Influence of positive margin on outcome after partial nephrectomy: a systematic review_Chinese Journal of Evidence-Based Medicine

Authors：

 XIONG Guobing ¹ , MAO Yu ² , WANG Shize ¹ , QIU Mingxing ¹

1. Department of Urology, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu 610072, P.R.China;
2. Children's Medical Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu 610072, P.R.China;

Corresponding author：

XIONG Guobing, Email: xiongguobing@med.uestc.edu.cn

Keywords：

Kidney neoplasm; Nephrectomy; Margins of excision; Positive; Systematic review; Meta-analysis; Cohort study

DOI：

10.7507/1672-2531.202006065

Video：

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Objectives To systematically review the influence of positive margin on outcome after partial nephrectomy (PN). Methods CCRCT, PubMed, EMbase, Sinomed, WanFang Data and CNKI databases were electronically searched to collect clinical studies on influence of positive margin on outcome after PN from inception to December 31^st, 2019. Two reviewers independently screened literature, extracted data and assessed risk of bias of included studies, then, meta-analysis was performed by using RevMan 5.4 software. Results A total of 22 cohort studies involving 20 822 patients were included. The results of meta-analysis showed that positive margin after PN could increase the rate of postoperative local recurrence (OR=4.18, 95%CI 2.88 to 6.05, P<0.000 01), distant metastasis (OR=5.28, 95%CI 2.84 to 9.81,P<0.000 01) and total mortality (OR=1.54, 95%CI 1.19 to 1.99,P=0.0010). However, there were no differences on overall survival (OR=0.64, 95% CI 0.34 to 1.19, P=0.16), distant metastasis free survival (OR=0.70, 95%CI 0.26 to 1.84, P=0.46), cancer specific survival (OR=0.43, 95% CI 0.06 to 3.01, P=0.40) and disease-free survival (OR=0.81, 95%CI 0.35 to 1.85, P=0.61) between two groups. Conclusions Current evidence suggests that positive margin after PN may be associated with tumor progression, however, it may not affect patient survival. Due to limited quality and quantity of the included studies, more high quality studies are required to verify above conclusions.

Citation： XIONG Guobing, MAO Yu, WANG Shize, QIU Mingxing. Influence of positive margin on outcome after partial nephrectomy: a systematic review. Chinese Journal of Evidence-Based Medicine, 2020, 20(10): 1193-1198. doi: 10.7507/1672-2531.202006065 Copy

