目的:上尿路癌患者手术切缘(SMs)的术中冰冻切片分析(FSA)的实用性尚未确定。我们在此评估了肾输尿管切除术(NU)或节段输尿管切除术(SU)中输尿管SMs常规FSA的临床意义。
方法:我们的外科病理学数据库的回顾性审查确定了2004年至2018年期间连续接受NU(n=246)或SU(n=42)的尿路上皮癌患者。FSA(n=54)与冰冻切片对照的诊断相关,最终SM的状态,以及患者的预后。
结果:在NU期间,在19例(7.7%)患者中进行了FSA,并且在输尿管肿瘤(13.1%)的病例中比在肾盂/花萼肿瘤(3.5%)的病例中要求的频率更高。仅在整个NU队列(8.4%;P=0.375)或输尿管下段肿瘤患者(57.6%;P=0.046)的非FSA病例中,输尿管远端/膀胱袖的最终SMs为阳性,但没有任何FSA患者(0%)。在SU期间,FSA在35例(83.3%)中进行,包括近端或远端SM处的19个和两个SM处的16个(SU-FSA2)。非FSA患者(42.9%)的最终阳性SM明显高于所有FSA(8.6%;P=0.048)或SU-FSA2(0%;P=0.020)患者。总的来说,FSA报告为阳性或高级别癌(n=7),非典型或发育不良(n=13),和负(n=34),所有这些诊断在冷冻切片对照上都被证实是准确的,除了一个从非典型到原位癌的修订。同时,20例初始阳性/非典型FSA患者中有16例(80.0%)通过切除其他组织实现了阴性转换。Kaplan-Meier分析显示,SU-FSA并没有显著降低膀胱肿瘤复发的风险,疾病进展,或癌症特异性死亡率。尽管如此,NU-FSA与无进展生存率(P=0.023)和癌症特异性生存率(P=0.007)降低密切相关。与非FSA相比,这可能意味着选择偏差(例如,FSA用于临床上更具侵袭性的肿瘤)。
结论:在NU期间对输尿管下段肿瘤进行FSA,以及在SU期间,显着降低了阳性SM的风险。然而,常规FSA治疗上尿路癌未能显著改善长期肿瘤预后.
The utility of intraoperative frozen section analysis (FSA) at the surgical margins (SMs) in patients with upper urinary tract cancer has not been established. We herein assessed the clinical significance of routine FSA of ureteral SMs during nephroureterectomy (NU) or segmental ureterectomy (SU).
A retrospective review of our Surgical Pathology database identified consecutive patients undergoing NU (n=246) or SU (n=42) for urothelial carcinoma from 2004 to 2018. FSA (n=54) was correlated with the diagnosis of frozen section controls, the status of final SMs, and the prognosis of patients.
During NU, FSA was performed in 19 (7.7%) patients and was significantly more often requested in cases with ureteral tumor (13.1%) than in those with renal pelvis/calyx tumor (3.5%). Final SMs at the distal ureter/bladder cuff were positive only in non-FSA cases in the entire NU cohort (8.4%; P=0.375) or those with tumor at the lower ureter (57.6%; P=0.046), but not in any of FSA patients (0%). During SU, FSA was performed in 35 (83.3%) cases, including 19 at either proximal or distal SM and 16 at both SMs (SU-FSA2). Final positive SMs were significantly more often detected in non-FSA patients (42.9%) than in all FSA (8.6%; P=0.048) or SU-FSA2 (0%; P=0.020) patients. Overall, FSAs were reported as positive or high-grade carcinoma (n=7), atypical or dysplasia (n=13), and negative (n=34), and all these diagnoses were confirmed accurate on the frozen section controls, except one with a revision from atypical to carcinoma in situ. Meanwhile, 16 (80.0%) of 20 cases with initial positive/atypical FSA achieved negative conversion by excision of additional tissue. Kaplan-Meier analysis revealed that SU-FSA did not significantly reduce the risk of tumor recurrence in the bladder, disease progression, or cancer-specific mortality. Nonetheless, NU-FSA was strongly associated with reduced progression-free (P=0.023) and cancer-specific (P=0.007) survival rates, compared with non-FSA, which may imply a selection bias (e.g., FSA for clinically more aggressive tumors).
Performing FSA during NU for lower ureteral tumor, as well as during SU, significantly reduced the risk of positive SMs. However, routine FSA for upper urinary tract cancer failed to considerably improve long-term oncologic outcome.