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Surgical Margins in Nephron-Sparing Surgery for Renal Cell Carcinoma

  • Kidney Diseases (G Ciancio, Section Editor)
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Abstract

The oncologic impact of positive surgical margins after nephron-sparing surgery is controversial. Herein, we discuss current data surrounding surgical margins in the operative management of renal cell carcinoma. The prevalence, risk factors, outcomes, and subsequent management of positive surgical margins will be reviewed. Literature suggests that the prevalence of positive surgical margins following kidney surgery varies by practice setting, tumor characteristics, and operation type. For patients undergoing nephron-sparing surgery, it is not necessary to remove a margin of healthy tissue. Tumor enucleation may be appropriate and is associated with comparable outcomes. Reflexive intraoperative frozen section use does not provide beneficial information and many patients with positive margins can be monitored closely with serial imaging. The impact of positive surgical margins on recurrence and survival remains conflicting. Though every effort must be performed to obtain negative margins, a positive surgical margin appears to have a marginal impact on recurrence and survival.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. King SC et al. Continued increase in incidence of renal cell carcinoma, especially in young patients and high grade disease: United States 2001 to 2010. J Urol. 2014;191(6):1665–70.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Buffi N et al. Margin, ischemia, and complications (MIC) score in partial nephrectomy: a new system for evaluating achievement of optimal outcomes in nephron-sparing surgery. Eur Urol. 2012;62(4):617–8.

    Article  PubMed  Google Scholar 

  3. Hung AJ et al. “Trifecta” in partial nephrectomy. J Urol. 2013;189(1):36–42.

    Article  PubMed  Google Scholar 

  4. Lista G et al. Margin, ischemia, and complications system to report perioperative outcomes of robotic partial nephrectomy: a European Multicenter Observational Study (EMOS project). Urology. 2015;85(3):589–95.

    Article  PubMed  Google Scholar 

  5. Sun M et al. Age-adjusted incidence, mortality, and survival rates of stage-specific renal cell carcinoma in North America: a trend analysis. Eur Urol. 2011;59(1):135–41.

    Article  PubMed  Google Scholar 

  6. Hwang YJ et al. Assessment of healthcare quality metrics: length-of-stay, 30-day readmission, and 30-day mortality for radical nephrectomy with inferior vena cava thrombectomy. Can Urol Assoc J. 2015;9(3–4):114–21.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Uzzo RG, Novick AC. Nephron sparing surgery for renal tumors: indications, techniques and outcomes. J Urol. 2001;166(1):6–18.

    Article  CAS  PubMed  Google Scholar 

  8. Piper NY et al. Is a 1-CM margin necessary during nephron-sparing surgery for renal cell carcinoma? Urology. 2001;58(6):849–52.

    Article  CAS  PubMed  Google Scholar 

  9. Li QL et al. Safety and efficacy of mini-margin nephron-sparing surgery for renal cell carcinoma 4-cm or less. Urology. 2008;71(5):924–7.

    Article  PubMed  Google Scholar 

  10. Castilla EA et al. Prognostic importance of resection margin width after nephron-sparing surgery for renal cell carcinoma. Urology. 2002;60(6):993–7.

    Article  PubMed  Google Scholar 

  11. Sutherland SE et al. Does the size of the surgical margin in partial nephrectomy for renal cell cancer really matter? J Urol. 2002;167(1):61–4.

    Article  PubMed  Google Scholar 

  12. Berdjis N et al. Impact of resection margin status after nephron-sparing surgery for renal cell carcinoma. BJU Int. 2006;97(6):1208–10.

    Article  PubMed  Google Scholar 

  13. Satkunasivam R et al. Robotic unclamped “minimal-margin” partial nephrectomy: ongoing refinement of the anatomic zero-ischemia concept. Eur Urol. 2015;68(4):705–12.

    Article  PubMed  Google Scholar 

  14. Kwon EO et al. Impact of positive surgical margins in patients undergoing partial nephrectomy for renal cortical tumours. BJU Int. 2007;99(2):286–9.

    Article  PubMed  Google Scholar 

  15. Antic T, Taxy JB. Partial nephrectomy for renal tumors: lack of correlation between margin status and local recurrence. Am J Clin Pathol. 2015;143(5):645–51.

    Article  PubMed  Google Scholar 

  16. Aufderklamm S et al. Oncologic impact of renal tissue adjacent to renal cell carcinoma. Anticancer Res. 2016;36(6):2865–9.

    PubMed  Google Scholar 

  17. Chen XS et al. Optimal surgical margin in nephron-sparing surgery for T1b renal cell carcinoma. Urology. 2012;79(4):836–9.