1.	Ferlay J, Colombet M, Soerjomataram I, et al. Cancer incidence and mortality patterns in Europe: estimates for 40 countries and 25 major cancers in 2018. Eur J Cancer, 2018, 103: 356-387.
2.	MacLennan S, Imamura M, Lapitan MC, et al. Systematic review of perioperative and quality-of-life outcomes following surgical management of localised renal cancer. Eur Urol, 2012, 62(6): 1097-1117.
3.	Thompson RH, Boorjian SA, Lohse CM, et al. Radical nephrectomy for pt1a renal masses may be associated with decreased overall survival compared with partial nephrectomy. J Urol, 2008, 179(2): 468-471.
4.	Miller DC, Schonlau M, Litwin MS, et al. Renal and cardiovascular morbidity after partial or radical nephrectomy. Cancer, 2008, 112(3): 511-520.
5.	Scosyrev E, Messing EM, Sylvester R, et al. Renal function after nephron-sparing surgery versus radical nephrectomy: results from eortc randomized trial 30904. Eur Urol, 2014, 65(2): 372-377.
6.	Choi JE, You JH, Kim DK, et al. Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: a systematic review and meta-analysis. Eur Urol, 2015, 67(5): 891-901.
7.	Shah PH, Moreira DM, Okhunov Z, et al. Positive surgical margins increase risk of recurrence after partial nephrectomy for high risk renal tumors. J Urol, 2016, 196(2): 327-334.
8.	Rothberg MB, Peak TC, Reynolds CR, et al. Long-term oncologic outcomes of positive surgical margins following robot-assisted partial nephrectomy. Transl Androl Urol, 2020, 9(2): 879-886.
9.	Rothberg MB, Paulucci DJ, Okhawere KE, et al. A multi-institutional analysis of the effect of positive surgical margins following robot-assisted partial nephrectomy on oncologic outcomes. J Endourol, 2020, 34(3): 304-311.
10.	熊国兵, 邱明星. 第四章研究/证据质量评估. 张天嵩, 钟文昭, 李博, 主编. 实用循证医学方法学(第2版). 长沙: 中南大学出版社, 2014: 95-227.
11.	Kizilay F, Eskidemir U, Bahceci T, et al. The effect of surgical margin on cancer-specific survival in patients treated with nephron-sparing surgery. Niger J Clin Pract, 2019, 22(10): 1396-1402.
12.	Daly K, Walsh A, Cahill A, et al. Partial nephrectomy and positive margins: What is the significance? European Urology, Supplements. Conference: Annual Meeting of the Irish Society of Urology (ISU), 2019, 18(5): e2545.
13.	Mari A, Tellini R, Amparore D, et al. Assessment of clinicopathological predictors of local recurrence on tumor resection bed in patients treated with partial nephrectomy for localized renal cell carcinoma (the RECORd 1 project). European Urology, Supplements. Conference: EAU19: 34th Annual EAU Congress, 2019, 18(1): e427-e428.
14.	Petros FG, Metcalfe MJ, Yu KJ, et al. Oncologic outcomes of patients with positive surgical margin after partial nephrectomy: a 25-year single institution experience. World J Urol, 2018, 36(7): 1093-1101.
15.	Marchiñena PG, Tirapegui S, Gonzalez IT, et al. Positive surgical margins are predictors of local recurrence in conservative kidney surgery for pT1 tumors. Int Braz J Urol, 2018, 44(3): 475-482.
16.	Tellini R, Antonelli A, Tardanico R, et al. Positive surgical margins predict progression-free survival after nephron-sparing surgery for renal cell carcinoma: results from a single center cohort of 459 cases with a minimum follow-up of 5 years. Clin Genitourin Cancer, 2019, 17(1): e2-e31.
17.	Wood EL, Adibi M, Qiao W, et al. Local tumor bed recurrence following partial nephrectomy in patients with small renal masses. J Urol, 2018, 199(2): 393-400.
18.	Shum CF, Bahler CD, Sundaram CP. Impact of positive surgical margins on overall survival after partial nephrectomy-A matched comparison based on the National Cancer Database. Urol Oncol, 2018, 36(3): e15-e21.
19.	Mouracade P, Chavali JS, Kara O, et al. Imaging strategy and outcome following partial nephrectomy. Urol Oncol, 2017, 35(11): e1-e8.
