52
H. Furberg et al. / Urologic Oncology: Seminars and Original Investigations 33 (2015) 49–52
medical, and radiation oncologists with open-minded communication and regular reports and conferences. While all of these support systems provide an invaluable sounding board, information is relayed and decisions are finalized in the office where the individual physician makes face-to-face and hands on patient contact. A urologist embarking in this treatment space must be absolutely current. Even lapses of 6 months in education and interaction will diminish this currency. Moreover, the urologist cannot presume that referral to medical oncology provides a ready solution to the patient's care. A medical oncologist with a practice caring for patients with breast cancer, lung cancer, colon cancer is unable to be abreast of the developments in prostate cancer.
In either specialty, the immediate need calls for disease state–focused physician—a champion. These champions will be the near-term backbone delivering informed and current therapy for patients with castration-resistant metastatic prostate cancer. When these champions are identified and step forward, their unique needs must be recognized, encouraged, and supported. From their efforts, the de Vere White/Lara framework may eventually materialize.
Surgeons' preferences and practice patterns regarding intraoperative frozen section during partial nephrectomy
tumors in their retrospective study of renal cell carcinoma specimens. Do the authors have an opinion about surgeon preference in these patients? It was shown that the nephrectomy specimen after partial nephrectomy will contain tumor remnants in 6.9% to 15% of cases [4,5]. Radical nephrectomy can be done to these patients, especially in tumors with high malignant potential. However, it is not possible every time to find tumor in final pathology. By considering this situation, do the authors offer nephrectomy to these patients without IFS?
To the Editor: The authors conducted a study to evaluate the preferences and practice patterns of urologists regarding intraoperative frozen section (IFS) during partial nephrectomy. The risk of incomplete tumor removal is a major problem related to surgical outcomes of partial nephrectomy. It is unclear how to define the patient at risk for a positive surgical margin (PMS) and for disease recurrence after PMS and if the incidence of PMS is related to the surgical approach or technique [1]. To ensure negative margins, IFS) analysis of resected tumor is commonly done [2]. However, there are falsenegative or inconclusive results of IFS that do not correlate with the final pathology. Moreover, tumor-bed biopsies represent only a small fraction of the resection margin and generally deliver unreliable results [1]. The current article represents a different point of view of surgeons' and practice patterns regarding IFS during partial nephrectomy. The authors concluded that most surgeons still obtain IFS during partial nephrectomy despite low utility of frozen section. We believe IFS is time consuming during surgery because it does not give distinguishing knowledge about tumor remnants and we do not prefer taking routine frozen section. There is a great interest for performing partial nephrectomy to T1b stage tumors. However, partial nephrectomies may result in higher tumor recurrence rates because of PMSs or multifocal tumors [3]. Chen et al. [3] indicate that 4 mm may be optimal surgical margin for patients with T1b
Paul Schellhammer, M.D. Department of Urology, Eastern Virginia Medical School, Urology of Virginia, 225 Clearfield Road, Virginia Bench, Virginia 23462
Yasin Ceylan, M.D. Bülent Günlüsoy, M.D. Department of Urology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
References [1] Marszalek M, Carini M, Chlosta P, Jeschke K, Kirkali Z, Knüchel R. Positive surgical margins after nephron-sparing surgery. Eur Urol 2012;61:757–63. [2] Sidana A, Donovan JF, Gaitonde K. Surgeons' preferences and practice patterns regarding intraoperative frozen section during partial nephrectomy. Urol Oncol 2014;32:864–8. [3] Chen XS, Zhang ZT, Du J, Bi XC, Sun G, Yao X. Optimal surgical margin in nephron-sparing surgery for T1b renal cell carcinoma. Urology 2012;79:836–9. [4] Raz O, Mendlovic S, Shilo Y, et al. Positive surgical margins with renal cell carcinoma have a limited influence on long-term oncological outcomes of nephron-sparing surgery. Urology 2010;75:277–80. [5] Sundram V, Figenshau RS, Roytman TM, et al. Positive margin during partial neprectomy: does cancer remain in the renal remnant? Urology 2011;77:1400–3.
