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Importance of surgical margins in the management of renal cell carcinoma

Nature Clinical Practice Urology volume 5, pages 308–317 (2008)Cite this article

Abstract

Surgical resection remains the standard treatment for clinically localized renal cell carcinoma. Pathological features of the surgical specimen, including the margin status, play an important part in determining the patient's prognosis. Negative surgical margins have traditionally been sought to maximize the efficacy of treatment. Initial concerns that partial nephrectomy might have high local recurrence rates compared with radical nephrectomy have now been minimized as a result of technological advances and refinements in surgical technique. Current concerns in relation to partial nephrectomy include the width of parenchymal tissue that should be removed to avoid positive surgical margins, effects of positive margins on recurrence-free survival, and the use of frozen-section analysis to determine margin status. Size of the surgical margin in partial nephrectomy does not seem to affect the risk of local tumor recurrence, and not all positive surgical margins lead to recurrent disease. Intraoperative frozen-section analysis is not definitive and its value in guiding the surgical management of renal tumors remains to be defined. Laparoscopic partial nephrectomy is emerging as an attractive approach for selected renal masses. Intraoperative use of ultrasound, cold-scissor parenchymal transection, embolization, and hilar clamping to achieve a bloodless operative field with clear visibility, may minimize the risk of positive margins during partial nephrectomy.

Key Points

  • Positive surgical margins after radical nephrectomy for clinically localized renal cell carcinoma are rare, and there has been no proven benefit for the use of additional treatments in this setting

  • Size of surgical margin in partial nephrectomy does not seem to affect the risk of local tumor recurrence

  • Any surgical margin (even less than 1 mm) is adequate as long as there is complete excision of the tumor

  • Intraoperative frozen-section analysis is not definitive and its value in guiding intraoperative management remains to be defined; site-directed frozen-section analysis of the partial nephrectomy specimen is recommended if there is suspicion of a positive margin on gross inspection of the specimen

  • Not all positive surgical margins on final pathology lead to recurrent disease and, therefore, may not require immediate management

  • Risk of positive margins during partial nephrectomy can be minimized with the use of intraoperative ultrasound, cold-scissor parenchymal transection, and hilar clamping or embolization

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Acknowledgements

Charles P Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape accredited continuing medical education activity associated with this article.

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  1. and PG Schulam is Associate Professor of Urology and Chief of the Division of Endourology and Minimally Invasive Surgery, all in the Department of Urology, JS Lam is a physician, J Bergman is a Resident in Urology, A Breda is Visiting Assistant Professor of Urology, David Geffen School of Medicine at University of California–Los Angeles, Los Angeles, CA, USA.,

    John S Lam, Jonathan Bergman, Alberto Breda & Peter G Schulam

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Correspondence to Peter G Schulam.

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Lam, J., Bergman, J., Breda, A. et al. Importance of surgical margins in the management of renal cell carcinoma. Nat Rev Urol 5, 308–317 (2008). https://doi.org/10.1038/ncpuro1121

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