Comparaison de la survie globale et des résultats oncologiques après nephrectomie partielle et radicale pour cancer du rein cT2a : une étude internationale menée par le réseau francais de recherche sur le cancer du rein UroCRR

25 mars 2018

Auteurs : B. Reix, J.-C. Bernhard, J.-J. Patard, P. Bigot, A. Villers, E. Suer, N.S. Vuong, G. Verhoest, Q. Alimi, J.-B. Beauval, T. Benoit, F.-X. Nouhaud, C. Lenormand, N. Hamidi, J. Cai, M. Eto, S. Larre, A. El Bakhri, G. Ploussard, A. Hung, N. Koutlidis, A. Schneider, J. Carrouget, S. Droupy, S. Marchal, A. Doerfler, S. Seddik, T. Matsugasumi, X. Orsoni, A. Descazeaud, C. Pfister, K. Bensalah, M. Soulie, I. Gill, V. Flamand, Kidney Cancer group of the CCAFU q
Référence : Prog Urol, 2018, 3, 28, 146-155




 




Introduction


The aging of population and the expansion of abdominal imaging in developed countries resulted in an increased incidence of renal cell carcinoma (RCC), including small tumors [1, 2]. Currently most tumors are fortuitously discovered at a localized stage [1].


However, epidemiological studies showed that despite earlier treatment of these cancers, there was no improvement in patients' overall survival (OS) after surgical management [3]. Survival would be dependent on other factors than cancer control. The main hypothesis is an increase in cardiovascular events caused by the deterioration of renal function after a kidney loss [4, 5, 6].


Partial nephrectomy (PN) aims to preserve kidney nephron and seems improving OS [7, 8, 9]. According Patard et al. [10], this benefit outweighs the increased peri-operative morbidity due to a highly technical act.


Indications of PN were initially limited to imperatives cases: solitary functional kidney, chronic kidney disease (CKD), bilateral synchronous tumors. Then it was extended to elective indications for the small size masses, which have low risk of recurrence. The PN is now the gold standard for cT1 tumors of UICC TNM classification of 2009 (size<7cm) [11].


The place of PN for tumors larger than 7cm (cT2) remains debated. PN is recommended in imperatives cases if surgery is technically feasible [11].


Many technical advances have improved surgical results on the nephron preservation and peri-operative morbidity. The question of the interest of PN in elective situation for cT2 stage tumors can be asked.


Several descriptive studies have demonstrated the feasibility of PN for cT2 tumors [12, 13, 14, 15]. The major complication rate between 11-15% of cases was acceptable [13, 14, 15]. Bigot et al. found significant impairment of renal function in only 22% of patients [15].


Oncologic risk limits achieving a partial surgery for these bad prognosis tumors. These tumors are often aggressive, with a greater proportion of high ISUP grade and a risk of upstaging (stage pT3a) [10, 16, 17]. However, recent publications showed equivalent oncologic results between PN and RN for treatment of high ISUP grade or pT3a stage [18, 19, 20].


Few studies compared PN and RN for cT2 tumors with discordant results [18, 19, 20]. Jeldres et al. found an increased risk of 5.3 times of cancer death in the PN group compared RN group [18]. Hansen et al. did not find significant differences in cancer specific survival (CSS) [19]. These studies included old cases and did not fully reflect modern practices of partial kidney surgery.


More recently, Shum et al. found a better OS for PN than RN for tumors>7cm (HR: 5.3), but do not study oncological results [21].


We hypothesized that tumor size>7cm was not a contraindication for PN.


The main objective of this study was to compare OS in patients treated surgically by RN or PN for cT2a stage renal cell carcinoma (7.1-10cm). Secondary objectives were to assess CSS and cancer free survival (CFS).


