Introduction and Objectives: Local recurrence (LR) in patients treated with surgery for renal cell carcinoma (RCC) remains a significant clinical challenge that requires thorough investigation. Our study aimed to identify the relative risk factors and explore the optimal clinical management of LR. Materials and Methods: We conducted a non-randomized, observational, retrospective multicentric registry involving multiple Italian urological centers. We included patients treated with surgery (either nephron-sparing or radical nephrectomy) who later developed LR, defined as recurrence in the ipsilateral kidney or renal fossa. Patients with hereditary syndromes or metastatic disease at the time of LR diagnosis were excluded. Results: We reported 135 cases of LR with the following characteristics: most primary lesions were monofocal (85.7%), with a median size of 42 mm (23–53), the median R.E.N.A.L. score was 7 (6–8), and the median Padua score was 7 (6–9). Patients were treated with robot-assisted techniques in 59% of cases, laparoscopic surgery in 32.4%, and open surgery in 8.6%. Nephron-sparing surgery was performed in 75.2% of cases. Ischemia occurred in 61% of the cases, with a median ischemia time of 21 min (15.5–24). Intraoperative complications occurred in 3.8% of cases, while postoperative complications were reported in 13.8%, all of which were grade ≤3 according to the Clavien–Dindo classification. The primary tumors were pT1a in 43.5% of cases, pT1b in 26.3%, pT2 in 14.7% and pT3 in 15.5%. Histologically, 84% of cases were clear cell, 11.3% papillary type 1 or 2, and 3.7% chromophobe. Sarcomatoid/rhabdoid variants were present in 10.5% of cases. The median rate of LR was 1.3% (range 0.2–3.6), while the median time to LR was 18 months (12–39). LR occurred in the ipsilateral kidney in 70.5% of cases and in the ipsilateral renal fossa in 29.5%. The median rate of PSM in LR cases at initial surgery was 2.4% (range 0–4.3), while the median rate of negative surgical margin (NSM) in LR cases at initial surgery was 0.1 (0–0.3). Following LR diagnosis, most patients (49.2%) underwent surgery, 29.1% received cryoablation or radiotherapy, 17.1% received systemic treatment alone, and 4.6% followed a watchful waiting/active surveillance approach. At a median follow-up of 62 months, the highest oncological control in terms of 5-year cancer-specific survival and overall survival rates was achieved in surgically treated patients. The PSM, the histological variant, and their combination were found to be independent variables correlated with the occurrence of LR, with relative risks of 3.62, 2.71, and 8.12, respectively. Conclusions: LR after nephron-sparing or radical nephrectomy represents a significant clinical dilemma. Known risk factors are not always sufficient to predict recurrence, emphasizing the necessity of consistent radiological follow-up per guideline recommendations. Early detection of recurrence and a multidisciplinary approach involving expert centers are crucial for optimizing patient outcomes.
引言与目的：肾细胞癌术后局部复发仍是临床面临的重大挑战，亟需深入研究。本研究旨在识别相关风险因素并探索局部复发的最佳临床管理策略。材料与方法：我们开展了一项非随机、观察性、回顾性多中心注册研究，纳入多家意大利泌尿外科中心数据。研究对象为接受手术（肾单位保留术或根治性肾切除术）后出现局部复发的患者，局部复发定义为同侧肾脏或肾窝的复发。排除遗传综合征患者及局部复发诊断时已发生转移的患者。结果：共纳入135例局部复发患者，其特征如下：原发灶多为单灶性（85.7%），中位直径42毫米（23-53），中位R.E.N.A.L.评分7分（6-8），中位帕多瓦评分7分（6-9）。手术方式中机器人辅助技术占59%，腹腔镜手术占32.4%，开放手术占8.6%。75.2%的病例实施肾单位保留手术。61%的病例出现缺血，中位缺血时间21分钟（15.5-24）。术中并发症发生率为3.8%，术后并发症为13.8%，所有并发症按Clavien-Dindo分级均为≤3级。原发肿瘤分期：pT1a占43.5%，pT1b占26.3%，pT2占14.7%，pT3占15.5%。组织学类型：透明细胞癌84%，1型或2型乳头状癌11.3%，嫌色细胞癌3.7%。10.5%的病例存在肉瘤样/横纹肌样变异。局部复发中位率为1.3%（范围0.2-3.6），中位复发时间18个月（12-39）。70.5%的复发位于同侧肾脏，29.5%位于同侧肾窝。初次手术局部复发病例中切缘阳性中位率为2.4%（范围0-4.3），切缘阴性中位率为0.1%（0-0.3）。局部复发确诊后，49.2%的患者接受手术治疗，29.1%接受冷冻消融或放疗，17.1%仅接受全身治疗，4.6%采取观察等待/主动监测策略。中位随访62个月显示，手术治疗患者在5年癌症特异性生存率和总生存率方面获得最佳肿瘤学控制。研究发现切缘阳性、组织学变异及其组合是局部复发的独立相关因素，相对风险分别为3.62、2.71和8.12。结论：肾单位保留术或根治性肾切除术后局部复发是重要的临床难题。已知风险因素尚不足以完全预测复发，强调必须遵循指南建议进行规范影像学随访。早期发现复发并通过多学科协作在专业中心进行治疗，对优化患者预后至关重要。
Local Recurrence After Nephron Surgery: What to Do? An Italian Multicentric Registry
肿瘤(癌症)患者之家