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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    ABSTRACT: INTRODUCTION Renal squamous cell carcinoma (RSCC) is a rare tumor that is usually diagnosed late as a locally advanced malignancy with adjacent structure involvement. Radical surgical resection with negative margins is the mainstay of treatment, as it is correlated with improved survival, while other modalities of treatment have been shown to have limited efficacy. PRESENTATION OF CASE We report a case of a 56 year old gentleman with right RSCC with tumor encasing the inferior vena cava (IVC), treated successfully with surgical resection. DISCUSSION The surgical management of vascular involvement of similar tumors has not been discussed in-depth in the literature. Surgical resection of the IVC without reconstruction can be done successfully in the circumstance of good collateral circulation; otherwise IVC resection with reconstruction will be necessary. CONCLUSION Radical resection with clear margins of RSCC tumors with vascular involvement is feasible in selected circumstances.
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