Impact of lymph node dissection at the time of radical nephrectomy with tumor thrombectomy on oncological outcomes: Results from the International Renal Cell Carcinoma-Venous Thrombus Consortium (IRCC-VTC) (original) (raw)
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European Urology, 2009
f EORTC Headquarters, Brussels, Belgium e u r o p e a n u r o l o g y 5 5 ( 2 0 0 9 ) 2 8 -3 4 a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m j o u r n a l h o m e p a g e : w w w . e u r o p e a n u r o l o g y . c o m Abstract Background: Until now the therapeutic value of lymphadenectomy for renal-cell carcinoma has remained controversial. Several studies attempting to solve this controversy have been published, but none of them were set up as prospective randomized trials. Objective: To assess whether a complete lymph-node dissection in conjunction with a radical nephrectomy for renal-cell cancer is more effective than a radical nephrectomy alone. Design, setting, and participants: In 1988, the European Organization for Research and Treatment of Cancer (EORTC) Genitourinary Group started a randomized phase 3 trial comparing radical nephrectomy with a complete lymphadenectomy to radical nephrectomy alone. After the renal-cell carcinoma was judged to be N0M0 and resectable, patients were randomly selected prior to surgery to undergo either a radical nephrectomy with a complete lymph-node dissection or to undergo a radical nephrectomy alone. Postoperatively all patients were followed for progression of disease and mortality. Intervention: All patients underwent a radical nephrectomy with or without a complete lymph-node dissection. Measurements: All patients were postoperatively evaluated for time-to-progression, overall survival, and progression-free survival. Time-to-event curves were estimated based on the Kaplan-Meier method and compared using a two-sided log-rank test. Results and limitations: Of the 772 patients selected for randomization, 40 were not eligible for the study. 383 patients were randomly selected to receive a complete lymph-node dissection together with a radical nephrectomy, and 389 patients were randomly selected to undergo a radical nephrectomy alone. The complication rate did not differ significantly between the two groups. Complete lymph-node dissections in 346 patients revealed an absence of lymph-node metastases in 332 patients. The study revealed no significant differences in overall survival, time to progression of disease, or progression-free survival between the two study groups. Conclusions: This study shows that, after proper preoperative staging, the incidence of unsuspected lymph-node metastases is low (4.0%) and that, notwithstanding a possible relationship to this low incidence rate, no survival advantage of a complete lymph-node dissection in conjunction with a radical nephrectomy could be demonstrated.
Current Problems in Cancer, 2020
Objective: The essential treatment for patients with renal cell carcinoma is nephrectomy. As no lymph node dissection (LND) could be performed in the majority of these patients, healthy staging could not be carried out. In this study, we investigated the impact of LND during nephrectomy on patient survival. Methods: A total of 181 patients-58 (32%) were female and 123 (68%) were male-were included in the study. Median follow-up period was 48 months. The patients were separated into 4 groups according to their stage during diagnosis; group 1 (T1-3N0M0), group 2 (T1-3NXM0), group 3 (T1-3N1M0), and group 4 (T1-4N0/XM1). The disease-free survival of nonmetastatic patients and the overall survival of all groups were calculated. Results: Mean age was 58.4 ± 12.0 years. Median survival for Group 1 could not be reached. Median survival was 89 months in Group 2, 50 months in Group 3, and 39 months in Group 4 (P < 0.001). There was no statistically significant difference between the N1 and M1 groups (P = 0.297). For the NX patient group without LND, median survival was 89 months, which is worse than the N0 group and better than the N1 group (P = 0.002). Conclusions: Our study presumes that the patients without LND are not staged sufficiently, NX patients have worse survival rates when compared with N0 patients, node
Urology, 2007
Approximately 4% to 10% of patients with renal cell carcinoma (RCC) present with vascular tumor thrombus. Often, these patients also present with metastatic disease. This study examined the clinical outcome and morbidity of patients with RCC and vascular tumor thrombus treated with aggressive surgical therapy. METHODS From 1989 to 2006, 118 patients were identified with Stage pT3b or pT3c RCC who had undergone radical nephrectomy and thrombectomy. Disease-specific survival (DSS) and overall survival were measured by Kaplan-Meier statistics with the log-rank test to assess differences in survival stratified by the clinical and pathologic variables. Cox regression techniques were used to identify significant predictors of DSS. RESULTS The median follow-up was 18 months (range 1 month to 13.55 years). Tumor thrombus was at the level of the renal vein in 67 patients (56.8%), the infradiaphragmatic inferior vena cava in 39 (33%), and the supradiaphragmatic inferior vena cava in 12 patients (10%). Of the 118 patients, 42 (35.6%) presented with metastasis. The median tumor size was 8.2 cm. The 5-year overall survival rate was 40.7%. The 5-year DSS rate was 60.3% in those without metastasis and 10% in those with metastasis (P Ͻ0.001). The level of tumor thrombus did not significantly affect survival (P ϭ 0.85). When the patients without metastasis were analyzed separately, nodal positivity (P ϭ 0.03) and a tumor diameter greater than 7 cm (P ϭ 0.05) were significant predictors of DSS. CONCLUSIONS Our results support the role of radical nephrectomy and thrombectomy in patients with RCC and vascular tumor thrombus. The absence of significant morbidity makes aggressive radical surgery feasible in the patients with tumor thrombus and metastatic disease. The current TNM staging system may need to be revised, given the evidence that the level of tumor thrombus invasion does not affect the survival outcomes.