Materials and methods


Data collection


Data source


Data were obtained from retrospective bases of patients treated for renal tumor at any stage of the disease. It was an international multicenter study involving fifteen university centers:

twelve French centers that are part of UroCCR (Angers, Bordeaux, Caen, Dijon, Lille, Limoges, Nimes, Paris Saint-Louis, Reims, Rennes, Rouen and Toulouse);
one American center (University of Southern California);
one Japanese Center (Kumamoto);
one Turkish Center (Ankara).


All databases were reported to the respective ethics committees.


Study population


All patients who underwent surgical treatment for a localized renal cancer cT2a stage, between 1 January 2000 and 31 December 2014, were included.


The treatment was a laparoscopic RN, an open PN or a laparoscopic PN. The therapeutic decision was taken by the surgeon and validated in multi-disciplinary consultation meeting.


The cT2a stage was defined according to the 7th edition of the 2010 TNM Classification by tumor size between 7.1 and 10 centimeters in long axis on preoperative imaging (CT scan or MRI).


Exclusion criteria were:

age<18 years;
benign tumors;
not primary tumors of the kidney;
cancers associated with genetic defects;
pT≥3b stages;
patients N+or M+on the staging or final histological analysis.


Variables collected



Clinical and demographic data


Age, gender, ECOG performance status and the American society of anesthesiologists score (ASA) were collected.


Radiological data


Preoperative imaging specified tumor size and RENAL score [22].


Surgical data


Partial or radical nephrectomy, and the approach, open or pure laparoscopy or laparoscopy with robotic assistance were notified. In case of partial nephrectomy, elective (ePN) or imperative (iPN) indication was specified and the cause for iPN: single kidney, bilateral tumors, CKD (estimated GFR<60mL/min/1,73m2).


Histological data


The pathological record showed histological type according to WHO classification of 2004, ISUP grade, pTNM stage, invasion of the resection margins, microvascular invasion, tumor necrosis or sarcomatoïde component. Low ISUP grade was defined as grade 1 or 2 and high ISUP grade was defined as grade 3 or 4.


In case of pT3a stage, cause of upstaging was filled: invasion of renal fat or peri-sinusal fat, tumoral thrombus in the renal vein or one of its branch.


Monitoring protocols


Monitoring was carried out by CT scan or MRI of the chest, abdomen and pelvis at 3 or 6 months of surgery and then according to each case.


Monitoring data


Duration was defined as the time between surgery date and date of the latest news. Death, related to cancer or not and local or metastatic recurrence were specified after analysis of medical records.


Statistical analysis


Qualitative parameters were described in terms of frequency and percentage. Numerical parameters were described in terms of mean, median and interquartile range (IQR). Normality of numerical parameters was checked graphically and tested using the Shapiro-Wilk test.


Comparisons between PN and RN on patients' characteristics were performed using the Chi−2 test or the Fisher exact test for categorical variables, the Student t test (or Mann-Whitney U for non-Gaussian distribution) for continuous variables and the Mantel-Haenszel test for ordinal variables.


OS and PFS were estimated and compared between PN and RN using the Kaplan-Meier and log-rank test. Comparisons were adjusted using a Cox model for predefined confounding factors selected a priori on the basis of their potential relationships with survival: age, gender, histological type, tumor size, stage pT of TNM classification, ISUP grade and ASA score. Given the sample size, the adjustment was done by including a propensity score as a covariate in the Cox model. Propensity score was estimated using a multivariate logistic regression model with the groups as a dependent variable and potential confounders as covariates. ASA score was not included in the calculation of propensity score because of a large number of missing data (23%). To minimize confounding bias, a sensitivity analysis was made by including the ASA score in the Cox model adjusted for propensity score.


The cumulative incidence of cancer recurrence was estimated and compared between the two groups using a model considering competitive risk death without recurrence as a competitive event. The cumulative incidence of recurrence of kidney cancer was estimated using Kalbfleisch and Prentice's approach and the comparison was made using the Gray test. We used the Fine-Gray regression model to adjust the difference between the groups on the propensity score and ASA score. Using the Cox and Fine-Gray models with PN as the reference group, we found hazard ratio (HR), sub-hazard ratio (SHR), size of measured effect, and their confidence interval 95%.