    Article  PubMed  Google Scholar 

  18. Ani I et al. Prevalence and impact on survival of positive surgical margins in partial nephrectomy for renal cell carcinoma: a population-based study. BJU Int. 2013;111(8):E300–5.

    Article  PubMed  Google Scholar 

  19. •• Kang HW et al. Surgical margin does not influence recurrence rate in pT1 clear cell renal cell carcinoma after partial nephrectomy: a multicenter study. J Surg Oncol. 2016;114(1):70–4. This recent multi-institutional analysis highlights the current controversy surrounding the oncologic potential of positive surgical margins after renal tumor excision. The data reports no significant increase in local tumor recurrence in the setting of positive surgical margins within a homogenous study population of T1 renal masses.

    Article  PubMed  Google Scholar 

  20. Khalifeh A et al. Positive surgical margins in robot-assisted partial nephrectomy: a multi-institutional analysis of oncologic outcomes (leave no tumor behind). J Urol. 2013;190(5):1674–9.

    Article  PubMed  Google Scholar 

  21. •• Shah PH et al. Positive surgical margins increase risk of recurrence after partial nephrectomy for high risk renal tumors. J Urol. 2016;196(2):327–34. This study discusses a correlation between tumor pathology and oncologic recurrence, showing that higher risk renal tumors have an increased risk of cancer recurrence than lower risk tumors when positive surgical margins are present.

    Article  PubMed  Google Scholar 

  22. Porpiglia F et al. Margins, ischaemia and complications rate after laparoscopic partial nephrectomy: impact of learning curve and tumour anatomical characteristics. BJU Int. 2013;112(8):1125–32.

    Article  PubMed  Google Scholar 

  23. Hillyer SP et al. Robotic partial nephrectomy for solitary kidney: a multi-institutional analysis. Urology. 2013;81(1):93–7.

    Article  PubMed  Google Scholar 

  24. Tabayoyong W et al. Variation in surgical margin status by surgical approach among patients undergoing partial nephrectomy for small renal masses. J Urol. 2015;194(6):1548–53.

    Article  PubMed  Google Scholar 

  25. Khalifeh A et al. Comparative outcomes and assessment of trifecta in 500 robotic and laparoscopic partial nephrectomy cases: a single surgeon experience. J Urol. 2013;189(4):1236–42.

    Article  PubMed  Google Scholar 

  26. •• Maurice MJ et al. Reexamining the association between positive surgical margins and survival after partial nephrectomy in a large American cohort. J Endourol. 2016;30(6):698–703. This is an important and comprehensive update of the outcomes related to positive surgical margins among kidney cancer patients treated with partial nephrectomy in the United States. Limitations include the hospital-based nature of the dataset (not truly population-based) and lack of cancer-specific survival data.

    Article  PubMed  Google Scholar 

  27. Minervini A et al. Endoscopic robot-assisted simple enucleation (ERASE) for clinical T1 renal masses: description of the technique and early postoperative results. Surg Endosc. 2015;29(5):1241–9.

    Article  PubMed  Google Scholar 

  28. Steinestel J et al. Positive surgical margins in nephron-sparing surgery: risk factors and therapeutic consequences. World J Surg Oncol. 2014;12:252.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Marszalek M et al. Laparoscopic and open partial nephrectomy: a matched-pair comparison of 200 patients. Eur Urol. 2009;55(5):1171–8.

    Article  PubMed  Google Scholar 

  30. •• Minervini A et al. Open versus laparoscopic partial nephrectomy for clinical T1a renal masses: a matched-pair comparison of 280 patients with TRIFECTA outcomes (RECORd Project). World J Urol. 2014;32(1):257–63. This large matched-pair series is an important reference for describing outcomes following open versus laparoscopic partial nephrectomy.

    Article  PubMed  Google Scholar 

  31. Aboumarzouk OM et al. Robotic versus laparoscopic partial nephrectomy: a systematic review and meta-analysis. Eur Urol. 2012;62(6):1023–33.

    Article  PubMed  Google Scholar 

  32. Gill IS et al. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol. 2007;178(1):41–6.

    Article  PubMed  Google Scholar 

  33. Bensalah K et al. Positive surgical margin appears to have negligible impact on survival of renal cell carcinomas treated by nephron-sparing surgery. Eur Urol. 2010;57(3):466–71.

    Article  PubMed  Google Scholar 

  34. Venkatesh R et al. Laparoscopic partial nephrectomy for renal masses: effect of tumor location. Urology. 2006;67(6):1169–74. discussion 1174.

