Renal cell carcinoma: considerations for nephron-sparing surgery

Area of Science:

• Urology
• Oncology
• Surgical Pathology

Background:

• Nephron-sparing surgery (NSS) is an alternative to radical nephrectomy for localized renal cell carcinoma (RCC).
• The success of NSS depends on accurate preoperative assessment and the absence of aggressive tumor features.
• Controversy exists regarding the performance of NSS when the contralateral kidney is healthy.

Purpose of the Study:

• To identify risk factors influencing the success or failure of NSS.
• To evaluate the accuracy of preoperative assessments in predicting tumor characteristics for NSS eligibility.
• To analyze discrepancies between radiographic and pathologic findings in patients with localized RCC.

Main Methods:

• Retrospective review of radiology and pathology reports for 278 patients who underwent radical nephrectomy for clinically localized RCC.
• Analysis of data from Eastern Cooperative Oncology Group protocol EST 2886 (Stage III RCC).
• Comparison of preoperative clinical staging with postoperative pathologic results, focusing on lesion size, multiplicity, and local/regional spread.

Main Results:

• Of 278 radical nephrectomy specimens, only 36 had primary lesions ≤5 cm.
• Preoperative imaging deemed 14 of these 36 ineligible for NSS.
• Pathologic examination of the remaining 22 potential candidates revealed multifocal disease (11), renal vein involvement (4), or nodal disease (2), with only 5 potentially having specimen-confined (T3a) disease.

Conclusions:

• Capsular-penetrating (T3a) RCC is frequently underestimated preoperatively.
• T3a disease is often associated with multifocal lesions and vascular or nodal involvement.
• Intraoperative frozen section analysis may be crucial to identify T3a disease and guide the decision between NSS and radical surgery.