Significance level was set at 5%. Statistical analyzes were performed using SAS software (SAS institute version 9.4).


Results


Population characteristics


Total population


A total of 267 patients underwent surgical treatment for RCC cT2a stage.


Median age was 62 years ([IQR]: 51-70), sex ratio was approximately one woman for two men, 52.2% (n =132) were asymptomatic tumors. ASA score was≥3 at 17.0% (n =35) and ECOG score≥1 in 31.7% (n =58) of patients.


RN was performed in 66% of cases (n =176) and PN in 34% (n =91).


PN was performed for elective indication in 63% (n =57) and imperative in 37% (n =34). The reason of iPN was bilateral tumors (37.5%, n =12), solitary functional kidney (43.8%, n =14) or chronic renal failure (18.8%, n =6).


RN were performed by robotic laparoscopy (8.5%, n =15) or conventional laparoscopy (91.5%, n =161). PN were performed by open surgery (67.0%, n =61), robotic laparoscopy (26.4%, n =24) and conventional laparoscopy (6.6%, n =6).


A pT3a stage was found in 42.0% of cases (n =112) and a high ISUP grade (3 or 4) in 60.2% (n =157) (Table 1, Table 2).


Comparison of radical nephrectomy (RN) and partial nephrectomy (PN) groups


There was no significant difference between RN and PN groups for age (P =0.46), sex (P =1.00), tumor size (P =0.38), ASA score (P =0.63), and ECOG PS (P =0.74).


Tumors removed by RN were more likely to be clear cell carcinomas (P <0.01), pT3a stage (P <0.01) and high ISUP grade (P <0.001) (Table 1, Table 2).


Comparison of elective partial nephrectomy (ePN) and imperative partial nephrectomy (iPN) groups


In the PN group, patients who had an imperative indication were older (P =0.002) and had a higher ASA score (P =0.021) and ECOG score (P =0.036). Positive margin, pT3a stage, and high ISUP grade were more frequent in iPN group but not significantly (Table 3).


Comparison of results by type of surgery


Overall Survival


After a median follow up of 24 months (IQR: 12-43), 28 patients died (10.49%).


OS at 3 and 5 years were 93.6% and 78.7% in the PN group and 88.0% and 76.2% in the RN group, respectively (Figure 1A).


Figure 1
Figure 1. 

Overall survival. A. Partial nephrectomy (PN) vs radical nephrectomy (RN). B. Elective partial nephrectomy (ePN) vs imperative partial nephrectomy (iPN) vs radical nephrectomy (RN).




After adjusting for propensity score, no significant difference was found between the two groups (HR 0.87, 95% CI: 0.37-2.05, P =0.75), even after adjustment for propensity score and ASA score (HR 0.85, 95% CI: 0.30-2.45, P =0.76).


One death from any cause (1.8%) was reported in ePN group and 8 (23.5%) in iPN group (Figure 1B).


Cancer specific survival


There were 17 deaths (6.4%) related to cancer.


CSS at 3 and 5 years were 95.4% and 80.2% in the PN group and 91.0% and 85.0% in the RN group, respectively (Figure 2A).


Figure 2
Figure 2. 

Cancer specific survival. A. Partial nephrectomy (PN) vs radical nephrectomy (RN). B. Elective partial nephrectomy (ePN) vs imperative partial nephrectomy (iPN) vs radical nephrectomy (RN).




After adjusting for propensity score, no significant difference was found between the two groups (HR 0.52, 95% CI: 0.18-1.54, P =0.24), even after adjustment for the propensity score and ASA score (HR 0.40, 95% CI: 0.12-1.41, P =0.15).


We noted one cancer death (1.8%) in the ePN group and 5 (14.7%) in the iPN group (Figure 2B).


