The role of lymphadenectomy in renal cancer surgery. An update (original) (raw)
The current role of lymph node dissection in the management of renal cell carcinoma
International journal of surgical oncology, 2011
The role of lymph node dissection remains controversial in the surgical management of renal cell carcinoma. Incidental renal masses are being diagnosed at increasing rates due to the routine use of CT scans. Despite the increase in incidental diagnosis of renal masses, 20% to 30% of patients present with metastatic disease. Currently, surgeons do not routinely perform lymph node dissection unless there is gross evidence of lymphadenopathy, as patients without clinical evidence of lymphadenopathy rarely have positive nodes at the time of surgery. Patients with metastatic disease to the regional lymph nodes have a poor overall prognosis. However, some evidence supports a therapeutic benefit of lymphadenectomy in these patients. Further, the staging information gained from diagnosing lymph node involvement may allow for the use of new agents to treat metastatic disease and effect outcomes.
Lymph node dissection during the surgical treatment of renal cancer in the modern era
International braz j urol, 2008
The increasing use of routine CT scan, along with advances in imaging technology, have facilitated the early diagnosis of incidental renal masses. This has resulted in the reduction in the rate of metastatic disease diagnosis. Although surgery remains the mainstay in the treatment of renal tumors, the decreasing incidence of lymph node involvement has created controversy regarding the importance and the ideal extent of lymph node dissection, formerly considered mandatory at the time of radical nephrectomy. In this review, we critically assessed the role of lymph node dissection when broadly employed. This is likely due to the low prevalence of lymph node metastasis at the time of presentation, the unpredictable pattern of lymph node metastasis from renal tumors, and the continued downward stage migration of the disease. As a result, lymph node dissection for renal cancer is currently not recommended in the absence of gross lymphadenopathy. In high risk patients, lymph node dissection may be considered, but it remains controversial and more clinical evidence is warranted. Extended lymph node dissection is still recommended in individuals with isolated gross nodal disease or those with lymphadenopathy at the time of cytoreductive surgery prior to systemic therapy. A practical approach is summarized in an algorithm form.
Lymph Node Dissection in Renal Cell Carcinoma
European Urology, 2011
Context: Although lymphadenectomy (lymph node dissection [LND]) is currently accepted as the most accurate and reliable staging procedure for the detection of lymph node invasion (LNI), its therapeutic benefit in renal cell carcinoma (RCC) still remains controversial. Objective: Review the available literature concerning the role of LND in RCC staging and outcome. Evidence acquisition: A Medline search was conducted to identify original articles, review articles, and editorials addressing the role of LND in RCC. Keywords included kidney neoplasms, renal cell cancer, renal cell carcinoma, kidney cancer, lymphadenectomy, lymph node excision, lymphatic metastases, nephrectomy, imaging, and complications. The articles with the highest level of evidence were identified with the consensus of all of the collaborative authors and were critically reviewed. This review is the result of an interactive peer-reviewing process by an expert panel of co-authors. Evidence synthesis: Renal lymphatic drainage is unpredictable. The newer available imaging techniques are still immature in detecting small lymph node metastases. Results from the European Organization for Research and Treatment of Cancer trial 30881 showed no benefit in performing LND during surgery for clinically node-negative RCC, but the results are limited to patients with the lowest risk of developing LNI. Numerous retrospective series support the hypothesis that LND may be beneficial in high-risk patients (clinical T3-T4, high Fuhrman grade, presence of sarcomatoid features, or coagulative tumor necrosis). If enlarged nodes are evident at imaging or palpable during surgery, LND seems justified at any stage. However, the extent of the LND remains a matter of controversy. Conclusions: To date, the available evidence suggests that an extended LND may be beneficial when technically feasible in patients with locally advanced disease (T3-T4) and/or unfavorable clinical and pathologic characteristics (high Fuhrman grade, larger tumors, presence of sarcomatoid features, and/or coagulative tumor necrosis). Although node-positive patients often harbor distant metastases as well, the majority of retrospective nonrandomized trials seem to suggest a possible benefit of regional LND even for this group of patients. In patients with T1-T2, clinically negative lymph nodes and absence of unfavorable clinical and pathologic characteristics, regional LND offers limited staging information and no benefit in terms of decreasing disease recurrence or improving survival.
