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

Financial and Other Disclosures • Off-label use of drugs, devices, or other agents: None • Data from IRB-approved human research is not presented I have the following financial interests or Disclosure code relationships to disclose: No financial relationships N 2

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

Urology Journals Pathology Journals • 3 manuscripts • 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

College of American Pathologists (CAP) Kidney Protocol 2017 • 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): ____________________

Initial Sectioning and Inking of Partial Nephrectomy Specimens Capsular margin Parenchymal margin

Initial Sectioning and Inking of Partial Nephrectomy Specimens Perinephric fat margin Parenchymal 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 High false negative rate due to False negative -Sampling error -Interpretation error FS Timsit et al Urology 2006

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 Negative margin – tumor not Positive margin - tumor at the inked specimen edge 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 7.5% 1.0% Antic and Taxy AJCP 2015

Relationship of Positive Margin with Survival 1103 cases from Canadian Kidney Cancer Basal et al, CUAJ 2017 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