20.	Peng D, He ZS, Li XS, et al. Partial nephrectomy for T3aN0M0 renal cell carcinoma: shall we step forward?. Int Braz J Urol, 2017, 43(5): 849-856.
21.	Bigot P, Bernhard JC, Flamand V, et al. Members of the kidney cancer group of the CCAFU. Localized chromophobe carcinomas treated by nephron-sparing surgery have excellent oncologic outcomes. Urol Oncol, 2017, 35(1): e15-e19.
22.	Maurice MJ, Zhu H, Kim SP, et al. Reexamining the association between positive surgical margins and survival after partial nephrectomy in a large American cohort. J Endourol, 2016, 30(6): 698-703.
23.	Kang HW, Lee SK, Kim WT, et al. Surgical margin does not influence recurrence rate in pt1 clear cell renal cell carcinoma after partial nephrectomy: a multicenter study. J Surg Oncol, 2016, 114(1): 70-74.
24.	Kieran K, Williams MA, Dome JS, et al. Margin status and tumor recurrence after nephron-sparing surgery for bilateral wilms tumor. J Pediatr Surg, 2013, 48(7): 1481-1485.
25.	Khalifeh A, Kaouk JH, Bhayani S, et al. Positive surgical margins in robot-assisted partial nephrectomy: a multi-institutional analysis of oncologic outcomes (leave no tumor behind). J Urol, 2013, 190(5): 1674-1679.
26.	Ani I, Finelli A, Alibhai SM, et al. Prevalence and impact on survival of positive surgical margins in partial nephrectomy for renal cell carcinoma: a population-based study. BJU Int, 2013, 111(8): E300-E305.
27.	Saito H, Matsuda T, Tanabe K, et al. Surgical and oncologic outcomes of laparoscopic partial nephrectomy: a japanese multi-institutional study of 1375 patients. J Endourol, 2012, 26(6): 652-659.
28.	Bensalah K, Pantuck AJ, Rioux-Leclercq N, et al. Positive surgical margin appears to have negligible impact on survival of renal cell carcinomas treated by nephron-sparing surgery. Eur Urol, 2010, 57(3): 466-471.
29.	Yossepowitch O, Thompson RH, Leibovich BC, et al. Positive surgical margins at partial nephrectomy: predictors and oncological outcomes. J Urol, 2008, 179(6): 2158-2163.
30.	Kwon EO, Carver BS, Snyder ME, et al. Impact of positive surgical margins in patients undergoing partial nephrectomy for renal cortical tumours. BJU Int, 2007, 99(2): 286-289.
31.	Sutherland SE, Resnick MI, Maclennan GT, et al. Does the size of the surgical margin in partial nephrectomy for renal cell cancer really matter? J Urol, 2002, 167(1): 61-64.
32.	Mir MC, Derweesh I, Porpiglia F, et al. Partial nephrectomy versus radical nephrectomy for clinical t1b and t2 renal tumors: a systematic review and meta-analysis of comparative studies. Eur Urol, 2017, 71(4): 606-617.
33.	Laganosky DD, Filson CP, Master VA. Surgical margins in nephron-sparing surgery for renal cell carcinoma. Curr Urol Rep, 2017, 18(1): 8.
34.	Abu-Ghanem Y, Ramon J, Berger R, et al. Positive surgical margin following radical nephrectomy is an independent predictor of local recurrence and disease-specific survival. World J Surg Oncol, 2017, 15(1): 193.
35.	Tellini R, Antonelli A, Tardanico R, et al. Positive surgical margins predict progression-free survival after nephron-sparing surgery for renal cell carcinoma: results from a single center cohort of 459 cases with a minimum follow-up of 5 years. Clin Genitourin Cancer, 2019, 17(1): e26-e31.
36.	Hüttner FJ, Doerr-Harim C, Probst P, et al. Study methods in evidence-based surgery: methodological impediments and suggested approaches for the creation and transfer of knowledge in surgery. Eur Surg Res, 2014, 53(1-4): 86-94.
37.	Diener MK, Simon T, Büchler MW, et al. Surgical evaluation and knowledge transfer--methods of clinical research in surgery. Langenbecks Arch Surg, 2012, 397(8): 1193-1199.
38.	Meshikhes AW. Evidence-based surgery: the obstacles and solutions. Int J Surg, 2015, 18: 159-162.
39.	Garas G, Ibrahim A, Ashrafian H, et al. Evidence-based surgery: barriers, solutions, and the role of evidence synthesis. World J Surg, 2012, 36(8): 1723-1731.