The role of lymphadenectomy in the radical nephrectomy for renal cell carcinoma
Zhonghua yi xue za zhi = Chinese medical journal; Free China ed, 2001
The value of lymphadenectomy in the management of renal cell carcinoma (RCC) remains controversial. Most would agree that lymphadenectomy (LD) provides accurate pathologic staging for prognostic data. The question remains whether there is any significant therapeutic benefit from extensive lymph node dissection with radical nephrectomy. The aim of this study was to compare outcomes in sampled lymphadenectomy (SLD) and extensive lymphadenectomy (ELD) with radical nephrectomy for RCC. One hundred and thirty-seven patients with RCC were enrolled in this study from Oct. 1982 to Dec. 1996. Eighty-one patients received radical nephrectomy with SLD (stage I: 43, II: 16, III: 22). Fifty-six patients received radical nephrectomy with ELD (stage I: 30, II: 11, III: 15). The mean number of lymph nodes removed by SLD was 4 (ranged from 1 to 8). The mean number of lymph nodes removed by ELD was 16.1 (ranged from 9 to 32). Overall 5-year survivals for SLD in stages I, II and III were 98%, 80% and ...
BJU International, 2001
Objectives To evaluate the role of regional lymph node dissection (LND) in a series of patients with renal cell carcinoma (RCC) with no suspicion of nodal metastases before or during surgery. Patients and methods A series of 167 patients with RCC, free from distant metastases at diagnosis, and who underwent radical nephrectomy at our hospital between January 1990 and October 1997, was reviewed. The mean (median, range) follow-up was 51 (45, 19±112) months. Of the 167 patients, 108 underwent radical nephrectomy alone and 59 had radical nephrectomy with regional LND limited to the anterior, posterior and lateral sides of the ipsilateral great vessel, from the level of the renal pedicle to the inferior mesenteric artery. Of these 59 patients, 49 had no evidence of nodal metastases before or during surgery. The probability of survival was estimated by the Kaplan±Meier method, using the log-rank test to estimate differences among levels of the analysed variables. Results The overall 5-year survival was 79%; the 5-year survival rate for the 108 patients who underwent radical nephrectomy alone was 79% and for the 49 who underwent LND was 78%. Of the 49 patients with no suspicion of lymph node metastases, one (2%) was found to have histologically con®rmed positive nodes. Conclusion These results suggest that there is no clinical bene®t in terms of overall outcome in undertaking regional LND in the absence of enlarged nodes detected before or during surgery.
Urology, 2007
Lymph node dissection (LND) may improve accuracy of staging, decrease recurrence rates, and improve survival in patients with advanced renal cell carcinoma (RCC). Here we assess the feasibility and safety of laparoscopic LND. METHODS Data were analyzed for patients who underwent combined laparoscopic radical nephrectomy (LRN) with LND between July 1997 and September 2006. Demographics, operative data, pathologic data, outcomes, and complications were assessed. RESULTS In a cohort of 700 patients who underwent LRN, 14 (13 male, 1 female) underwent LND. Transperitoneal LRN was conducted in 12 patients (86%). Retroperitoneal LRN and laparoscopic partial nephrectomy were conducted in 1 patient each (7%). Lymph node dissection yielded an average of 2.7 lymph nodes. Median tumor size was 9.5 cm (range, 1.5 to 13 cm), and median node size was 2.3 cm (range, 0.8 to 11 cm). Tumor stage was T2 or higher in 9 cases (64%), and distant metastasis was present in 7 patients (50%). One elective hand-assist and one open conversion were performed. Median estimated blood loss was 250 mL (range, 100 to 2100 mL). Median length of hospital stay was 2.5 days (range, 2 to 5 days). Median operative time was 199 minutes (range, 152 to 260 minutes). There was a single grade 1 complication (7%). CONCLUSIONS Patients with advanced or metastatic RCC may require cytoreductive nephrectomy for staging and tumor debulking before secondary therapy. Laparoscopic LND is both feasible and safe in select patients. Decreased morbidity associated with the laparoscopic approach is beneficial to patients with advanced disease. UROLOGY 70: 43-46, 2007.
Clinical Outcome of Surgical Resection for Renal Cell Carcinoma
Japanese Journal of Clinical Oncology, 2002
Purpose: To evaluate prognostic factors for patients with renal cell carcinoma (RCC) who had undergone surgical resection. Patients and methods: We analyzed data from 371 patients with RCC who had undergone surgical resection. Prognostic factors were identified from clinical and pathological data using univariate and multivariate analysis. Results: When we analyzed all patients including lymph node metastasis, multivariate analysis showed that only pN factor was an independent prognostic factor. We then analyzed 359 patients without lymph node metastasis, and the presence of symptoms, pT, grade, IFN and venous involvement were considered significant. However, pT (pT1 vs pT2-4), tumor grade and presence of symptom were judged to be independent prognostic factors by multivariate analysis. When the patients were stratified according to the tumor size (2.5, 4, 7 cm), a significant difference in disease specific survival was found by 4 and 7 cm, but not by 2.5 cm. Conclusions: The current TNM staging accurately predicts patient survival. Tumor grade is also an important prognostic factor for patients with RCC.
