Traditionally, radical nephrectomy (RN) has been the gold standard in the surgical management of clinical T1 renal masses; however, with evidence demonstrating equivalent oncologic outcomes and superior kidney functional outcomes, there has been a shift towards partial nephrectomy (PN) for cT1 renal tumors.
The choice of the type nephrectomy for cT1 tumors is dependent on patient factors such as age and comorbidities and tumors characteristics such as location, size and complexity. As time has gone on, experience with PN has increased, and surgeons have become comfortable managing tumors of increasing size and complexity with PN as opposed to RN. Not surprisingly, there has been an increase in the number of tumors found to have occult adverse pathologic features following PN.
Risk factors for upstaging cT1 tumors to pathologic T3a (pT3a) are poorly defined and the consequences of performing a PN on locally advanced kidney tumors remains unknown. By striving to maximize renal preservation and improve kidney functional outcomes, it is only natural to second guess the decision to perform a PN, since cT3a tumors are usually managed with radical nephrectomy. By performing elective PN on pT3a tumors, questions are raised regarding the risk of local and distant recurrence, the need for “completion” nephrectomy and a compromise of oncologic outcomes.
There is a paucity of literature addressing the issue of occult pT3a tumors. Our report suggests that a PN for pT3a tumors does not necessarily implicate a worsened outcome when compared to RN. In the short and intermediate follow-up duration, patients with pathological upstaging did not fare any worse than non-upstaged patients at our institution. Oncologic outcomes were similar between both groups and those treated with PN benefited from better renal function. Our findings thus suggest that in spite of pT3a pathological upstaging, adjuvant treatment may not necessarily be warranted. It is the opinion of the authors, however, that given the risk of recurrence with pT3a tumors, the post-operative surveillance imaging schedule should appropriately reflect the upgraded stage.
Obviously, proper patient selection is compulsory for optimizing treatment outcomes. Since size appeared to be the only pre-operative predictor of pathologic upstaging, it remains difficult to accurately identify patients at risk for unfavorable pathology following PN. Surgeons will continue to refine the limits of PN until it becomes obvious as to which lines cannot be crossed. Until that time, unanticipated upstaging will continue to occur. Based on our findings, however, PN for pT3a tumors may not necessarily alter oncologic outcomes and should not prompt additional treatment unless clinically warranted.
Krishna Ramaswamy, MD, Emil Kheterpal, MD, Hai Pham, Sanjay Mohan, Michael
Stifelman, MD, Samir Taneja, MD, William C. Huang, MD