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ABSTRACT: Current surgical practice for nephron sparing surgery allows at least 1 cm margin of normal tissue around the tumour. However, recent studies show that the width of the margin is not important, even simple enucleation is as effective as partial nephrectomy. We explored whether margin size has significant impacts on clinical outcomes in nephron sparing surgery for renal cell carcinoma of 4 cm or less.
Between 1998 and 2006, 115 patients with sporadic, pathologically confirmed, renal cell carcinoma 4 cm or less (T1a) and normal contralateral kidney were treated by nephron sparing surgery using a margin less than 5 mm. The surgical margin status was evaluated from frozen and permanent paraffin sections.
Mean and median tumour diameter were 3.3 cm and 3.5 cm (range 1.0-4.0). The mean margin width was 2.2 mm (median 2.0, range 0-6). In addition, 114 cases had margins 5 mm or less (99.1%), 97 cases (84.3%) had margin 3 mm or less, and 26 cases had margin zero (22.6%). None of the patients had positive surgical margins. No patients died during follow-up (mean 65 months). There were no any major surgical complications and no distant metastasis was detected. Local recurrence was detected in one case (0.9%) at a different site of the kidney.
For early localized renal cell carcinoma of 4 cm or less, as long as tumour is completely excised, the size of margin in nephron sparing surgery is not important. Nephron sparing surgery with 5 mm margin is enough for tumour control. It provides excellent renal function preservation, favourable long term progression free survival and is not associated with an increased risk of local recurrence.
Chinese medical journal 10/2008; 121(17):1662-5. · 0.86 Impact Factor
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ABSTRACT: To explore whether mini-margin nephron-sparing surgery (NSS) is clinically safe and effective for renal cell carcinoma (RCC) of 4 cm or less with a normal contralateral kidney.
A total of 115 patients with sporadic, pathologically confirmed RCC of 4 cm or less (Stage T1a), with a normal contralateral kidney, were treated by NSS using a mini-margin of less than 5 mm from 1998 to 2006. The surgical margin status was evaluated by both frozen and permanent paraffin section studies. The patients were followed up, and the data were analyzed.
The mean and median tumor diameter was 3.3 and 3.5 cm (range 1.0 to 4.0). None of the patients had positive surgical margins detected at either frozen section or final paraffin section analysis. The mean margin width was 2.2 mm (median 2.0, range 0 to 6). Of the 115 patients, 114 had margins of 5 mm or less (99.1%), 97 (84.3%) had margins of 3 mm or less, and 26 had margins of 0 mm (22.6%). At a mean follow-up of 65 months (median 66, range 9 to 105), all patients were alive. No distant metastasis was detected. Local recurrence was detected in 1 patient (0.9%) at a different site in the kidney. No major surgical complications, such as hemorrhage or urinary leakage/urinoma requiring reoperation, occurred. Considering only the 97 patients with follow-up of more than 3 years in the analysis, the mean and median follow-up time was 73 and 69 months (range 37 to 105), respectively. All 97 patients were alive with no evidence of disease at the last visit.
The results of our study have shown that mini-margin NSS is a safe and effective approach for treating early localized RCC of 4 cm or less.
Urology 06/2008; 71(5):924-7. · 2.43 Impact Factor
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ABSTRACT: To study the safety and effects of mini-margin nephron sparing surgery (NSS) for renal cell carcinoma (RCC).
From January 1998 to December 2006, 115 cases of RCC with diameter of 4 cm or less and stage of T1aN0M0 were treated with NSS using a margin of 5 mm or more. The mean diameter of the tumors was 3.3 cm (range 1.0-4.0 cm). Of the cases, 3 were with synchronous bilateral cancer while 112 cases were with normal opposite kidneys. The clinical results were followed and analyzed.
All of the operations were technically successful. The mean duration of surgical procedures was 90 min (ranged 80-120 min). The blood loss was 50 -200 ml. No patient needed blood transfusion. Renal arteries were occluded in 98 cases under hypothermic technique for a mean duration of 22 min (20-25 min). While in 17 cases, renal parenchyma squeezing was used for bleeding control. All of the 115 cases were of negative margin by weather frozen or routine pathologic study. The mean follow-up was 62 months (6-96 months). Local recurrence was found in 1 case during follow-up, with a local recurrence rate of 0.9%, while no distant metastasis was detected. All the patients were alive with no evidence of tumor bearing until last evaluation. Secondary gross hematuria occurred in 3 cases during hospital stay and cured by bed limitation. There were no major complications such as bleeding and urinary leakage or urinoma requiring re-operation.