1. Ferlay J, Colombet M, Soerjomataram I, et al. Cancer incidence and mortality patterns in Europe: estimates for 40 countries and 25 major cancers in 2018. Eur J Cancer, 2018, 103: 356-387.
2. MacLennan S, Imamura M, Lapitan MC, et al. Systematic review of perioperative and quality-of-life outcomes following surgical management of localised renal cancer. Eur Urol, 2012, 62(6): 1097-1117.
3. Thompson RH, Boorjian SA, Lohse CM, et al. Radical nephrectomy for pt1a renal masses may be associated with decreased overall survival compared with partial nephrectomy. J Urol, 2008, 179(2): 468-471.
4. Miller DC, Schonlau M, Litwin MS, et al. Renal and cardiovascular morbidity after partial or radical nephrectomy. Cancer, 2008, 112(3): 511-520.
5. Scosyrev E, Messing EM, Sylvester R, et al. Renal function after nephron-sparing surgery versus radical nephrectomy: results from eortc randomized trial 30904. Eur Urol, 2014, 65(2): 372-377.
6. Choi JE, You JH, Kim DK, et al. Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: a systematic review and meta-analysis. Eur Urol, 2015, 67(5): 891-901.
7. Shah PH, Moreira DM, Okhunov Z, et al. Positive surgical margins increase risk of recurrence after partial nephrectomy for high risk renal tumors. J Urol, 2016, 196(2): 327-334.
8. Rothberg MB, Peak TC, Reynolds CR, et al. Long-term oncologic outcomes of positive surgical margins following robot-assisted partial nephrectomy. Transl Androl Urol, 2020, 9(2): 879-886.
9. Rothberg MB, Paulucci DJ, Okhawere KE, et al. A multi-institutional analysis of the effect of positive surgical margins following robot-assisted partial nephrectomy on oncologic outcomes. J Endourol, 2020, 34(3): 304-311.
10. 熊国兵, 邱明星. 第四章研究/证据质量评估. 张天嵩, 钟文昭, 李博, 主编. 实用循证医学方法学(第2版). 长沙: 中南大学出版社, 2014: 95-227.
11. Kizilay F, Eskidemir U, Bahceci T, et al. The effect of surgical margin on cancer-specific survival in patients treated with nephron-sparing surgery. Niger J Clin Pract, 2019, 22(10): 1396-1402.
12. Daly K, Walsh A, Cahill A, et al. Partial nephrectomy and positive margins: What is the significance? European Urology, Supplements. Conference: Annual Meeting of the Irish Society of Urology (ISU), 2019, 18(5): e2545.
13. Mari A, Tellini R, Amparore D, et al. Assessment of clinicopathological predictors of local recurrence on tumor resection bed in patients treated with partial nephrectomy for localized renal cell carcinoma (the RECORd 1 project). European Urology, Supplements. Conference: EAU19: 34th Annual EAU Congress, 2019, 18(1): e427-e428.
14. Petros FG, Metcalfe MJ, Yu KJ, et al. Oncologic outcomes of patients with positive surgical margin after partial nephrectomy: a 25-year single institution experience. World J Urol, 2018, 36(7): 1093-1101.
15. Marchiñena PG, Tirapegui S, Gonzalez IT, et al. Positive surgical margins are predictors of local recurrence in conservative kidney surgery for pT1 tumors. Int Braz J Urol, 2018, 44(3): 475-482.
16. Tellini R, Antonelli A, Tardanico R, et al. Positive surgical margins predict progression-free survival after nephron-sparing surgery for renal cell carcinoma: results from a single center cohort of 459 cases with a minimum follow-up of 5 years. Clin Genitourin Cancer, 2019, 17(1): e2-e31.
17. Wood EL, Adibi M, Qiao W, et al. Local tumor bed recurrence following partial nephrectomy in patients with small renal masses. J Urol, 2018, 199(2): 393-400.
18. Shum CF, Bahler CD, Sundaram CP. Impact of positive surgical margins on overall survival after partial nephrectomy-A matched comparison based on the National Cancer Database. Urol Oncol, 2018, 36(3): e15-e21.
19. Mouracade P, Chavali JS, Kara O, et al. Imaging strategy and outcome following partial nephrectomy. Urol Oncol, 2017, 35(11): e1-e8.
20. Peng D, He ZS, Li XS, et al. Partial nephrectomy for T3aN0M0 renal cell carcinoma: shall we step forward?. Int Braz J Urol, 2017, 43(5): 849-856.
