Drs. Puppo and coworkers have to be congratulated for the presentation of their findings in a series of 94 clinically pT1a renal masses treated by enucleoresection and followed for a median follow up of nearly 5 years [1]. The authors specifically reported on the safety and effectiveness of their technique that consist in “excising the tumor taking care of leaving around it a minimal layer of healthy renal tissue technically feasible” and therefore they present their point of view on the precise amount of healthy parenchyma to excise with the tumor to avoid the risk of positive surgical margins and/or local recurrence, that currently represents a subject of a great controversy. On the basis of the mean and median shortest distance from tumor to inked healthy tissue (2.4mm and 1.9mm) and of their excellent 5-year cancer-specific and disease-specific survival rates (98.9%) the authors conclude that histologic tumor-free resection margins, leaving only 2–3mm of grossly normal renal parenchyma are sufficient to achieve complete local excision of renal cell cancer [1]. Interestingly, in this paper, the authors failed to provide the data about the range shortest distance from tumor to inked healthy tissue so we do not know whether or not in some of their enucleoresections they excised the tumor without a rim of normal parenchyma but only with its pseudocapsule, in other words performing a simple enucleation technique that implies to enucleate the tumor, using the natural cleavage plane between the pseudocapsule and normal parenchyma. In their study, none of the patients experience local recurrence and only one patient with a pT3a/G3 tumor experienced progressive metastatic disease without local recurrence and died of renal cell carcinoma [1], therefore another conclusion not stated in the paper would be that the width of healthy parenchyma does not correlate with local recurrence/disease progression. Several recently published papers on this issue, have reached this conclusion. Castilla et al. microscopically measured the width of the resection margins in a group of 107 patients treated by NSS and concluded that, after a mean follow-up of 8.5 years, the width of healthy parenchyma did not correlate with disease progression when expressed as a continuous or a categorical variable, one of the categories being a resection margin of <1mm [2]. Accordingly, Sutherland et al. concluded that if the tumor is completely excised, the margin size is irrelevant and not correlated with disease progression [3]. Moreover, in the Piper series reported by the authors in the discussion it is true that all the 49 patients treated by NSS with margins >1mm were alive and free from local recurrence and distant metastasis at a mean follow up of 60 months [4]. But, interestingly, among the tumors resected with <1mm margins of healthy tissue no local recurrences alone were diagnosed while in 1 case (9%) local recurrence and lung metastasis were diagnosed simultaneously 5 months after the operation [4]; the early detection of metastatic lesions postoperatively, as in this case, implying concomitant and clinically undetectable systemic disease at the time of NSS. Another major concern after elective NSS is the risk of unknown multifocality that is 5–6% [5] and [6]. But the incidence of local recurrence due to tumor multifocality is not related to the width of the resection margins and therefore to the type of conservative NSS adopted. Indeed, published evidence shows that most of the satellite lesions are found >1.0cm beyond the primary tumor [7] and [8]. Drs. Puppo and coworkers as all the abovementioned authors do not advocate tumor enucleation as an acceptable approach for NSS but effectively provide an intriguing insight into the real necessity of adequate surgical margins and therefore into the possibility to perform a simple enucleation technique in such patients. As far as we are concerned, simple enucleation is our treatment of choice for NSS since the late 1980s with excellent long-term progression free and cancer-specific survival rates comparable to those presented by Puppo and coworkers.

Re: Puppo P, Introini C, Calvi P, Naselli A. Long term results of excision of small renal cancer surrounded by a minimal layer of grossly normal parenchyma: review of 94 cases. Eur Urol 2004;46:477-81 / Carini M;Lapini A;Minervini A;Serni S. - In: EUROPEAN UROLOGY. - ISSN 0302-2838. - STAMPA. - 47:(2005), pp. 264-267. [10.1016/j.eururo.2004.10.012]

Re: Puppo P, Introini C, Calvi P, Naselli A. Long term results of excision of small renal cancer surrounded by a minimal layer of grossly normal parenchyma: review of 94 cases. Eur Urol 2004;46:477-81.

CARINI, MARCO;MINERVINI, ANDREA;SERNI, SERGIO
2005

Abstract

Drs. Puppo and coworkers have to be congratulated for the presentation of their findings in a series of 94 clinically pT1a renal masses treated by enucleoresection and followed for a median follow up of nearly 5 years [1]. The authors specifically reported on the safety and effectiveness of their technique that consist in “excising the tumor taking care of leaving around it a minimal layer of healthy renal tissue technically feasible” and therefore they present their point of view on the precise amount of healthy parenchyma to excise with the tumor to avoid the risk of positive surgical margins and/or local recurrence, that currently represents a subject of a great controversy. On the basis of the mean and median shortest distance from tumor to inked healthy tissue (2.4mm and 1.9mm) and of their excellent 5-year cancer-specific and disease-specific survival rates (98.9%) the authors conclude that histologic tumor-free resection margins, leaving only 2–3mm of grossly normal renal parenchyma are sufficient to achieve complete local excision of renal cell cancer [1]. Interestingly, in this paper, the authors failed to provide the data about the range shortest distance from tumor to inked healthy tissue so we do not know whether or not in some of their enucleoresections they excised the tumor without a rim of normal parenchyma but only with its pseudocapsule, in other words performing a simple enucleation technique that implies to enucleate the tumor, using the natural cleavage plane between the pseudocapsule and normal parenchyma. In their study, none of the patients experience local recurrence and only one patient with a pT3a/G3 tumor experienced progressive metastatic disease without local recurrence and died of renal cell carcinoma [1], therefore another conclusion not stated in the paper would be that the width of healthy parenchyma does not correlate with local recurrence/disease progression. Several recently published papers on this issue, have reached this conclusion. Castilla et al. microscopically measured the width of the resection margins in a group of 107 patients treated by NSS and concluded that, after a mean follow-up of 8.5 years, the width of healthy parenchyma did not correlate with disease progression when expressed as a continuous or a categorical variable, one of the categories being a resection margin of <1mm [2]. Accordingly, Sutherland et al. concluded that if the tumor is completely excised, the margin size is irrelevant and not correlated with disease progression [3]. Moreover, in the Piper series reported by the authors in the discussion it is true that all the 49 patients treated by NSS with margins >1mm were alive and free from local recurrence and distant metastasis at a mean follow up of 60 months [4]. But, interestingly, among the tumors resected with <1mm margins of healthy tissue no local recurrences alone were diagnosed while in 1 case (9%) local recurrence and lung metastasis were diagnosed simultaneously 5 months after the operation [4]; the early detection of metastatic lesions postoperatively, as in this case, implying concomitant and clinically undetectable systemic disease at the time of NSS. Another major concern after elective NSS is the risk of unknown multifocality that is 5–6% [5] and [6]. But the incidence of local recurrence due to tumor multifocality is not related to the width of the resection margins and therefore to the type of conservative NSS adopted. Indeed, published evidence shows that most of the satellite lesions are found >1.0cm beyond the primary tumor [7] and [8]. Drs. Puppo and coworkers as all the abovementioned authors do not advocate tumor enucleation as an acceptable approach for NSS but effectively provide an intriguing insight into the real necessity of adequate surgical margins and therefore into the possibility to perform a simple enucleation technique in such patients. As far as we are concerned, simple enucleation is our treatment of choice for NSS since the late 1980s with excellent long-term progression free and cancer-specific survival rates comparable to those presented by Puppo and coworkers.
2005
47
264
267
Carini M;Lapini A;Minervini A;Serni S
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Utilizza questo identificatore per citare o creare un link a questa risorsa: https://hdl.handle.net/2158/687328
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