ORLANDO, FL (UroToday) - Pathology results after partial nephrectomy reveal a positive margin. What should the urologist tell the patient? Is immediate reoperation warranted? Patard and colleagues addressed these questions by examining data from a large international multi-institution surgical series that included 811 patients who underwent partial nephrectomy (PN) for tumors with a mean size of 3cm (0.5-16). 40% of operations were performed for imperative indications, while 60% of PNs were elective. 119 (14.7%) specimens contained a positive margin (PSM), and all patients were managed expectantly. The authors did two separate comparative analyses using the data. They first contrasted the PSM patients with the rest of the cohort. Then they compared the 109 PSM patients to the 108 controls that were closely match by indication for surgery, tumor size, and Fuhrman grade.

When the authors compared the PSM patients to the rest of the cohort, not surprisingly, the PSM patients tended to have higher T stage (p=0.03) and higher Fuhrman grade (p=0.003) tumors. A statistically significant higher recurrence rate was noted (p=0.001); however, cancer-specific mortality rates did not reach statistical significance (p=0.08).

Comparison of the PSM patients to the matched controls also revealed higher recurrence rates in the PSM group (15.6% vs 2.8%, p=0.001), but no differences in cancer-specific mortality were observed (8.3% vs 8.3%). The authors report that recurrences occurred mainly in the imperative indication group. When elective cases were examined, recurrence rates were low (1.6 % PSM vs 3.3% negative margins) and were not affected by margin status (p=0.6).

The authors conclude that in a subset of patients positive surgical margins result in higher recurrence rates. Fortunately, cancer-specific survival does not appear to be affected with appropriate subsequent management. Clearly patients with PSM need very close follow-up, but expectant management does appear to be a safe approach.

Presented by Jean-Jacques Patard, MD, at the Annual Meeting of the American Urological Association (AUA) - May 17 - 22, 2008. Orange County Convention Center - Orlando, Florida, USA.

Reported by UroToday Contributing Editor Alexander Kutikov, MD

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