A Prospective, Multicenter Evaluation of Predictive Factors for Positive Surgical Margins After Nephron-Sparing Surgery for Renal Cell Carcinoma: The RECORd1 Italian Project

Abstract

The early oncological goal of any partial nephrectomy (PN) is to achieve negative surgical margins (SMs). Several factors have been advocated as predictors of positive SMs (PSMs) after nephron-sparing surgery (NSS). In our study, age, upper pole tumor location, standard PN and Fuhrman 3/4 nuclear grade were found to be independent predictors of PSMs at multivariable analysis. Further evaluations are required to verify the oncological effect of the PSM on local and systemic recurrence. Background: The purpose of this study was to evaluate the predictors of positive margins in one of the largest available prospective multi-institutional studies. Patients and Methods: We evaluated all patients who underwent NSS for radiologically diagnosed kidney tumors between January 2009 and December 2012 at 19 urological Italian centers (Registry of Conservative Renal Surgery [RECORd] project). Preoperative and anthropometric data, comorbidities, intraoperative and postoperative outcomes, and histological findings were analyzed. The negative and PSMs were compared according to the clinical and surgical variables. Multivariable logistic regression models were applied to analyze predictors of PSMs. Results: Eight hundred consecutive patients were evaluated. Seven hundred sixty-one (95.1%) and 39 patients (4.9%) achieved negative and PSMs, respectively. Patients with PSMs were significantly older compared with those with negative margins (median age: 66.6 vs. 61.8 years, respectively; P ¼ .001). A higher incidence of PSMs was observed when NSS was performed for renal masses located in the upper pole (P ¼ .001). A lower rate of PSMs was found in patients treated with simple enucleation rather than standard PN (1.6% vs. 7.4%, respectively; P < .0001). A greater incidence of PSMs was found in Fuhrman 3/4 tumors (11.3%; P < .0001). At multivariable analysis, age (odds ratio [OR], 1.04; P ¼ .01), upper pole tumor location (OR, 2.85; P ¼ .005), standard PN (OR, 3.45; P ¼ .004), and Fuhrman 3-4 nuclear grade (OR, 4.81; P ¼ .001) were found to be independent predictors of PSMs. Conclusion: In our multi-institutional report, young age, simple enucleation, middle or lower tumor location, and low-grade tumor were demonstrated to be independent predictors of negative SMs.

Prognostic factors for surgical margin status and recurrence in partial nephrectomy

“…Irregular forms of aggressive and infiltrative cancers and their growth patterns cause difficult dissection and consequently increased PSM rates. In a prospective, multi‐centre study in 2015 with 800 patients, a statistically significant difference was found between surgical margin status and tumour grade 19 . In our study, nuclear grades of patients with PSM and NSM were significantly different.…”

“…Ani et al found a statistically significant relationship between PSM and stage 9 . Schiavina et al found no association between PSM and tumour stage and size 19 . Bensalah et al also evaluated the PSM and tumour stage and found no significant correlation between T‐stage and surgical margin status 20 .…”

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

“…In recent years, large series have analyzed the preoperative risk factors for PSM after PN. Several factors have been advocated as predictors, such as older age, tumour size, location, pathological stage, Fuhrman grade and indication (elective vs. imperative) [ 5 , 13 – 15 ]. Correspondingly, conflicting evidence has accumulated on whether PSM is also a significant risk factor for disease progression, while large-scale studies like Yossepowitch et al, Lopez-Costea et al or Antic et al suggest no correlation between PSM and local recurrence or distant progression [ 14 , 16 , 17 ].…”

Tumor Enucleation for Renal Cell Carcinoma

“…In a large, multicenter retrospective series, the Surveillance and Treatment Update Renal Cancer (SATURN) study found a PSM rate of 0.2% with SE and 3.4% with PN (p=<0.001) (28). Similarly, the prospective Italian Registry of Conservative Renal Surgery (RECORd) project found PSM rates of 1.6% and 7.4% with SE and PN, respectively (p=<0.001) (29). …”

“…Overall, positive surgical margins (PSMs) are relatively rare events at the time of NSS, with current literature identifying positive surgical margin (PSM) rates after PN to range from 0% to 7% (29,38–41). When investigating the significance of a PSM on final pathological analysis, little effect on survival has been shown (40–42).…”