H. Furberg et al. / Urologic Oncology: Seminars and Original Investigations 33 (2015) 49–52
medical, and radiation oncologists with open-minded communication and regular reports and conferences. While all of these support systems provide an invaluable sounding board, information is relayed and decisions are finalized in the office where the individual physician makes face-to-face and hands on patient contact. A urologist embarking in this treatment space must be absolutely current. Even lapses of 6 months in education and interaction will diminish this currency. Moreover, the urologist cannot presume that referral to medical oncology provides a ready solution to the patient's care. A medical oncologist with a practice caring for patients with breast cancer, lung cancer, colon cancer is unable to be abreast of the developments in prostate cancer.
In either specialty, the immediate need calls for disease state–focused physician—a champion. These champions will be the near-term backbone delivering informed and current therapy for patients with castration-resistant metastatic prostate cancer. When these champions are identified and step forward, their unique needs must be recognized, encouraged, and supported. From their efforts, the de Vere White/Lara framework may eventually materialize.
Surgeons' preferences and practice patterns regarding intraoperative frozen section during partial nephrectomy
tumors in their retrospective study of renal cell carcinoma specimens. Do the authors have an opinion about surgeon preference in these patients? It was shown that the nephrectomy specimen after partial nephrectomy will contain tumor remnants in 6.9% to 15% of cases [4,5]. Radical nephrectomy can be done to these patients, especially in tumors with high malignant potential. However, it is not possible every time to find tumor in final pathology. By considering this situation, do the authors offer nephrectomy to these patients without IFS?
To the Editor: The authors conducted a study to evaluate the preferences and practice patterns of urologists regarding intraoperative frozen section (IFS) during partial nephrectomy. The risk of incomplete tumor removal is a major problem related to surgical outcomes of partial nephrectomy. It is unclear how to define the patient at risk for a positive surgical margin (PMS) and for disease recurrence after PMS and if the incidence of PMS is related to the surgical approach or technique [1]. To ensure negative margins, IFS) analysis of resected tumor is commonly done [2]. However, there are falsenegative or inconclusive results of IFS that do not correlate with the final pathology. Moreover, tumor-bed biopsies represent only a small fraction of the resection margin and generally deliver unreliable results [1]. The current article represents a different point of view of surgeons' and practice patterns regarding IFS during partial nephrectomy. The authors concluded that most surgeons still obtain IFS during partial nephrectomy despite low utility of frozen section. We believe IFS is time consuming during surgery because it does not give distinguishing knowledge about tumor remnants and we do not prefer taking routine frozen section. There is a great interest for performing partial nephrectomy to T1b stage tumors. However, partial nephrectomies may result in higher tumor recurrence rates because of PMSs or multifocal tumors [3]. Chen et al. [3] indicate that 4 mm may be optimal surgical margin for patients with T1b
Paul Schellhammer, M.D. Department of Urology, Eastern Virginia Medical School, Urology of Virginia, 225 Clearfield Road, Virginia Bench, Virginia 23462
Yasin Ceylan, M.D. Bülent Günlüsoy, M.D. Department of Urology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
References [1] Marszalek M, Carini M, Chlosta P, Jeschke K, Kirkali Z, Knüchel R. Positive surgical margins after nephron-sparing surgery. Eur Urol 2012;61:757–63. [2] Sidana A, Donovan JF, Gaitonde K. Surgeons' preferences and practice patterns regarding intraoperative frozen section during partial nephrectomy. Urol Oncol 2014;32:864–8. [3] Chen XS, Zhang ZT, Du J, Bi XC, Sun G, Yao X. Optimal surgical margin in nephron-sparing surgery for T1b renal cell carcinoma. Urology 2012;79:836–9. [4] Raz O, Mendlovic S, Shilo Y, et al. Positive surgical margins with renal cell carcinoma have a limited influence on long-term oncological outcomes of nephron-sparing surgery. Urology 2010;75:277–80. [5] Sundram V, Figenshau RS, Roytman TM, et al. Positive margin during partial neprectomy: does cancer remain in the renal remnant? Urology 2011;77:1400–3.
