Editorial Comment for Yoshino et al.: Image-Guided Research in the Clinic to Reduce Surgical Margins

Physical manipulation and positioning of a tumor may have negligible effects on tumor recurrence but it may also have serious consequences if unaccounted for. For example, accidental tumor incision (ATI) is uncommon, but in cases of large tumors, it may occur, and although not a concern in open surgery cases, it is less straightforward to resolve in robotic or laparoscopic procedures. Yoshino et al. present an elegant and direct assessment of this potential issue because surgical instrumentation is not as easily exchanged perioperatively. Incision of tumors in their preclinical model reveals deposition of tumor cells along the scissor blade, which remain viable after culture in vitro. After establishing this, the authors offer electrocautery of the scissors as a means to prevent the threat of tumor cell dissemination if it is understood that the instrument is contaminated in the setting of robotic or laparoscopic procedures for partial nephrectomy (PN).

These results are thought provoking and stir the notion that other instances apart from ATI may contribute to recurrence as seen in patients who receive PN. Although there are many reasons for higher rates of recurrence in patients who receive PN through robotic or laparoscopic surgery, ^{1 –6} the act of renal incision remains heavily scrutinized. In a separate clinical observational study, Ito and colleagues evaluated the long-term impact of ATI in a cohort of 156 patients who underwent laparoscopic PN for renal cell carcinoma. From this cohort, 12 patients had a documented ATI event; positive surgical margins and local tumor recurrence rates were found in none of these cases. ⁷ Although this study appears to assuage any concerns of tumor cell spillage as it occurs during ATI in the perioperative setting, the results generated by Yoshino et al. underscore the viability of tumor cells present on surgical equipment and their proliferative potential in vitro. Furthermore, the means at which tumor cells are eliminated for sterilization purposes are apt and appear to be reliable.