Should mediastinal lymphadenectomy be performed during lung metastasectomy of renal cell carcinoma?
Interactive CardioVascular and Thoracic Surgery, 2013
A best evidence topic was constructed according to a structured protocol. The question addressed was whether radical mediastinal lymphadenectomy should be performed during lung metastasectomy of renal cell carcinoma (RCC). Of the 13 papers found through a report search, seven represent the best evidence to answer this clinical question. The authors, journal, date, country of publication, study type, group studied, relevant outcomes and results of these papers are given. We conclude that on the whole, the seven-retrieved studies support the realization of systematic radical mediastinal lymphadenectomy. The published literature showed a prevalence of lymph node involvement (LNI) that approaches 30%. The majority of the studies conclude that LNI is a significant, independent prognostic of survival. Indeed, some authors did not report any 5-year survival in the case of LNI. On the contrary, however, a 5-year survival of 50% was reported when no LNI was present. To date, the published data do not allow conclusions to be drawn regarding the prognosis of hilar vs mediastinal LNI: only one paper focused on the difference between hilar and mediastinal location and showed no difference. In addition, only one study has compared the survival of patients with or without lymphadenectomy, showing greater survival when mediastinal lymphadenectomy was performed. Despite the poor prognosis of patients with LNI, surgery seems to be the best treatment for potentially curative RCC with metastases. It is known that RCC metastases do not respond well to chemotherapy and radiotherapy. Indeed, reported 5-year survival rate ranged between 3 and 11% for non-operated patients. Consequently, resection must be as complete as possible and include a systematic total mediastinal lymphadenectomy, which will probably yield better loco-regional control and evaluation of prognostic factor. However, the published evidence remains quite limited and mainly based on retrospective studies on highly selected patients, with a low level of evidence. Indeed, most patients referred to surgery are younger, fitter, and have fewer metastases. Consequently, the survival gain could be biased, related more to the resectability and the good performance status rather to the resection itself. Consequently, although these preliminary results are interesting, they must be interpreted with caution.
Frontiers in surgery, 2018
Positive nodal status (pN1) is an independent predictor of survival in renal cell carcinoma (RCC) patients. However, no study to date has tested whether the location of lymph node (LN) metastases does affect oncologic outcomes in a population submitted to radical nephrectomy (RN) and extended lymph node dissection (eLND). To describe nodal disease dissemination in clear cell RCC (ccRCC) patients and to assess the effect of the anatomical sites and the number of nodal areas affected on cancer specific mortality (CSM). The study included 415 patients who underwent RN and eLND, defined as the removal of hilar, side-specific (pre/paraaortic or pre/paracaval) and interaortocaval LNs for ccRCC, at two institutions. Descriptive statistics were used to depict nodal dissemination in pN1 patients, stratified according to nodal site and number of involved areas. Multivariable Cox regression analyses and Kaplan-Meier curves were used to explore the relationship between pN1 disease features and ...
Patterns of enlarged lymph nodes in patients with metastatic renal cell carcinoma
Urologic oncology
We reviewed the imaging studies of patients with known metastatic renal cell carcinoma (RCC) in order to more accurately assess where retroperitoneal lymphadenopathy occurs. The database of patients with metastatic RCC was reviewed and 101 patients were found from 2002 to 2006. Each patient's CT scans were then reviewed. Twenty-seven retroperitoneal sections were defined for each patient, with 3 positions in each of the x-, y-, and z-axis. Lymph nodes greater than 1 cm were then counted for each section. Of the 101 patients, 31, of whom 28 qualified, were found to have retroperitoneal lymphadenopathy of a least 1 cm or greater. Two-thirds of nodes (87 out of 124) exhibited a suprahilar, intra-aortocaval, and retro-aortocaval trend of lymph node enlargement. Three patients (11%) had isolated infrahilar nodes, while 8 patients (29%) exhibited a skip lesion pattern by imaging criteria. Only 4 patients (14%) were noted to have lymph nodes that were confined to the ipsilateral (paraa...