Article

Positive vascular wall margins have minimal impact on cancer outcomes in non-metastatic RCC patients with tumor thrombus.

Department of Urology, University of Wisconsin School of Medicine and Public Health.
BJU International (Impact Factor: 3.13). 10/2013; 114(5). DOI: 10.1111/bju.12515
Source: PubMed

ABSTRACT ● Despite resection of all visible tumor, RCC may be present within the vein wall of after nephrectomy with thrombectomy, but the significance of positive vein wall margins is unknown. ● The purpose of this study was to evaluate the impact of microscopically positive vascular margins on recurrence and cancer specific survival in RCC patients with venous thrombus PATIENTS AND METHODS: ● All records were reviewed from 1993-2009 at University of Texas MD Anderson Cancer Center of consecutive patients treated surgically for RCC with venous tumor thrombus. ● Patients with metastatic disease, positive soft tissue margins or gross residual disease at time of thrombectomy were excluded. ● Primary outcome measurements were local or systemic disease recurrence, and cancer specific survival. ● Univariate and multivariate analysis was used to evaluate whether microscopically positive vascular margins were associated with RCC recurrence or cancer specific survival after nephrectomy with thrombectomy.
● A total of 256 RCC patients were identified with median follow-up of 36.7 months (IQR 18.4-63.5). Microscopic tumor was present at margin of resection in 47 (18.4%) patients. ● 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 2 of 256 (0.8%) patients. ● Patients with positive vascular margins had significantly worse CSS compared to patients with negative vascular margins, 37.7 vs. 93.0 months (p=0.004). ● After multivariable analysis, positive vascular margins were independently predictive of local recurrence but not systemic recurrence or CSS.
● Complete surgical excision should always be attempted because positive vascular wall margins increase local recurrence rates. ● Invasion of RCC into the vein wall at the resection margin is associated with aggressive tumor biology, and the majority of patients with positive vascular wall margins recur systemically.

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