Positive Surgical Margins in Partial Nephrectomy Specimens Evgeny - - PowerPoint PPT Presentation

Positive Surgical Margins in Partial Nephrectomy Specimens

Evgeny Yakirevich, MD, DSc

Department of Pathology Lifespan Academic Medical Center Alpert Medical School at Brown University Providence, RI, USA

• Off-label use of drugs, devices, or other agents: None
• Data from IRB-approved human research is not presented

2

I have the following financial interests or relationships to disclose: Disclosure code No financial relationships N

Financial and Other Disclosures

Outline

• Pathology handling of partial

nephrectomy specimens

• Intraoperative assessment of surgical

margins

• Definition of positive and adequate

margins

• Relationship of positive margins with

– Local recurrence – Survival

Pathology Journals

• 3 manuscripts

Urology Journals

• 474 manuscripts

Initial Sectioning and Inking of Partial Nephrectomy Specimens

• 95% use ink for partial nephrectomies
• Selective inking of renal parenchymal

margin (62%)

• Entire specimen inking (33%)
• The specimens are sectioned

perpendicular to the inked marginal surface

ISUP Vancouver 2012 Consensus Conference recommendations

• Margins (select all that apply) (Note H)

– Cannot be assessed – Uninvolved by invasive carcinoma – Involved by invasive carcinoma

• Renal parenchymal margin (partial nephrectomy only)
• Renal capsular margin (partial nephrectomy only)
• Perinephric fat margin
• Renal sinus soft tissue margin
• Gerota’s fascial margin
• Renal vein margin
• Ureteral margin
• Other (specify): ____________________

College of American Pathologists (CAP) Kidney Protocol 2017

Initial Sectioning and Inking of Partial Nephrectomy Specimens

Parenchymal margin Capsular margin

Initial Sectioning and Inking of Partial Nephrectomy Specimens

Parenchymal margin Perinephric fat margin

Intraoperative Assessment of Surgical Margins

• By surgeon macroscopically
• Frozen section margin analysis only if

needed

– From entire specimen – From tumor bed only

Intraoperative Assessment of Surgical Margins

Timsit et al Urology 2006

FS

False negative

High false negative rate due to

• Sampling error
• Interpretation

error

High False-Negative rate of Frozen Section Margins

Gordetsky et al 2014 BJUI

Potential Pitfalls in the Frozen Sections

Detached atypical cells Crushed tubules McHale et al, AJCP 2002

How Many Blocks should be Submitted for Examination?

• No guidelines for partial nephrectomy
• One section per cm, minimum of 3

blocks (subject to modification as needed in individual cases)

• Proposal to submit the entire tumor if <3

cm (Vancouver survey); however, may result in more blocks being submitted

Should Margins be Submitted Entirely?

• Sample

closest margin area

• Perpendicular

to margin sections (not shaved)

• 1-2 sections

from each margin

Definition of Positive Margin

Positive margin - tumor at the inked specimen edge Negative margin – tumor not touching ink

Capsular and Fat Margins

Negative capsular margin Negative perinephric fat margin

Definition of Adequate Margin

• No adopted definition
• 1-2 cm in other organs (colon, melanoma,

sarcoma)

• 1 cm in partial nephrectomy (Vermooten, 1950)
• At least 1 mm may be adequate to prevent local

recurrence (Piper et al, 2001)

• Only a minimal margin of N renal parenchyma <5

mm must be removed (Sutherland et al, 2002)

Does Cancer Remain in the Renal Remnant after Partial Nephrectomy?

• Sundaram et al, Urology 2010

– 29 patients with positive margin – No residual cancer in 8 nephrectomies – Two residual carcinomas of 21 total re- resections

• A positive surgical margin does not

necessarily mean that cancer remains in the renal remnant in most cases.

Relationship of Positive Margin with Recurrence and Survival

• Limitations

– Most are retrospective – Lack of central pathology review – Relatively short follow-up

Margin Status and Local Tumor Recurrence

Antic and Taxy AJCP 2015

7.5% 1.0%

Relationship of Positive Margin with Survival

Basal et al, CUAJ 2017 1103 cases from Canadian Kidney Cancer information system collaborative

Conclusion

• Both surgeons and pathologists must pay attention to

surgical margins

• Pathologists should follow CAP guidelines and

incorporate margin stratus in pathology report

• Interpretation of FS may present diagnostic
• challenge. FS should be performed only if needed
• Even though positive margins have a higher tumor

recurrence rate, in most studies survival of these patients is comparable to that of patients with negative surgical margins