Cancer free survival


Fifty patients (18.7%) had a local or metastatic recurrence (Figure 3A).


Figure 3
Figure 3. 

Cancer free survival. A. Partial nephrectomy (PN) vs radical nephrectomy (RN). B. Elective partial nephrectomy (ePN) vs imperative partial nephrectomy (iPN) vs radical nephrectomy (RN).




In PN group, with a median follow-up of 27 months, a recurrence occurred in 13.2% of patients (n =12) at a median time of 23 months (IQR: 12-48). 1.0% (n =1) had only local recurrence, 3.3% (n =3) had local and metastatic recurrence and 8.8% (n =8) had metastatic recurrence.


In RN group, with a median follow-up of 23 month, a recurrence occurred in 21.6% of patients (n =38) at a median time of 19 months (IQR: 9.5-37). A total of 1.1% (n =2) had only local recurrence, 2.3% (n =4) had local and metastatic recurrence and 18,2% (n =32) patients had metastatic recurrence.


No significant difference was found between the two groups (HR 1.02, 95% CI: 0.50-2.09, P =0.96), even after adjustment for the propensity score and ASA score (HR 0.52, 95% CI: 0.23-1.21, P =0.13).


Recurrences occurred in 10.5% of ePN (n =6) and 17.6% of iPN (n =6) with a median follow-up of 24 and 42 months respectively (Figure 3B).


Discussion


PN and RN give identical oncological results in management of T1 stage kidney tumors. PN seems, however, to provide overall survival gain [7, 8, 23] with the specific benefits of preserving nephron and decreasing cardiovascular events [5, 9]. Current recommendations still advise RN in first intention for patients having T2 stage and normal contralateral kidney, or T3a stage suspected to imaging due to a theoretical better cancer control [11].


Despite a significant proportion of poor prognosis of tumors in our cohort, the results of PN were equivalent to RN for CSS and CFS for cT2a stage. These prognostic factors were taken into account in our analysis by a propensity score adjustment. Our results are in line with recent publications that do not put in evidence difference for cancer outcomes between PN and RN for tumors>7cm, stage pT3a and high ISUP grade [18, 19]. Jeldres et al. found inferiority of PN compared to RN on CSS for tumors>7cm but the PN group included only 17 patients [18]. Hansen et al. did not find significant differences in specific survival (CSS) for patients treated between 1988 and 2008 [19]. Whatever type of surgery, cancer control would be equivalent for cT2 stages.


With a CSS at 5 years of 80.2% for PN and 85% for RN, our oncological results were below others publications analyzing the T2 stage, which found CSS at 5 years between 94.5 and 98.1% for PN [14, 15, 18] and 87.2% for RN [18]. Nevertheless, our population had a higher rate of pT3a stage (42.0% vs 5.9 to 25%) and high ISUP grade (60.2% vs 17.6 to 50.0%), which are major prognostic factors [14, 15, 18, 19]. This also reflects the current trend of widening surgical indications in the treatment of locally advanced renal tumors.


In our study, we did not find significant difference between the 2 groups regarding OS. This lack of superiority of PN could be explained by a relatively small monitoring period (median 24 months), which failed to highlight a decrease of cardiovascular events associated with nephron preservation. Recently, Shum et al. found a better OS for PN than RN for tumors>7cm (HR: 5.3), with a larger cohort and a better global follow up of 49 months but respective follow up in each group are not described [21].


Another explanation of our result for OS is the high proportion of imperative PN (37.4%), suggesting a poorer preoperative renal function in the PN group compared to RN group. Data on pre and postoperative renal function and the presence of a normal contralateral kidney were not registered.


Several arguments limit the expansion of PN for cT2 tumors. First, importance of renal parenchyma resection may limit the nephron preservation. On this point, the results of PN for tumors>7cm seem close of PN for tumors<7cm. Long et al. and Bigot et al. found respectively on 10.9% and 22% of patients a significantly worse renal function after PN. Careful analysis of preoperative imaging and use of latest techniques of selective clamping, early unclamping and robotic support have any interest in these difficult cases.