    Article  PubMed  Google Scholar 

  35. Patard JJ et al. Morbidity and clinical outcome of nephron-sparing surgery in relation to tumour size and indication. Eur Urol. 2007;52(1):148–54.

    Article  PubMed  Google Scholar 

  36. Porpiglia F et al. Does tumour size really affect the safety of laparoscopic partial nephrectomy? BJU Int. 2011;108(2):268–73.

    Article  PubMed  Google Scholar 

  37. Yossepowitch O et al. Positive surgical margins at partial nephrectomy: predictors and oncological outcomes. J Urol. 2008;179(6):2158–63.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Raz O et al. Positive surgical margins with renal cell carcinoma have a limited influence on long-term oncological outcomes of nephron sparing surgery. Urology. 2010;75(2):277–80.

    Article  PubMed  Google Scholar 

  39. Sorokin I et al. Self-assessment of surgical technique leads to reduction of positive surgical margins in partial nephrectomy. J Robot Surg. 2015;9(1):45–50.

    Article  PubMed  Google Scholar 

  40. Benway BM et al. Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of perioperative outcomes. J Urol. 2009;182(3):866–72.

    Article  PubMed  Google Scholar 

  41. Peycelon M et al. Long-term outcomes after nephron sparing surgery for renal cell carcinoma larger than 4 cm. J Urol. 2009;181(1):35–41.

    Article  PubMed  Google Scholar 

  42. Wang L et al. Critical histologic appraisal of the pseudocapsule of small renal tumors. Virchows Arch. 2015;467(3):311–7.

    Article  PubMed  Google Scholar 

  43. Minervini A et al. Histopathologic analysis of peritumoral pseudocapsule and surgical margin status after tumor enucleation for renal cell carcinoma. Eur Urol. 2009;55(6):1410–8.

    Article  PubMed  Google Scholar 

  44. Azhar RA et al. Histological analysis of the kidney tumor-parenchyma interface. J Urol. 2015;193(2):415–22.

    Article  PubMed  Google Scholar 

  45. Minervini A et al. Simple enucleation is equivalent to traditional partial nephrectomy for renal cell carcinoma: results of a nonrandomized, retrospective, comparative study. J Urol. 2011;185(5):1604–10.

    Article  PubMed  Google Scholar 

  46. Longo N et al. Simple enucleation versus standard partial nephrectomy for clinical T1 renal masses: perioperative outcomes based on a matched-pair comparison of 396 patients (RECORd project). Eur J Surg Oncol. 2014;40(6):762–8.

    Article  CAS  PubMed  Google Scholar 

  47. Carini M et al. Simple enucleation for the treatment of PT1a renal cell carcinoma: our 20-year experience. Eur Urol. 2006;50(6):1263–8. discussion 1269–71.

    Article  PubMed  Google Scholar 

  48. Carini M et al. Simple enucleation for the treatment of renal cell carcinoma between 4 and 7 cm in greatest dimension: progression and long-term survival. J Urol. 2006;175(6):2022–6. discussion 2026.

    Article  PubMed  Google Scholar 

  49. Liu NW et al. The prognostic impact of a positive vascular margin on pT3 clear cell renal cell carcinoma. J Urol. 2016;195(2):264–9.

    Article  PubMed  Google Scholar 

  50. Kato S et al. Resection of the inferior vena cava for urological malignancies: single-center experience. Int J Clin Oncol. 2013;18(5):905–9.

    Article  PubMed  Google Scholar 

  51. Abel EJ et al. Positive vascular wall margins have minimal impact on cancer outcomes in patients with non-metastatic renal cell carcinoma (RCC) with tumour thrombus. BJU Int. 2014;114(5):667–73.

    Article  PubMed  Google Scholar 

  52. Bernhard JC et al. Predictive factors for ipsilateral recurrence after nephron-sparing surgery in renal cell carcinoma. Eur Urol. 2010;57(6):1080–6.

    Article  PubMed  Google Scholar 

  53. Chawla SN et al. The natural history of observed enhancing renal masses: meta-analysis and review of the world literature. J Urol. 2006;175(2):425–31.

    Article  PubMed  Google Scholar 

  54. Sidana A, Donovan JF, Gaitonde K. Surgeons’ preferences and practice patterns regarding intraoperative frozen section during partial nephrectomy. Urol Oncol. 2014;32(6):864–8.

    Article  PubMed  Google Scholar 

  55. Duvdevani M et al. Is frozen section analysis in nephron sparing surgery necessary? A clinicopathological study of 301 cases. J Urol. 2005;173(2):385–7.

