Department of Urology, University of California San Diego School of Medicine, La Jolla, CA, USA.
Department of Radiation Medicine, University of California San Diego School of Medicine, La Jolla, CA, USA.
Minerva Urol Nephrol. 2021 Apr;73(2):233-244. doi: 10.23736/S2724-6051.20.03728-5. Epub 2020 Aug 4.
The impact of positive surgical margins (PSM) on outcomes in partial nephrectomy (PN) is controversial. We investigated impact of PSM for patients undergoing PN on overall survival (OS) in different stages of renal cell carcinoma (RCC).
Retrospective analysis of patients from the US National Cancer Database who underwent PN for cT1a-cT2b N0M0 RCC between 2004-13. Patients were stratified by pathological stage (pT1a, pT1b, pT2a, pT2b, and pT3a [upstaged]) and analyzed by margin status. Cox Regression multivariable analysis (MVA) was performed to investigate associations of PSM and covariates on all-cause mortality (ACM). Kaplan-Meier analysis (KMA) of OS was performed for PSM versus negative margin (NSM) by pathological stage. Sub-analysis of Charlson Comorbidity Index 0 (CCI=0) subgroup was conducted to reduce bias from comorbidities.
We analyzed 42,113 PN (pT1a: 33,341 [79.2%]; pT1a, pT1b: 6689 [15.9%]; pT2a: 757 [1.8%]; pT2b: 165 [0.4%]; and pT3a: upstaged 1161 [2.8%]). PSM occurred in 6.7% (2823) (pT1a: 6.5%, pT1b: 6.3%, pT2a: 5.9%, pT2b: 6.1%, pT3a: 14.1%, P<0.001). On MVA, PSM was associated with 31% increase in ACM (HR 1.31, P<0.001), which persisted in CCI=0 sub-analysis (HR: 1.25, P<0.001). KMA revealed negative impact of PSM vs. NSM on 5-year OS: pT1 (87.3% vs. 90.9%, P<0.001), pT2 (86.7% vs. 82.5%, P=0.48), and upstaged pT3a (69% vs. 84.2%, P<0.001).
PSM after PN was independently associated with across-the-board decrement in OS, which worsened in pT3a disease and persisted in sub-analysis of patients with CCI=0. PSM should prompt more aggressive surveillance or definitive resection strategies.
在部分肾切除术 (PN) 中，阳性切缘 (PSM) 对结果的影响存在争议。我们研究了 PSM 对不同分期肾细胞癌 (RCC) 接受 PN 治疗的患者的总生存 (OS) 的影响。
回顾性分析了 2004-13 年间在美国国家癌症数据库中接受 cT1a-cT2b N0M0 RCC 行 PN 的患者。患者根据病理分期 (pT1a、pT1b、pT2a、pT2b 和 pT3a[升级]) 分层，并按切缘状态进行分析。使用 Cox 回归多变量分析 (MVA) 研究 PSM 与全因死亡率 (ACM) 的其他因素之间的关联。通过病理分期对 PSM 与阴性切缘 (NSM) 进行 Kaplan-Meier 分析 (KMA)。进行 Charlson 合并症指数 0 (CCI=0) 亚组的亚组分析，以减少合并症引起的偏倚。
我们分析了 42113 例 PN(pT1a：33341[79.2%]；pT1a、pT1b：6689[15.9%]；pT2a：757[1.8%]；pT2b：165[0.4%]；pT3a：升级 1161[2.8%])。PSM 发生率为 6.7%(2823)(pT1a：6.5%，pT1b：6.3%，pT2a：5.9%，pT2b：6.1%，pT3a：14.1%，P<0.001)。在 MVA 中，PSM 与 ACM 增加 31%相关(HR 1.31，P<0.001)，在 CCI=0 亚组分析中仍然存在(HR：1.25，P<0.001)。KMA 显示 PSM 与 NSM 相比对 5 年 OS 的负面影响：pT1(87.3% vs. 90.9%，P<0.001)，pT2(86.7% vs. 82.5%，P=0.48)和升级的 pT3a(69% vs. 84.2%，P<0.001)。
PN 后的 PSM 与 OS 的全面下降独立相关，在 pT3a 疾病中恶化，并在 CCI=0 患者的亚组分析中持续存在。PSM 应促使更积极的监测或明确的切除策略。