Second, the risk of positive margins would be higher than for smaller tumors. Our rate of positive margins of 8.9% by PN was comparable to those published previously, ranging from 10.2-11.2% [14, 15]. This rate is superior to those described for cT1 stages (0 to 5.5%) [24]. However, it has been shown that the positive margins do not significantly increase the risk of recurrence [24, 25]. In our cohort, about 11 cases of positive margins, 3 recurrences occurred, which should induce increased surveillance for these patients.


Finally, risk of per and postoperative complications is higher. For tumors>7cm, complication rate is estimated between 21.7% and 48.8%, including 10.9%-14.9% of major complications (Dindo Clavien≥3) [13, 15]. These rates are higher but close to RN's for T2 stages, estimated between 28.7% and 29.2% of complications [26, 27] including 2.6% of major complications [26]. Furthermore, it has been proved that the rate of complications in PN decrease with the surgeon's experience and advanced surgical techniques [28].


Regarding elective PN (n =57), our results were satisfactory with 10.5% of recurrences and only one death during follow-up. These patients were younger, with low comorbidities, but their tumors had same characteristics than in imperative indications. This results has to be interpreted with caution because of a short medium follow up of only 24 months in ePN group against 42 months in iPN group.


PN seems to have a place in the management of tumors>7cm, particularly in elective indications, in young patients without comorbidities that can support a higher peri-operative morbidity and get the benefit of the nephron preservation. The risk of recurrence seems more related to clinical and pathological prognostic factors than the surgical technique.


We believe that tumor size should no longer be the decision-making criterion for the realization of a PN, but more the technical feasibility with complete tumor resection. Systematic evaluation of RENAL score or PADUA score could help the surgeon's choice.


Our study has several limitations. Its retrospective and non-randomized nature let to selection bias, with more aggressive tumors in the RN group than in the PN group. Our statistical analysis adjusting for propensity score has limited these confounders. In case of multiple tumors, pathological data and treatment of the other tumors were not known. Follow-up was relatively short but there is evidence that the majority of recurrences occur in the first years after treatment. The numbers of patients were limited but our PN cohort is one of the most important in literature for tumors>7cm. Finally, this study has included only expert centers and do not represent all urologists' practices.


Prospective studies may provide a higher level of evidence but their implementation remains difficult for surgical treatments, especially to the low incidence of non-metastatic stages cT2.


Our results lead to further studies in larger numbers and using prospectively held databases.


Conclusion


PN seems equivalent to RN for OS, CSS and CFS in cT2a stage kidney tumors.


The risk of recurrence is probably more related to prognostic factors than surgical technique.


PN seems to have a place in the management of tumors>7cm, particularly in elective situation, in young patients without comorbidities.


The decision to perform a PN should depend on technical feasibility rather than tumor size, both in imperative and elective situation.


Disclosure of interest


The authors have not supplied their declaration of competing interest.