    Article  PubMed  Google Scholar 

  56. Breda A et al. Positive margins in laparoscopic partial nephrectomy in 855 cases: a multi-institutional survey from the United States and Europe. J Urol. 2007;178(1):47–50. discussion 50.

    Article  CAS  PubMed  Google Scholar 

  57. Kirkali Z et al. What does the urologist expect from the pathologist (and what can the pathologists give) in reporting on adult kidney tumour specimens? Eur Urol. 2007;51(5):1194–201.

    Article  PubMed  Google Scholar 

  58. • Venigalla S, Wu G, Miyamoto H. The impact of frozen section analysis during partial nephrectomy on surgical margin status and tumor recurrence: a clinicopathologic study of 433 cases. Clin Genitourin Cancer. 2013;11(4):527–36. This is an important reference for understanding the utility (or lack thereof) related to reflexive frozen section analysis during partial nephrectomy cases.

    Article  PubMed  Google Scholar 

  59. Kubinski DJ et al. Utility of frozen section analysis of resection margins during partial nephrectomy. Urology. 2004;64(1):31–4.

    Article  PubMed  Google Scholar 

  60. Gordetsky J et al. Frozen section during partial nephrectomy: does it predict positive margins? BJU Int. 2015;116(6):868–72.

    Article  PubMed  Google Scholar 

  61. Nguyen TT et al. Technique for ensuring negative surgical margins during laparoscopic partial nephrectomy. J Endourol. 2005;19(3):410–5.

    Article  PubMed  Google Scholar 

  62. Kaczmarek BF et al. Comparison of robotic and laparoscopic ultrasound probes for robotic partial nephrectomy. J Endourol. 2013;27(9):1137–40.

    Article  PubMed  Google Scholar 

  63. Veeratterapillay R et al. Intraoperative and surgical specimen (ex vivo) ultrasound in the assessment of margins at partial nephrectomy. Int Urol Nephrol. 2015;47(10):1665–9.

    Article  CAS  PubMed  Google Scholar 

  64. Gill IS et al. Laparoscopic partial nephrectomy for renal tumor: duplicating open surgical techniques. J Urol. 2002;167(2 Pt 1):469–7. discussion 475–6.

    PubMed  Google Scholar 

  65. Duvdevani M et al. Renal artery occlusion during nephron-sparing surgery: retrospective review of 301 cases. Urology. 2006;68(5):960–3.

    Article  PubMed  Google Scholar 

  66. Bollens R et al. Laparoscopic partial nephrectomy with “on-demand” clamping reduces warm ischemia time. Eur Urol. 2007;52(3):804–9.

    Article  PubMed  Google Scholar 

  67. Desai PJ et al. Laparoscopic partial nephrectomy at the Mayo Clinic Arizona: follow-up surveillance of positive margin disease. Urology. 2008;71(2):283–6.

    Article  PubMed  Google Scholar 

  68. Lopez-Costea MA et al. Positive margins after nephron-sparing surgery for renal cell carcinoma: long-term follow-up of patients on active surveillance. BJU Int. 2010;106(5):645–8.

    Article  PubMed  Google Scholar 

  69. Weight CJ et al. Nephrectomy induced chronic renal insufficiency is associated with increased risk of cardiovascular death and death from any cause in patients with localized cT1b renal masses. J Urol. 2010;183(4):1317–23.

    Article  PubMed  Google Scholar 

  70. Sundaram V et al. Positive margin during partial nephrectomy: does cancer remain in the renal remnant? Urology. 2011;77(6):1400–3.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Urology, Emory University, 1365 Clifton Road, Clinic B, 5th Floor, Atlanta, GA, 30322, USA

    Dean D. Laganosky & Viraj A. Master

  2. Department of Urology, Atlanta Veterans Affairs Medical Center, Emory University, 1365 Clifton Road, Clinic B, Atlanta, GA, 30322, USA

    Christopher P. Filson

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  1. Dean D. Laganosky
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  2. Christopher P. Filson
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  3. Viraj A. Master
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Correspondence to Viraj A. Master.

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Dean D. Laganosky, Christopher P. Filson, and Viraj A. Master each declare no potential conflicts of interest.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Kidney Diseases

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Laganosky, D.D., Filson, C.P. & Master, V.A. Surgical Margins in Nephron-Sparing Surgery for Renal Cell Carcinoma. Curr Urol Rep 18, 8 (2017). https://doi.org/10.1007/s11934-017-0651-5

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