Regional lymph node dissection in the treatment of renal cell carcinoma: is it useful in patients with no suspected adenopathy before or during surgery?

Abstract

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.

Renal lymphatics, and lymphatic involvement in sinus vein invasive (pT3b) clear cell renal cell carcinoma: a study of 40 cases

“…Although lymphatic emboli was an infrequent finding in this study, four of 40 cases (10%), this is within the reported range of hilar and loco-regional lymph node involvement of 7-17% based upon lymph node dissections. 3,4 This study suggests that intravenous tumor can often be distinguished from intralymphatic tumor based upon size of the involved structure, or by histologic features. All grossly visible involved structures within the sinus fat believed to represent veins were shown to be veins in this study.…”

“…Renal cell carcinoma, however, also spreads by lymphatic routes; from 7-17% patients with lymph node dissections have hilar or locoregional lymph node metastases. 3,4 As the major lymphatic system drains from the cortex into the renal sinus and then to regional lymph nodes, it is possible that some renal sinus structures involved by tumor may actually represent lymphatics, not veins. The development of endothelial cell markers specific for lymphatic endothelium permits investigation of this possibility.…”

“…Lymph node dissections have demonstrated that from 7 to 17% of patients have hilar or locoregional lymph node metastases. 3,4 Distinguishing venous involvement from lymphatic involvement in human cancers has been hampered by the difficulty in distinguishing veins from lymphatics. Although lymphatics show distinctive ultrastructural differences, such as gaps between endothelial cells, and absent to interrupted basal lamina, smooth muscle and pericytic investments, histologic appreciation of these ultrastructural features is not feasible.…”

Advances and controversies in grading and staging of renal cell carcinoma

“…It has been shown that extensive lymphadenectomy confers no survival advantage in those patients where there is no clinical evidence of lymph node involvement by RCC. 114,115 It has also been shown that although lymph node dissection is associated with increased survival in the short term-with an increased median survival of 5 months, this advantage was lost over a 5-year follow-up period. 115 Lymph node metastases have been reported in 9-27% of cases of RCC, 107 however, evaluation of the role of lymph node dissection in the management of patients with RCC is hampered by the relative scarcity of patients with lymph node metastases in the absence of extranodal tumor spread.…”

Renal Lymph Nodes for Tumor Staging: Appraisal of 871 Nephrectomies With Examination of Hilar Fat

“…11,17,19,20 Of the patients with metastatic disease, historically 40% have distant metastases only without evidence of LN involvement, 50% have both distant metastases and LN involvement, and up to 10% present with LN metastases. [21][22][23] Interestingly, in our series, patients with distant metastases also had a high rate of renal sinus and/or vein involvement: 68%, 92%, and 79% in groups Nx, N0, and N1, respectively. This suggests that renal sinus/vein involvement may be associated with alternative metastatic routes.…”