Table 1 - Clinical data.
  Total  RN  PN  P value 
Patients, n (%)  267  176 (65.9)  91 (34.1)   
Age, years         
Mean±SD  60.1±62 (51-70)  60.5 (63)  59.4 (62)  0.458 
Median (IQR)    51-71  50-68 
Gender, n (%)         
179 (67.0)  118 (67.1)  61 (67.0)  0.998 
88 (33.0)  58 (32.9)  30 (33.0) 
Symptoms at diagnosis, n (%)         
No  132 (52.2)  75 (44.6)  57 (67.1)  0.003 
Yes  121 (47.8)  93 (55.4)  28 (32.9) 
ASA score, n (%)         
≤ 171 (83.0)  114 (84.5)  57 (80.3)  0.626 
≥ 35 (17.0)  21 (15.5)  14 (19.7) 
ECOG PS, n (%)         
125 (68.3)  85 (69.1)  40 (66.7)  0.739 
≥ 58 (31.7)  38 (30.9)  20 (33.3) 
Radiological tumor size, cm         
Mean±SD  8.40 (8.0)  8.51 (8.5)  8.17 (8.0)  0.0006 
Median (IQR)  8.0-9.0  8.0-9.0  7.0-9.0 
RENAL score         
≤ 81 (44.0)  47 (43.9)  34 (44.2)  0.421 
≥ 103 (56.0)  60 (56.1)  43 (55.8) 
Approach, n (%)         
Open  61 (22.9)  61 (67.0)   
Pure laparoscopy  167 (62.5)  161 (91.5)  6 (6.6)   
Robot assisted  39 (14.6)  15 (8.5)  24 (26.4)   
Indication of PN, n (%)         
ePN      57 (62.6)   
iPN      34 (37.4)   
Indication if iPN, n (%)         
Bilateral tumors      12 (37.5)   
Solitary kidney      14 (43.75)   
Chronic kidney disease      6 (18.75)   



Légende :
RN: radical nephrectomy; PN: partial nephrectomy; ePN: elective partial nephrectomy; iPN: imperative partial nephrectomy.



Table 2 - Histological data.
  Total (n =267)  RN (n =176)  PN (n =91)  P value 
Histological tumoral size, cm         
Mean (median)  8.2 (8.0)  8.3 (8.0)  8.0 (8.0)  0.378 
IQR  7.5-9.0  7.5-9.0  7.5-9.0 
Histology, n (%)         
Clear cell  198 (74.2)  141 (80.1)  57 (62.6)  0.002 
Papillary, type I  21 (7.9)  8 (4.6)  13 (14.3) 
Papillary, type II  8 (3.0)  3 (1.7)  5 (5.5) 
Chromophobe  26 (9.7)  16 (9.1)  10 (11.0) 
Others  14 (5.2)  8 (4.6)  6 (6,6) 
ISUP grade, n (%)         
Low grade,≤ 104 (39.9)  57 (32.8)  47 (54.0)  0.0008 
High grade,≥ 157 (60.2)  117 (67.2)  40 (46.0) 
pT stage, n (%)         
pT1b  23 (8.6)  19 (10.8)  4 (4.4)  0.008 
pT2a  130 (48.7)  71 (40.3)  59 (64.8) 
pT2b  2 (0.7)  2 (1.1) 
pT3a  112 (42.0)  84 (47.7)  28 (30.8) 
Peri-renal fat invasion, n (%)         
Yes  72 (27.0)  49 (27.8)  23 (25.3)  0.654 
No  195 (73.0)  127 (72.2)  68 (74.7) 
Sinusal fat invasion, n (%)         
Yes  54 (22.5)  46 (29.5)  8 (9.5)  0.0004 
No  186 (77.5)  110 (70.5)  76 (90.5) 
Tumor thrombus in the renal vein, n (%)         
Yes  26 (10.2)  24 (14.0)  2 (2.4)  0.004 
No  229 (89.8)  147 (86.0)  82 (97.6) 
Microvascular invasion, n (%)         
Yes  52 (22.5)  43 (27.9)  9 (11.7)  0.005 
No  179 (77.5)  111 (72.1)  68 (88.3) 
Tumor necrosis, n (%)         
Yes  104 (47.3)  77 (49.7)  27 (41.5)  0.270 
No  116 (52.7)  78 (50.3)  38 (58.5) 
Sarcomatoïd component, n (%)         
Yes  12 (4.8)  10 (6.0)  2 (2.5)  0.347 
No  236 (95.2)  157 (94.0)  79 (97.5) 
Positive surgical margins, n (%)         
Yes  11 (4.7)  3 (2.1)  8 (8.9)  0.024 
No  225 (95.3)  143 (97.9)  82 (91.1) 



Légende :
RN: radical nephrectomy; PN: partial nephrectomy.



