Center for Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
J Urol. 2013 Nov;190(5):1674-9. doi: 10.1016/j.juro.2013.05.110. Epub 2013 Jun 11.
Expanding indications for robot-assisted partial nephrectomy raise major oncologic concerns for positive surgical margins. Previous reports showed no correlation between positive surgical margins and oncologic outcomes. We report a multi-institutional experience with the oncologic outcomes of positive surgical margins on robot-assisted partial nephrectomy.
Pathological and clinical followup data were reviewed from an institutional review board approved, prospectively maintained joint database from 5 institutions. Tumors with malignant pathology were isolated and statistically analyzed for demographics and oncologic followup. The log rank test was used to compare recurrence-free and metastasis-free survival between patients with positive and negative surgical margins. The proportional hazards method was used to assess the influence of multiple factors, including positive surgical margins, on recurrence and metastasis.
A total of 943 robot-assisted partial nephrectomies for malignant tumors were successfully completed. Of the patients 21 (2.2%) had positive surgical margins on final pathological assessment, resulting in 2 groups, including the 21 with positive surgical margins and 922 with negative surgical margins. Positive surgical margin cases had higher recurrence and metastasis rates (p<0.001). As projected by the Kaplan-Meier method in the population as a whole at followup out to 63.6 months, 5-year recurrence-free and metastasis-free survival was 94.8% and 97.5%, respectively. There was a statistically significant difference in recurrence-free and metastasis-free survival between patients with positive and negative surgical margins (log rank test<0.001), which favored negative surgical margins. Positive surgical margins showed an 18.4-fold higher HR for recurrence when adjusted for multiple tumors, tumor size, tumor growth pattern and pathological stage.
Positive surgical margins on final pathological evaluation increase the HR of recurrence and metastasis. In addition to pathological and molecular tumor characteristics, this should be considered to plan appropriate management.
机器人辅助部分肾切除术适应证的扩大引起了对阳性手术切缘的主要肿瘤学关注。先前的报告表明，阳性手术切缘与肿瘤学结果之间没有相关性。我们报告了一个多机构的机器人辅助部分肾切除术阳性手术切缘的肿瘤学结果经验。
从 5 个机构的经机构审查委员会批准的前瞻性维护的联合数据库中回顾了病理和临床随访数据。对有恶性病理的肿瘤进行了分离，并对其人口统计学和肿瘤学随访进行了统计学分析。对数秩检验用于比较阳性和阴性手术切缘患者的无复发生存和无转移生存。比例风险法用于评估包括阳性手术切缘在内的多个因素对复发和转移的影响。
共成功完成了 943 例恶性肿瘤的机器人辅助部分肾切除术。在最终病理评估中，21 例（2.2%）患者有阳性手术切缘，结果分为 2 组，包括 21 例阳性手术切缘和 922 例阴性手术切缘。阳性手术切缘病例的复发和转移率较高（p<0.001）。根据Kaplan-Meier方法，在随访至 63.6 个月的整个人群中，5 年无复发生存率和无转移生存分别为 94.8%和 97.5%。阳性和阴性手术切缘患者的无复发生存和无转移生存存在统计学差异（对数秩检验<0.001），阴性手术切缘更有利。在调整了多个肿瘤、肿瘤大小、肿瘤生长模式和病理分期后，阳性手术切缘显示复发的 HR 增加了 18.4 倍。
最终病理评估中的阳性手术切缘增加了复发和转移的 HR。除了病理和分子肿瘤特征外，这应该被考虑在内以规划适当的管理。
