The largest systematic review to date, including 42 observational studies and 101,153 patients with renal cell carcinoma, finds that the presence of positive surgical margins (PSM) after partial nephrectomy (PN) correlates with poor oncologic outcomes and possibly worse mortality.
In 5 distinct meta-analyses published in Urology, PSM was significantly associated with a 6.1-fold increased risk of local recurrence, a 3.3-fold increased risk of metastasis, and a 2.3-fold increased risk of overall relapse, based on moderate to high quality evidence. Characteristics of the populations differed among the analyses explaining some discrepancies, Raja B. Khauli, MD, of University of Massachusetts Medical Center and colleagues noted.
PSM also was associated with a significant 30% increased risk for overall mortality, but this result was largely driven by a study using the National Cancer Database, which has inherent selection bias, the investigators cautioned. Cancer-specific mortality did not differ significantly between the groups with PSM and negative surgical margins after PN.
Over the years, indications for PN have expanded to include higher-risk and more complex tumors. According to Dr Khauli and colleagues, their results highlight the need for redefining the indications for performing nephron-sparing surgery abiding by strict clinico-pathological criteria.
“Our findings underscore the importance of proper patient selection for [nephron-sparing surgery], combined with surgical techniques aiming to achieve negative surgical margins,” Dr Khauli’s team stated. “Patients with PSM, especially deemed to be high risk, should be counselled for the possibility of additional surgery, novel adjuvant therapies, and more rigorous surveillance.”
The meta-analyses were limited by the observational nature of included studies and the lack of data on PSM size and RCC histologic subtype.
Hakam N, Abou Heidar N, Khabsa J, Hneiny L, Akl EA, Khauli R. Does a positive surgical margin after nephron sparing surgery affect oncological outcome in renal cell carcinoma? A systematic review and meta-analysis. Urology. Published online June 26, 2021. doi:10.1016/j.urology.2021.04.058