Mini-margin nephron sparing surgery is likewise safe and effective in treating early localized renal cell carcinoma 4 cm or less. It provides excellent renal function preservation, favorable long-term progression-free survival, and is not associated with an increased risk of local recurrence.
Zhonghua wai ke za zhi [Chinese journal of surgery] 03/2008; 46(4):286-8.
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ABSTRACT: Cyclooxygenase-2 (COX-2) has been shown to play oncogenic roles during stepwise gastrocarcinogenesis, and its expression is correlated with Helicobacter pylori infection, tumor necrosis factor alpha-mediated nuclear factor (NF)-kappaB activation, and Wnt signaling. To examine COX-2 expression and the status of its regulatory factors, we examined 49 gastric cancers (GCs), 21 premalignant tissues, and 10 noncancerous gastric mucosa from residents of Dalian, China. Unexpectedly, it was found that COX-2 expression was infrequent in the gastric samples (18.8%, 15/80) regardless of the type of lesion or morphological phenotype. H pylori infection was detected in 19 of 35 tested GC cases. Tumor necrosis factor alpha expression, NF-kappaB nuclear translocation, or Wnt2 overexpression was observed in 56 (82.3%) of 68, 40 (50.0%) of 80, and 62 (77.5%) of 80 of the gastric tissue samples, respectively. Methylation-sensitive restriction enzyme digestion followed by polymerase chain reaction of COX-2 promoter regions revealed a remarkably high hypermethylation rate (100%, 20/20) among the COX-2-negative GCs, which was associated with the overexpression of DNA methyltransferase (DNMT) 1 (r = 0.587, P < .01). These results indicate that (1) in contrast to previous findings using other GC sources, our results show that COX-2 activity may not be a critical molecular event during GC formation, (2) the tumor-promoting effects of H pylori infection and Wnt and NF-kappaB activities may be mediated by COX-2-independent pathways, and (3) promoter hypermethylation is the major cause of COX-2 silencing in Dalian GCs, apparently because of increased expression of DNMTs (especially DNMT1). Consequently, a COX-2-oriented preventive or therapeutic strategy is not practical for Dalian GCs. The frequent COX-2 hypermethylation observed in Dalian GCs could have insightful epigenetic and epidemiologic implications.
Human Pathlogy 12/2006; 37(12):1557-67. · 2.88 Impact Factor
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ABSTRACT: The potential correlation of E-cadherin reduction and Wnt2 up-regulation in determining the intracellular distribution of beta-catenin in gastric cancers was investigated by the methods of frozen tissue array-based immunohistochemistry, Western blot and RT-PCR analysis. It was revealed that membranous E-cadherin was reduced frequently in the two major subtypes of gastric cancer (intestinal gastric cancer, i-GC and diffuse gastric cancer, d-GC) and closely correlated with the risk of lymphoid node metastasis (P < 0.05). The reduction of membranous E-cadherin was paralleled with cytosolic and nuclear accumulation of beta-catenin and the increased Wnt2 expression. These results indicate that the reduced E-cadherin is a common genetic phenotype of GCs and plays beneficial roles in tumor metastasis. Altered beta-catenin distribution may result from the imbalance of E-cadherin production and Wnt expression, which confers on gastric cancer cells more aggressive behaviors.
Clinical and Experimental Metastasis 02/2005; 22(1):85-93. · 3.52 Impact Factor
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ABSTRACT: Renal cell carcinoma (RCC) of 4 cm or less is with a low incidence of multicentricity and metastasis and is usually considered suitable for nephron-sparing surgery (NSS). This study was designed to investigate the distance between extra-pseudocapsule cancer lesions and primary tumors, and to suggest the optimal margin of normal parenchyma in NSS for RCC 4 cm or less.