Table 3 - Clinical and pathological characteristics of patients in the partial nephrectomy (PN) group: elective partial nephrectomy (ePN) vs imperative partial nephrectomy (iPN).
  PN  ePN  iPN  P value 
Patients, n   91  57 (62.6)  34 (37.4)   
Age in years, mean (median)  59.4 (62)  56.2 (57)  64.7 (65)  0.002 
Gender n (%)         
61 (67.0)  36 (61.8)  25 (73.5)  0.309 
30 (33.0)  21 (38.2)  9 (26.5) 
Symptoms at diagnosis, n (%)         
No  57 (67.1)  40 (72.7)  17 (56.7)  0.320 
Yes  28 (32.9)  15 (27.3)  13 (43.3) 
ASA score, n (%)         
≤ 57 (80.3)  38 (86.4)  19 (70.4)  0.021 
≥ 14 (19.7)  6 (13.6)  8 (29.6) 
ECOG PS, n (%)         
40 (66.7)  28 (73.7)  12 (54.6)  0.036 
≥ 20 (33.3)  10 (26.3)  10 (45.4)   
Radiological tumor size in cm, mean (median)  8.2 (8.0)  8.1 (8.0)  8.3 (8.0)  0.102 
RENAL score         
≤ 34 (44.16)  23 (47.9)  2 (11.8)  0.250 
≥ 43 (55.84)  25 (52.1)  15 (88.2) 
Approach, n (%)         
Open  61 (67.0)  36 (63.2)  25 (73.5)  0.585 
Classical laparoscopy  6 (6.6)  4 (7.0)  2 (5.9) 
Robot assisted  24 (26.4)  17 (29.8)  7 (20.6) 
Histology, n (%)         
Clear cell  57 (62.6)  35 (61.4)  22 (64.7)  0.753 
Others  34 (37.4)  22 (38.6)  12 (35.3) 
ISUP grade, n (%)         
Low grade,≤ 47 (54.0)  34 (63.0)  13 (39.4)  0.078 
High grade,≥ 40 (46.0)  20 (37.0)  20 (60.6) 
pT stage, n (%)         
pT3a  28 (30.8)  16 (28.1)  12 (35.3)  0.470 
<pT3a  63 (69.2)  41 (81.9)  22 (64.7) 
Invasion of renal fat, n (%)         
Yes  23 (25.3)  11 (19.3)  12 (35.3)  0.075 
No  68 (4.7)  46 (80.7)  22 (64.7) 
Invasion of peri-sinusal fat, n (%)         
Yes  8 (9.5)  6 (11.3)  2 (6.5)  0.463 
No  76 (90.5)  47 (88.7)  29 (93.5) 
Tumoral thrombus in the renal vein, n (%)         
Yes  2 (2.4)  2 (3.8)  0 (0,0)  0.274 
No  82 (97.6)  51 (96.2)  31 (100.0) 
Microvascular invasion, n (%)         
Yes  9 (11.7)  5 (10.4)  4 (13.8)  0.655 
No  68 (88.3)  43 (89.6)  25 (86.2) 
Tumor necrosis, n (%)         
Yes  27 (41.5)  18 (41.9)  9 (40.9)  0.941 
No  38 (58.5)  25 (58.1)  13 (59.1) 
Sarcomatoïd component, n (%)         
Yes  2 (2.5)  0 (0.0)  2 (6.9)  0.055 
No  79 (97.5)  52 (100.0)  27 (93.1) 
Positive surgical margins, n (%)         
Yes  8 (8.9)  4 (7.0)  4 (12.1)  0.412 
No  82 (91.1)  53 (93.0)  29 (87.9) 



Légende :
PN: partial nephrectomy; ePN: elective partial nephrectomy; iPN: imperative partial nephrectomy.


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