Positive vascular wall margins have minimal
impact on cancer outcomes in patients with
non-metastatic renal cell carcinoma (RCC) with
E. Jason Abel, Alonso Carrasco*, Jose Karam*, Pheroze Tamboli†, Scott Delacroix*,
Ara A. Vaporciyan‡and Christopher G. Wood*
Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, and Departments
of *Urology,‡Thoracic Surgery and†Pathology, The University of Texas M.D.Anderson Cancer Center, Houston, TX, USA
• To evaluate the impact of microscopically positive vascular
margins on recurrence and cancer-specific survival (CSS) in
patients with renal cell carcinoma (RCC) with venous
Patients and Methods
• We reviewed the records from the period 1993 to 2009 of
consecutive patients treated surgically for RCC with venous
tumour thrombus at the University of Texas MD Anderson
• Patients with metastatic disease, positive soft tissue margins
or gross residual disease at time of thrombectomy were
• The primary outcome measures were local or systemic
disease recurrence, and CSS.
• Univariate and multivariate analysis were used to evaluate
whether microscopically positive vascular margins were
associated with RCC recurrence or CSS after nephrectomy
• A total of 256 patients with RCC were identified with a
median (interquartile range) follow-up of 36.7 (18.4–63.5)
months. Microscopic tumour was present at the margin of
resection in 47 patients (18.4%).
• The median recurrence-free interval was significantly
shorter in patients with positive vascular margins: 22.1 vs
70.2 months (P = 0.009).
• The rate of local recurrence was higher in patients with
positive vein margins: 12.8 vs 4.3% (P < 0.01). Local
recurrence without concomitant systemic recurrence was
identified in only two of 256 (0.8%) patients.
• Patients with positive vascular margins had significantly
worse CSS times compared with patients with negative
vascular margins: 37.7 vs 93.0 months (P = 0.004).
• In multivariable analysis, positive vascular margins were
found to be independently predictive of local recurrence but
not of systemic recurrence or CSS.
• Complete surgical excision should always be attempted
because positive vascular wall margins increase local
• Invasion of RCC into the vein wall at the resection margin
is associated with aggressive tumour biology, and the
majority of patients with positive vascular wall margins
experience systemic recurrence.
renal cell carcinoma, thrombus, margins, recurrence, prognosis
Almost 3% of adult malignancies are accounted for by RCC
and invasion of the venous system is present in 10% of
patients at initial evaluation . In patients without metastatic
disease, nephrectomy with complete removal of all tumour
thrombus may be curative; however, tumour invading the
venous system increases the risk of metastatic recurrence and
the 5-year cancer-specific survival (CSS) in historical series is
only 60% .
To produce a thrombus, the tumour must invade a vein wall at
some point, but the extent of its invasion of the venous system
is variable.When tumour invasion occurs only within the
renal veins, a free-floating thrombus may extend into the
inferior vena cava (IVC), while in some patients invasion of
© 2013 The Authors
BJU International © 2013 BJU International | doi:10.1111/bju.12515
Published by John Wiley & Sons Ltd. www.bjui.org
BJU Int 2014; 114: 667–673
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Correspondence: E. Jason Abel, Department of Urology,
University of Wisconsin School of Medicine and Public
Health, 1685 Highland Avenue, Madison,WI 53705-2281,
Abbreviations: CSS, cancer-specific survival; IVC, inferior vena
Impact of positive vascular margins in RCC recurrence
© 2013 The Authors
BJU International © 2013 BJU International