associated with survival than performance status. A similar observation has been noted in the current study by Pantuck et al. from UCLA. Multi-modality therapy is less likely to be helpful in patients with metastatic RCC and retroperitoneal lymphadenopathy, and this approach should be cautiously and selectively utilized in these patients. doi:10.1016/j.urolonc.2003.11.008 Andrew C. Novick, M.D.
Reference [1] Vasselli JR, Yang JC, Linehan WM, et al. Lack of retroperitoneal lymphadenopathy predicts survival of patients with metastatic renal cell carcinoma. J Urol 2001;166:68 –72.
Renal cell carcinoma: histological findings on surgical margins after nephron sparing surgery. Zucchi A, Mearini L, Mearini E, Costantini E, Vivacqua C, Porena M, Urology Department, University of Perugia, Italy. J Urol 2003;169:905–908 Purpose: We evaluated the incidence of peritumoral satellite lesions in nephron sparing surgery and examined whether these findings have a negative effect on cancer specific survival and on the percent of local recurrence. Materials and Methods: We performed nephron sparing surgery in 63 patients with kidney cancer, including 53 elective (group 1) and 10 imperative (group 2) operations. In all cases we removed 10 mm. of apparently healthy peritumoral parenchyma with the tumor. This tissue was subsequently examined by an anatomical pathologist to identify any satellite lesions. Results: Four satellite lesions were identified, including 3 in group 1 and 1 in group 2, at a mean of 5.3 mm. from the primary lesion. None of the patients in either group had local recurrence at follow-up. Cancer specific survival was 96.3% in group 1 (mean follow-up 61 months) and 58% in group 2 (mean follow-up 39 months). It was not influenced by the presence of satellite micro-lesions. Conclusions: Despite common perplexities concerning the risk of multifocality in renal cell carcinoma we believe that the nephron sparing procedure in select patients is as effective as radical surgery. Based on our experience the surgical safety margin must be at least 10 mm of macroscopically healthy, peritumoral tissue.
Commentary During nephron-sparing surgery (NSS) for renal cell carcinoma (RCC), it is standard practice to excise the tumor along with a surrounding margin of normal parenchyma to ensure complete resection of the neoplasm. However, there have been disparate views on how wide the margin of resection should be. The traditional recommendation has been to excise the tumor with a relatively wide margin of resection, ranging from 4.5 to 1.5 cm in various reports. Recent studies now suggest that the width of the resection margin during NSS is not prognostically significant. Sutherland et al. examined 44 partial nephrectomies with a mean follow-up of 49 months and found no correlation of the margin width with outcome [1]. Piper et al. reviewed 67 patients with a mean follow-up of 60 months and also found that surgical margin was not a predictor of disease recurrence [2]. More recently, we retrospectively reviewed 69 patients with localized RCC who had undergone NSS between 1976 and 1988 to determine whether the margin of resection was associated with disease progression [3]. The mean postoperative follow-up was 8.5 years. Our analysis demonstrated no association between width of the resection margin and disease progression. The basic principle of achieving a histologic tumor-free margin of resection during NSS remains integral to a successful outcome. However, recent studies suggest that 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, Fuhrman nuclear grade and tumor size remain the most significant predictors of disease progression. doi:10.1016/j.urolonc.2003.11.012 Andrew C. Novick, M.D.
References [1] Sutherland SE, Resnick MI, Maclennan GT, Goldman HB. Does the size of the surgical margin in partial nephrectomy for renal cell cancer really matter? J Urol 2002;167:61– 4. [2] Piper NY, Bishoff JT, Magee C, et al. Is a 1-cm margin necessary during neprhon-sparing surgery for renal cell carcinoma? Urology 2001;58:849 –52. [3] Castilla EA, Liou LS, Abrahams NA, et al. Prognostic importance of resection margin width after nephron-sparing surgery for renal cell carcinoma. Urology 2002;60:993–7.
