EXPANDING INDICATIONS FOR CONSERVATIVE RENAL SURGERY IN RENAL-CELL CARCINOMA

Objective. To more clearly define the selection criteria for conservat ive renal surgery in renal cell carcinoma. Method. The survival experi ence of 42 patients who underwent in situ partial nephrectomy (21), en ucleation (18), or both (3) over an eighteen-year period was examined. The presence or a history of contralateral cancer, type of surgery, g ender, grade, diameter of tumor, age at diagnosis, presenting symptoms , positive surgical margins, smoking history, and stage were examined with regard to prognostic significance. Results. The five-year cancer- specific survival rates were 100 percent for those patients undergoing partial nephrectomy and 84 percent for those undergoing enucleation. The local recurrence rate was 4.8 percent (2/42) for the group, with b oth recurrences occurring in patients with von Hippel-Lindau disease. The mean diameter of tumor resected was 4.2 cm. Those patients found t o have a positive surgical margin (6) had a significantly shorter dise ase-specific survival than those who did not (37) (p = 0.004), and tho se with a smoking history (23) had a significantly shorter survival th an non-smokers (19) (p = 0.038). Conclusions. We conclude that both pa rtial nephrectomy and enucleation are acceptable approaches to renal c ell carcinoma in select cases, with survival rates that closely approx imate those found in radical nephrectomy series. Renal carcinomas that are peripherally located and small in diameter (less-than-or-equal-to 5 cm) are most appropriate for these procedures, and given the excell ent results noted to date, the expanded use of these approaches to inc lude very young patients and those with any disease process that may a ffect renal function is warranted. A positive surgical margin is an om inous pathologic finding and should be avoided by frozen section biops y at surgery or possibly intraoperative ultrasonography. Additionally, smokers with renal cell carcinoma have a poorer disease-specific surv ival than non-smokers, further questioning a carcinogenic etiology in this disease.