21. Bigot P, Bernhard JC, Flamand V, et al. Members of the kidney cancer group of the CCAFU. Localized chromophobe carcinomas treated by nephron-sparing surgery have excellent oncologic outcomes. Urol Oncol, 2017, 35(1): e15-e19.
22. Maurice MJ, Zhu H, Kim SP, et al. Reexamining the association between positive surgical margins and survival after partial nephrectomy in a large American cohort. J Endourol, 2016, 30(6): 698-703.
23. Kang HW, Lee SK, Kim WT, et al. Surgical margin does not influence recurrence rate in pt1 clear cell renal cell carcinoma after partial nephrectomy: a multicenter study. J Surg Oncol, 2016, 114(1): 70-74.
24. Kieran K, Williams MA, Dome JS, et al. Margin status and tumor recurrence after nephron-sparing surgery for bilateral wilms tumor. J Pediatr Surg, 2013, 48(7): 1481-1485.
25. Khalifeh A, Kaouk JH, Bhayani S, et al. Positive surgical margins in robot-assisted partial nephrectomy: a multi-institutional analysis of oncologic outcomes (leave no tumor behind). J Urol, 2013, 190(5): 1674-1679.
26. Ani I, Finelli A, Alibhai SM, et al. Prevalence and impact on survival of positive surgical margins in partial nephrectomy for renal cell carcinoma: a population-based study. BJU Int, 2013, 111(8): E300-E305.
27. Saito H, Matsuda T, Tanabe K, et al. Surgical and oncologic outcomes of laparoscopic partial nephrectomy: a japanese multi-institutional study of 1375 patients. J Endourol, 2012, 26(6): 652-659.
28. Bensalah K, Pantuck AJ, Rioux-Leclercq N, et al. Positive surgical margin appears to have negligible impact on survival of renal cell carcinomas treated by nephron-sparing surgery. Eur Urol, 2010, 57(3): 466-471.
29. Yossepowitch O, Thompson RH, Leibovich BC, et al. Positive surgical margins at partial nephrectomy: predictors and oncological outcomes. J Urol, 2008, 179(6): 2158-2163.
30. Kwon EO, Carver BS, Snyder ME, et al. Impact of positive surgical margins in patients undergoing partial nephrectomy for renal cortical tumours. BJU Int, 2007, 99(2): 286-289.
31. Sutherland SE, Resnick MI, Maclennan GT, et al. Does the size of the surgical margin in partial nephrectomy for renal cell cancer really matter? J Urol, 2002, 167(1): 61-64.
32. Mir MC, Derweesh I, Porpiglia F, et al. Partial nephrectomy versus radical nephrectomy for clinical t1b and t2 renal tumors: a systematic review and meta-analysis of comparative studies. Eur Urol, 2017, 71(4): 606-617.
33. Laganosky DD, Filson CP, Master VA. Surgical margins in nephron-sparing surgery for renal cell carcinoma. Curr Urol Rep, 2017, 18(1): 8.
34. Abu-Ghanem Y, Ramon J, Berger R, et al. Positive surgical margin following radical nephrectomy is an independent predictor of local recurrence and disease-specific survival. World J Surg Oncol, 2017, 15(1): 193.
35. Tellini R, Antonelli A, Tardanico R, et al. Positive surgical margins predict progression-free survival after nephron-sparing surgery for renal cell carcinoma: results from a single center cohort of 459 cases with a minimum follow-up of 5 years. Clin Genitourin Cancer, 2019, 17(1): e26-e31.
36. Hüttner FJ, Doerr-Harim C, Probst P, et al. Study methods in evidence-based surgery: methodological impediments and suggested approaches for the creation and transfer of knowledge in surgery. Eur Surg Res, 2014, 53(1-4): 86-94.
37. Diener MK, Simon T, Büchler MW, et al. Surgical evaluation and knowledge transfer--methods of clinical research in surgery. Langenbecks Arch Surg, 2012, 397(8): 1193-1199.
38. Meshikhes AW. Evidence-based surgery: the obstacles and solutions. Int J Surg, 2015, 18: 159-162.
39. Garas G, Ibrahim A, Ashrafian H, et al. Evidence-based surgery: barriers, solutions, and the role of evidence synthesis. World J Surg, 2012, 36(8): 1723-1731.

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