A.C. Novick / Urologic Oncology: Seminars and Original Investigations 22 (2004) 71– 84
Recent data suggest that retroperitoneal lymphadenopathy may be a significant independent negative prognostic variable in patients with metastatic RCC. A recent study from the National Cancer Institute evaluated 154 patients with metastatic RCC who underwent cytoreductive nephrectomy and interleukin-2-based systemic therapy [1]. Patients with no preoperative retroperitoneal lymphadenopathy had significantly longer survival than those with lymphadenopathy. A multi-variate analysis indicated that lymphadenopathy was more closely associated with survival than performance status. A similar observation has been noted in the current study by Pantuck et al. from UCLA. Multi-modality therapy is less likely to be helpful in patients with metastatic RCC and retroperitoneal lymphadenopathy, and this approach should be cautiously and selectively utilized in these patients. doi:10.1016/j.urolonc.2003.11.008 Andrew C. Novick, M.D.
Reference [1] Vasselli JR, Yang JC, Linehan WM, et al. Lack of retroperitoneal lymphadenopathy predicts survival of patients with metastatic renal cell carcinoma. J Urol 2001;166:68 –72.
Renal cell carcinoma: histological findings on surgical margins after nephron sparing surgery. Zucchi A, Mearini L, Mearini E, Costantini E, Vivacqua C, Porena M, Urology Department, University of Perugia, Italy. J Urol 2003;169:905–908 Purpose: We evaluated the incidence of peritumoral satellite lesions in nephron sparing surgery and examined whether these findings have a negative effect on cancer specific survival and on the percent of local recurrence. Materials and Methods: We performed nephron sparing surgery in 63 patients with kidney cancer, including 53 elective (group 1) and 10 imperative (group 2) operations. In all cases we removed 10 mm. of apparently healthy peritumoral parenchyma with the tumor. This tissue was subsequently examined by an anatomical pathologist to identify any satellite lesions. Results: Four satellite lesions were identified, including 3 in group 1 and 1 in group 2, at a mean of 5.3 mm. from the primary lesion. None of the patients in either group had local recurrence at follow-up. Cancer specific survival was 96.3% in group 1 (mean follow-up 61 months) and 58% in group 2 (mean follow-up 39 months). It was not influenced by the presence of satellite micro-lesions. Conclusions: Despite common perplexities concerning the risk of multifocality in renal cell carcinoma we believe that the nephron sparing procedure in select patients is as effective as radical surgery. Based on our experience the surgical safety margin must be at least 10 mm of macroscopically healthy, peritumoral tissue.
Commentary During nephron-sparing surgery (NSS) for renal cell carcinoma (RCC), it is standard practice to excise the tumor along with a surrounding margin of normal parenchyma to ensure complete resection of the neoplasm. However, there have been disparate views on how wide the margin of resection should be. The traditional recommendation has been to excise the tumor with a relatively wide margin of resection, ranging from 4.5 to 1.5 cm in various reports. Recent studies now suggest that the width of the resection margin during NSS is not prognostically significant. Sutherland et al. examined 44 partial nephrectomies with a mean follow-up of 49 months and found no correlation of the margin width with outcome [1]. Piper et al. reviewed 67 patients with a mean follow-up of 60 months and also found that surgical margin was not a predictor of disease recurrence [2]. More recently, we retrospectively reviewed 69 patients with localized RCC who had undergone NSS between 1976 and 1988 to determine whether the margin of resection was associated with disease progression [3]. The mean postoperative follow-up was 8.5 years. Our analysis demonstrated no association between width of the resection margin and disease progression. The basic principle of achieving a histologic tumor-free margin of resection during NSS remains integral to a successful outcome. However, recent studies suggest that 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, Fuhrman nuclear grade and tumor size remain the most significant predictors of disease progression. doi:10.1016/j.urolonc.2003.11.012 Andrew C. Novick, M.D.
References [1] Sutherland SE, Resnick MI, Maclennan GT, Goldman HB. Does the size of the surgical margin in partial nephrectomy for renal cell cancer really matter? J Urol 2002;167:61– 4. [2] Piper NY, Bishoff JT, Magee C, et al. Is a 1-cm margin necessary during neprhon-sparing surgery for renal cell carcinoma? Urology 2001;58:849 –52. [3] Castilla EA, Liou LS, Abrahams NA, et al. Prognostic importance of resection margin width after nephron-sparing surgery for renal cell carcinoma. Urology 2002;60:993–7.