Extent of lymph node dissection at nephrectomy affects cancer‐specific survival and metastatic progression in specific sub‐categories of patients with renal cell carcinoma (RCC)

Abstract

Objective• To test whether the number of lymph nodes removed affects cancer-specific survival (CSS) or metastatic progression-free survival (MPFS) in different renal cell carcinoma (RCC) scenarios. Methods• We used Cox regression analyses to analyse the effect of the number of lymph nodes removed on CSS and MPFS in 1983 patients with RCC treated with nephrectomy.• To adjust for possible clinical and surgical selection bias, analyses were further adjusted for number of positive nodes, presence of metastases, age, performance status, T stage, tumour size and grade. Results• The prevalence of lymph node invasion was 6.1%. The mean follow-up period was 83.3 months.• Multivariable analyses showed that the number of nodes removed had an independent, protective effect on CSS in patients with pT2a-pT2b or pT3c-pT4 RCC (hazard ratio [HR] 0.91, P = 0.008 and HR 0.89, P < 0.001, respectively), in patients with bulky tumours (tumour size >10 cm, HR 0.97, P = 0.03) or when sarcomatoid features were found (HR 0.81, P = 0.006).• The removal of each additional lymph node was associated with a 3-19% increase in CSS.• When considering MPFS as an endpoint, the number of nodes removed had an independent, protective effect in the same patient categories. Conclusions• When clinically indicated, the number of nodes removed affects CSS and MPFS in specific sub-categories of patients with RCC.

The rationale and the role of lymph node dissection in renal cell carcinoma

“…Similarly, in another non-randomized retrospective study, Pantuck et al [11] [20,32]. For instance, Capitanio et al [20] did not find any correlation between the number of nodes removed and cancer-specific mortality in patients with metastases at diagnosis, unless the patient had one of the previous above-cited unfavorable characteristics. More recent data from Memorial Sloan-Kettering Cancer Center on 258 metastatic patients treated with cytoreductive nephrectomy showed similar cancer control in patients treated with different lymph node templates (hilar vs. other) or different number of nodes removed (0-3, 4-7 or ≥8) [32].…”

“…Similarly, in another previously cited study, the number of nodes removed showed an independent, protective effect on CSS also in patients with pT3c-pT4 RCC (HR 0.89, p < 0.001). The removal of each additional lymph node was associated with roughly a 10 % increase in CSS and metastatic progression-free survival [20].…”

“…Older studies have suggested a potential role of LND in patients with high-risk metastatic RCC patients: The National Cancer Institute analyzed 154 cases treated with cytoreductive nephrectomy before cytokine systemic therapy [10] showing that among patients treated with LND, no difference in survival was observed between cN1 cases treated with LND (cN1 pN any cases) and pathologically confirmed N0 disease (cN0 pN0 cases), suggesting a potential benefit of LND [10]. Similarly, in another non-randomized retrospective study, Pantuck et al [11] [20,32]. For instance, Capitanio et al [20] did not find any correlation between the number of nodes removed and cancer-specific mortality in patients with metastases at diagnosis, unless the patient had one of the previous above-cited unfavorable characteristics.…”

“…However, neither of these manuscripts assessed the impact of LND on survival. More recently, Capitanio et al [20] tested the hypothesis that the number of lymph nodes removed may affect cancer-specific survival (CSS) or metastatic progression-free survival (MPFS) in specific renal cell carcinoma (RCC) scenarios. After a mean followup period of 7 years, the number of nodes removed showed an independent, protective effect on CSS in patients with pT2a-pT2b [hazard ratio (HR) 0.91, p = 0.008] and bulky tumors (tumor size > 10 cm, HR 0.97, p = 0.03) [20].…”

“…More recently, Capitanio et al [20] tested the hypothesis that the number of lymph nodes removed may affect cancer-specific survival (CSS) or metastatic progression-free survival (MPFS) in specific renal cell carcinoma (RCC) scenarios. After a mean followup period of 7 years, the number of nodes removed showed an independent, protective effect on CSS in patients with pT2a-pT2b [hazard ratio (HR) 0.91, p = 0.008] and bulky tumors (tumor size > 10 cm, HR 0.97, p = 0.03) [20]. Conversely, Feuerstein et al [21] with a median followup of 5 years did not find a difference in recurrence-free or overall survival in patients with ≥7-cm tumors whether or not they underwent LND but they could not adjust their results for the number of positive nodes [21].…”