The Journal of urology, 2015
Metastatic renal cell carcinoma can be clinically diverse in terms of the pattern of metastatic disease and response to treatment. We studied the impact of metastasis and location on cancer specific survival. The records of 2,017 patients with renal cell cancer and tumor thrombus who underwent radical nephrectomy and tumor thrombectomy from 1971 to 2012 at 22 centers in the United States and Europe were analyzed. Number and location of synchronous metastases were compared with respect to patient cancer specific survival. Multivariable Cox regression models were used to quantify the impact of covariates. Lymph node metastasis (155) or distant metastasis (725) was present in 880 (44%) patients. Of the patients with distant disease 385 (53%) had an isolated metastasis. The 5-year cancer specific survival was 51.3% (95% CI 48.6-53.9) for the entire group. On univariable analysis patients with isolated lymph node metastasis had a significantly worse cancer specific survival than those wi...
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.
Analysis of lymph node dissection in patients with ≥7-cm renal tumors
World Journal of Urology, 2014
Purpose To analyze the role of lymph node dissection (LND) in patients with large renal tumors. Methods We performed a retrospective study of patients with renal cell carcinoma C7 cm in size undergoing surgery between 1990 and 2012. Primary outcome measures were recurrence-free and overall survival of patients who did and did not undergo LND. Cox proportional hazards regression models were created to account for known risk factors for recurrence and survival. Secondary outcomes were recurrence-free and overall survival by lymph node status, lymph node template and number of lymph nodes removed. Results Of 524 patients, 164 had disease recurrence and 197 died. Median follow-up was 5 and 5.5 years for patients who did not die or have a recurrence, respectively. A total of 334 (64 %) patients underwent LND, and nodepositive disease was identified in 26 (8 %). For patients who did and did not undergo LND, 5-year recurrence-free survival was 64 and 77 %, respectively. Five-year overall survival was 75 and 78 %, respectively. LND was not a predictor of recurrence or survival in multivariate analysis. Node-positive disease was associated with recurrence (p \ 0.0005) and mortality (p = 0.032), although nodepositive patients had a 5-year overall survival of 65 %. Conclusions We did not find a difference in recurrencefree or overall survival in patients with C7-cm tumors whether or not they underwent LND. Node-positive disease was associated with worse outcomes, suggesting that LND provides important staging information that can be important in the design of adjuvant clinical trials.
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.
Revista Urología Colombiana / Colombian Urology Journal
Objective To describe the five-year overall survival (OS) and perioperative morbidity of patients with renal cell carcinoma (RCC) with venous tumor thrombus (VTT) treated through radical nephrectomy and thrombectomy. Materials and Methods We evaluated a cohort of 530 patients with a diagnosis of RCC from January 2009 to December 2019, and found VTT in 42 of them; these 42 patients composed the study sample. The patients were stratified according to the Neves Thrombus Classification (NTC). The baseline and perioperative characteristics, as well as the follow-up, were described. The Kaplan-Meier curve and its respective Cox regression were applied to present the 5-year OS and the OS stratified by the NTC. Results The average age of the sample was of 63.19 ± 10.7 years, and there were no differences regarding gender. In total, VTT was present in 7.9% of the patients. According to the NTC, 30.9% of the cases corresponded to level I, 21.4%, to level II, 26.1%, to level III, and 21.4%, to...