Is lymph node dissection necessary for staging while undergoing nephrectomy in patients with renal cell carcinoma? (original) (raw)
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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.
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.
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.
Journal of Urology, 2009
Purpose: We examined the impact of lymphadenectomy on the clinical outcomes of patients with upper tract urothelial cancer treated with radical nephroureterectomy. Materials and Methods: Data were collected on 1,130 consecutive patients with pT1-4 upper tract urothelial cancer treated with radical nephroureterectomy at 13 centers worldwide. Patients were grouped according to nodal status (pN0 vs pNx vs pNϩ). The choice to perform lymphadenectomy was determined by the treating surgeon. All pathology slides were reevaluated by dedicated genitourinary pathologists. Univariable and multivariable Cox regression models measured the association of nodal status (pN0 vs pNx vs pNϩ) with cancer specific survival. Results: Overall 412 patients (36.5%) had pN0 disease, 578 had pNx disease (51.1%) and 140 had pNϩ disease (12.4%). The 5-year cancer specific survival estimate was lower in patients with pNϩ compared to those with pNx disease (35% vs 69%, p Ͻ0.001), which in turn was lower than that in those with pN0 disease (69% vs 77%, p ϭ 0.024). In the subgroup of patients with pT1 disease (345) cancer specific survival rates were not different in those with pN0 and pNx. In pT2-4 cases (813) cancer specific survival estimates were lowest in pNϩ, intermediate in pNx and highest in pN0 (33% vs 58% vs 70%, p ϭ 0.017). When adjusted for the effects of standard clinicopathological features pNϩ was an independent predictor of cancer specific survival (p Ͻ0.001). pNx was significantly associated with worse prognosis than pN0 in pT2-4 upper tract urothelial cancer only. Conclusions: Nodal status is a significant predictor of cancer specific survival in upper tract urothelial cancer. pNx is significantly associated with a worse prognosis than pN0 in pT2-4 tumors. Patients expected to have pT2-4 disease should undergo lymphadenectomy to improve staging and thereby help guide decision making regarding adjuvant chemotherapy.
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.
Urologic oncology, 2017
To study the effect of lymph node dissection (LND) at the time of nephrectomy and tumor thrombectomy on oncological outcomes in patients with renal cell carcinoma (RCC) and tumor thrombus. The records of 1,978 patients with RCC and tumor thrombus who underwent radical nephrectomy and tumor thrombectomy from 1985 to 2014 at 24 centers were analyzed. None of the patients had distant metastases. Extent and pathologic results of LND were compared with respect to cancer-specific survival (CSS). Multivariable Cox regression models were used to quantify the effect of multiple covariates. LND was performed in 1,026 patients. In multivariable analysis, the presence of LN metastasis, the number of positive LNs, and LN density were independently associated with cancer-specific mortality (CSM). Clinical node-negative (cN-) disease was documented in 573 patients, 447 of them underwent LND with 43 cN- patients (9.6%) revealing positive LNs at pathology. LN positive cN- patients showed significant...
2012
Abbreviations & Acronyms CSM = cancer-specific mortality FG = Fuhrman grade HR = hazard ratio IQR = interquartile range LND = lymph node dissection pN0 = without nodal metastases pN1 = with nodal metastases RCC = renal cell carcinoma Ref = referent category SEER = Surveillance, Epidemiology and End Objectives: To examine cancer-specific mortality in patients with nodal metastases relative to patients without nodal involvement at nephrectomy for non-metastatic renal cell carcinoma in a population-based cohort. Methods: A total of 11 374 non-metastatic renal cell carcinoma patients who underwent a lymph node dissection at nephrectomy were identified using the Surveillance, Epidemiology and End Results database . The 5-year cancer-specific mortality-free survival rates were examined according to the presence or absence of nodal involvement within the entire cohort, and stratified according to pathological tumor stage (pT1 vs pT2 vs pT3 vs pT4) and Fuhrman grade (I vs II vs III vs IV). Cox regression analyses for prediction of cancer-specific mortality were modeled to assess the effect of nodal metastases versus no nodal involvement in the entire population. Finally, separate Cox regression models were fitted within each pathological stage and grade. Results: Overall, 1260 (11%) patients had nodal metastases at nephrectomy. The overall 5-year cancer-specific mortality-free survival rates were 38.4 versus 83.8% in patients with nodal metastases and without nodal metastases, respectively. In multivariable analyses, amongst pT1, pT2, pT3 and pT4, patients with nodal metastases were 6.0-, 3.6-, 3.2-and 2.0-fold, respectively, more likely to die after nephrectomy (all P < 0.001). Similarly, amongst Fuhrman grade I, Fuhrman grade II, Fuhrman grade III and Fuhrman grade IV, patients with nodal metastases were 3.9-, 3.5-, 3.1-and 2.7-fold, respectively, more likely to die of cancer-specific mortality (all P < 0.001). Conclusions: Nodal involvement is an important determinant of higher cancerspecific mortality after nephrectomy. The detrimental effect of nodal metastases is particularly strong amongst patients with low-stage or low-grade non-metastatic renal cell carcinoma.