Collaborative Review – Kidney CancerLymph Node Dissection in Renal Cell Carcinoma☆
Introduction
Although lymphadenectomy (lymph node dissection [LND]) represents the most accurate and reliable staging and therapeutic procedure for the detection of lymph node invasion (LNI) in bladder and prostate cancer patients [1], [2], the value of LND in patients with renal cell carcinoma (RCC) still remains controversial. To date, no data have clearly demonstrated which candidates should undergo LND and which template should be used for LND in RCC surgical management. Consequently, many urologists have abandoned systematic and standardized LND at the time of nephrectomy because of the lack of a proven benefit.
In this context, in 2008 the European Organization for Research and Treatment of Cancer (EORTC) Genito-Urinary Group published the final results of a randomized phase 3 trial showing no survival advantage for clinically node-negative patients treated with nephrectomy alone compared with nephrectomy with LND [3]. However, although the EORTC 30881 trial represents the only available prospective randomized study, some flaws regarding the study design partially undermined the clinical applicability of its results [4]. The most important criticism was that the majority of the patients included in the trial had low-stage tumors with a negligible risk for nodal involvement [4]. As has been demonstrated in other urologic settings, RCC patients who may benefit most from LND are those with intermediate- and high-risk disease [4]. However, despite the large number of RCC patients included in EORTC 30881, the number of high-risk patients was too small to allow for a final oncologic statement regarding the benefit of performing LND [4]. Finally, EORTC 30881 could not address the crucial point of where and to what extent LND should be performed, because precise information regarding the template for LND used or the number of lymph nodes removed was lacking.
The objective of the current study was to review the available literature concerning the prevalence and prognostic implication of LNI in the RCC setting, as well as the indications and morbidity associated with performing LND at the time of nephrectomy.
Section snippets
Evidence acquisition
A Medline search was conducted to identify original articles, review articles, and editorials addressing the role of LND in kidney cancer. Keywords included kidney neoplasms, renal cell cancer, renal cell carcinoma, kidney cancer, lymphadenectomy, lymph node excision, lymphatic metastases, nephrectomy, imaging, and complications. Links to related articles and cross-reading of citations in related articles were surveyed. The articles with the highest level of evidence (1b, 2a, 2b, 2c, 3a, and
Anatomic pattern of the renal regional lymph nodes
Two major aspects must be considered: (1) the presence of many possible different lymphatic routes in normal retroperitoneal anatomy [5] and (2) the unpredictable effects of local progression of the tumor, which may induce neovascularization, blockage of lymphatic vessels by cancer cells, collateral lymphatic drainage, and invasion of tissue with different lymphatic drainage (eg, perinephric fat [6]).
Since Parker's anatomic studies in 1935, several reports have confirmed the unpredictable
Conclusions
Current imaging techniques do not allow for detection of small metastases in normal-sized lymph nodes. Large regional nodes should not necessarily be considered metastatic. The template for primary landing sites is not uniform; for the left kidney it encompasses the para-aortic and preaortic nodes from the crus of the diaphragm to the inferior mesenteric artery, and for the right kidney it encompasses the paracaval, retrocaval, and precaval nodes from the adrenal vein to the level of the
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