We prospectively studied 82 kidneys in which RCCs of 4 cm or less were resected by radical nephrectomy. According to UICC TNM classification (1997), all tumors were staged as T1 and classified as conventional RCC in 76 cases and papillary RCC in 6 cases. The kidney samples were first step sectioned at 3mm intervals and examined for multicentricity. Then, on each layer of tissue sectioned, parenchyma margins of 15 mm beyond pseudocapsule were continuously sectioned and examined microscopically to investigate completeness of pseudocapsule and possible presence of extra-pseudocapsule cancer lesions. The greatest distance between extra-pseudocapsule lesions and primary tumors was measured.
The diameter of 82 primary tumors was 3.4+/-0.7 mm (range 1.5-4.0 cm). Of them, 31.7% (26/82) were found without intact pseudocapsule. Of the 82 cases, 19.5% (16/82) were with positive cancer lesions beyond pseudocapsule, with invasion into normal parenchyma in 12.2% (10/82), into venule in 2.4% (2/82) and satellite tumors in 4.9%(4/82). The average distance between extra-pseudocapsule cancer lesions and primary tumors was 0.5+/-1.3mm (range 0-5.0mm), with a 95% confidential interval (CI) (0.11, 0.94). No significant difference was found in the incidence of extra-pseudocapsule cancer lesions between the tumors 2.5 cm or less and that greater than 2.5 cm.
These data suggest that when partial nephrectomy is performed in RCC 4 cm or less, a 10mm margin may be too large and go against renal function maintaining. Enucleation alone was associated with a significant risk of incomplete excision, and therefore liable for local recurrence. Thorough inspection of the whole kidney before and during operation may help to avoid leaving over large and distant multifocal lesions.
European Urology 11/2003; 44(4):448-51. · 8.49 Impact Factor
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ABSTRACT: To investigate the optimal margin in nephron-sparing surgery (NSS) for renal cell carcinoma (RCC) 4 cm or less in diameter.
Eighty-two kidneys with RCC 4 cm or less in diameter resected by radical nephrectomy were prospectively studied. The kidney samples were sectioned at 3 mm interval and examined for multicentricity. On each layer of tissue sectioned, parenchyma margin of 15 mm beyond pseudocapsule was continuously sectioned and examined for completeness of pseudocapsule and extra-pseudocapsule cancer lesion. The farthest distance between extra-pseudocapsule lesion and primary tumor was measured. PCNA expression was detected in 41 patients by using standard SP immunohistochemistry technique.
The diameter of 82 primary tumors was 3.4 +/- 0.8 cm (range 1.5 - 4.0 cm). Of these, 31.7% (26/82) were found without intact pseudocapsule and 17.1% (14/82) with positive cancer lesions beyond pseudocapsule. The average distance between extra-pseudocapsule cancer lesion and primary tumor was 0.5 +/- 1.3 mm (range 0 - 5.0 mm), with a confidential interval (CI) of 95% (0.11, 0.94). Statistically, the one side percentile P(95) was 4.9 mm, P(97.5) was 5.0 mm and P(100) was 5.0 mm. The mean PCNA index in the 41 patients with RCC was (29.5 +/- 17.6)%, which was (49.6 +/- 21.5)% in the group with extra-pseudocapsule cancer lesions and (24.6 +/- 12.7)% in the group without (t = 3.162, P = 0.013). The ratio of strong expression was 5/8 in the group with extra-pseudocapsule cancer lesions, and 18.2% (6/33) in the group without the lesions (chi(2) = 6.442, P = 0.011). Logistic regression analysis showed that completeness of pseudocapsule and PCNA index were significant predictors of extra-pseudocapsule cancer lesions (P = 0.019).
These data suggest that when NSS is performed in RCC 4 cm or less in diameter, a margin of more than 5 mm of adjacent parenchyma should be excised with the tumor. Enucleation alone was associated with a significant risk of incomplete excision, and therefore liable for local recurrence. Tumors with incomplete pseudocapsule and(or) high PCNA indices are more likely to have extra-pseudocapsule cancer lesions, so intensive follow-up is necessary after NSS.
Zhonghua wai ke za zhi [Chinese journal of surgery] 03/2003; 41(2):81-3.
