Abstract
Renal tumor enucleation allows for maximal parenchymal preservation. Identifying pseudocapsule integrity is critically important in nephron sparing surgery by enucleation. Tumor invasion into and through the capsule may have clinical implications, although it is not routinely commented on in standard pathological reporting. We describe a system to standardize the varying degrees of pseudocapsule invasion and identify predictors of invasion. We performed a multicenter retrospective review between 2002 and 2014 at Indiana University Hospital and Loyola University Medical Center. A total of 327 tumors were evaluated following removal via radical nephrectomy, standard margin partial nephrectomy or enucleation partial nephrectomy. Pathologists scored tumors using our i-Cap (invasion of pseudocapsule) scoring system. Multivariate analysis was done to determine predictors of higher score tumors. Tumor characteristics were similar among surgical resection groups. Enucleated tumors tended to have thinner pseudocapsule rims but not higher i-Cap scores. Rates of complete capsular invasion, scored as i-Cap 3, were similar among the surgical techniques, comprising 22% of the overall cohort. Papillary histology along with increasing tumor grade was predictive of an i-Cap 3 score. A capsule invasion scoring system is useful to classify renal cell carcinoma pseudocapsule integrity. i-Cap scores appear to be independent of surgical technique. Complete capsular invasion is most common in papillary and high grade tumors. Further work is warranted regarding the relevance of capsular invasion depth as it relates to the oncologic outcome for local recurrence and disease specific survival.
Highlights
Partial nephrectomy (PN) remains the preferred surgical therapy for renal masses less than 7 centimeters whenever feasible secondary to the well described benefits of nephron preservation and equivalent oncologic outcomes when compared to radical nephrectomy.[1,2] Tumor enucleation (TE) is a nephron sparing surgical technique, commonly employed in patients with hereditary renal syndromes, which maximally preserves normal renal parenchyma.[3]
A capsule invasion scoring system is useful in classifying renal cell carcinoma (RCC) pseudocapsule integrity. invasion of pseudocapsule (i-Cap) scores appear independent of surgical technique
Further work regarding the relevance of capsular invasion depth as it relates to oncological outcome in both local recurrence and disease specific survival is warranted
Summary
Partial nephrectomy (PN) remains the preferred surgical therapy for renal masses less than 7 centimeters whenever feasible secondary to the well described benefits of nephron preservation and equivalent oncologic outcomes when compared to radical nephrectomy.[1,2] Tumor enucleation (TE) is a nephron sparing surgical technique, commonly employed in patients with hereditary renal syndromes, which maximally preserves normal renal parenchyma.[3]. Renal tumor enucleation takes advantage of the renal tumor pseudocapsule, consisting of a fibrous band of compressed renal parenchyma that isolates the tumor from the surrounding healthy renal parenchyma and provides a natural dissection plane during surgery (Figure 1).[6] When compared to healthy margin partial nephrectomy for RCC, tumor enucleation has demonstrated comparable oncological outcomes in some series.[7] Opponents of this technique caution that the integrity of the tumor pseudocapsule may predict the presence of a positive surgical margin. Several publications have suggested that the presence of a positive margin does not predict tumor recurrence after partial nephrectomy, pathologic invasion of the tumor pseudocapsule may play an important role in predicting cancer recurrence and overall worse outcomes.[8,9,10,11,12] Surgeons have recently purposely enucleated renal tumors at the base of the tumor/parenchymal interface, leading to a new standardization of surgical technique reporting.[5]
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