Renal Cell Carcinoma With Nodal Metastases in the Absence of Distant Metastatic Disease (Clinical Stage TxN1-2M0): The Impact of Aggressive Surgical Resection on Patient Outcome

Canfield, Steven E.; Kamat, Ashish M.; Sánchez-Ortiz, Ricardo; Detry, Michelle A.; Swanson, David A.; Wood, Christopher G.

doi:10.1016/s0022-5347(05)00334-4

Cited by 109 publications

(54 citation statements)

References 19 publications

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“…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.…”

Section: Commentsupporting

confidence: 44%

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

Mehta

Mudaliar

Ghai

et al. 2013

Archives of Pathology &Amp; Laboratory Medicine

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Context.-Despite decades of research, the role of lymphadenectomy in the management of renal cell carcinoma (RCC) is still not clearly defined. Before the implementation of targeted therapies, lymph node metastases were considered to be a portent of markedly decreased survival, regardless of the tumor stage. However, the role of lymphadenectomy and the relative benefit of retroperitoneal lymph node dissection in the context of modern adjunctive therapies have not been conclusively addressed in the clinical literature. The current pathologic literature does not offer clear recommendations with regard to the minimum number of lymph nodes that should be examined in order to accurately stage the pN in renal cell carcinoma. Although gross examination of the hilar fat to assess the nodal status is performed routinely, it has not yet been determined whether this approach is adequate.Objective.-To evaluate the status of lymph nodes and their rate of identification in the pathologic examination of nephrectomy specimens in adult renal malignancies.Design.-We reviewed the operative and pathology reports of 871 patients with renal malignancies treated by nephrectomy. All tumors were classified according to the seventh edition of the Tumor-Nodes-Metastasis classification. Patients were divided into 3 groups: Nx, no lymph nodes recovered; N0, negative; and N1, with positive lymph nodes. Grossly visible lymph nodes were submitted separately; as per grossing protocol, hilar fatty tissue was submitted for microscopic examination. We evaluated the factors that affected the number of lymph nodes identified and the variables that allowed the prediction of nodal involvement.Results.-Lymph nodes were recovered in 333 of 871 patients (38%): hilar in 125 patients, nonhilar in 137 patients, and hilar and nonhilar in 71 patients. Patients with positive lymph nodes (n ¼ 87) were younger, had larger primary tumors, and had lymph nodes of average size, as well as a higher pT stage, nuclear grade, and rate of metastases. Metastases were seen only in grossly identified lymph nodes (65% hilar, 16% nonhilar); all microscopic nodes were negative. Even with the microscopic examination of fat, hilar lymph nodes were recovered in only 22.5% of patients. A nonhilar route of node metastasis was suspected in 40 patients.Conclusions.-Only grossly identifiable lymph nodes, both hilar and nonhilar, were positive for metastases. Although microscopic examination of the hilar fat increased the number of lymph nodes recovered, the identification rate of these nodes was low (22.5%), and such microscopic nodes were invariably negative. Hence, microscopic examination of the hilar fat may be unnecessary. (Arch Pathol Lab Med. 2013;137:1584-1590 doi: 10.5858/arpa.2012-0485-OA) L ymph node (LN) dissection represents one of the most accurate and reliable staging and therapeutic procedures for the detection of LN involvement in prostate and urinary bladder cancer patients, but its role in the management of renal cell carcinoma (RCC) is less clear.1,2 Before the ...

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Section: Commentsupporting

confidence: 44%

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

Mehta

Mudaliar

Ghai

et al. 2013

Archives of Pathology &Amp; Laboratory Medicine

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“…The reported survival rate of patients with exclusive NM demonstrates great variability, and ranges from 5 to 40%. [3][4][5][6][7][8][9] Even after consideration of staging biases, these survival rates are in clear contrast with survival estimates from patients with localized disease (T 1-3 N 0 M 0 ), where 5-year survival exceeds 85%. Therefore, patients with NM have clearly more aggressive disease than even the worst variant of localized disease.…”

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confidence: 92%

“…This possibly justifies more aggressive treatment in patients with NM, such as nephrectomy and resection of the NM or nephrectomy followed by immediate systemic therapy. 3,9 Better ability to identify patients with NM can be useful in pre-operative counselling, targeting patients for potential involvement in adjuvant therapy trials, and may also assist in surgical planning if more extensive or complete nodal dissections are contemplated. 3,9 In this manuscript we address the issue of accurate identification of patients at risk of NM and we develop a multivariable (MVA) logistic regression model-based nomogram for this purpose.…”

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confidence: 99%

Patients with renal cell carcinoma nodal metastases can be accurately identified: External validation of a new nomogram

Hutterer

Patard

Perrotte

et al. 2007

Intl Journal of Cancer

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Outcome of patients with renal cell carcinoma nodal metastases (NM) is substantially worse than that of patients with localized disease. This justifies more thorough staging and possibly more aggressive treatment in those at risk of or with established NM. We developed and externally validated a nomogram capable of highly accurately predicting renal cell carcinoma NM in patients without radiographic evidence of distant metastases. Age, symptom classification, tumour size and the pathological nodal stage were available for 4,658 individuals. The data of 2,522 (54.1%) individuals from 7 centers were used to develop a multivariable logistic regression model-based nomogram predicting the individual probability of NM. The remaining data from 2,136 (45.9%) patients from 5 institutions were used for external validation. In the development cohort, 107/2,522 (4.2%) had lymph node metastases vs. 100/2,136 (4.7%) in the external validation cohort. Symptom classification and tumour size were independent predictors of NM in the development cohort. Age failed to reach independent predictor status, but added to discriminant properties of the model. A nomogram based on age, symptom classification and tumour size was 78.4% accurate in predicting the individual probability of NM in the external validation cohort. Our nomogram can contribute to the identification of patients at low risk of NM. This tool can help to risk adjust the need and the extent of nodal staging in patients without known distant metastases. More thorough staging can hopefully better select those in whom adjuvant treatment is necessary. ' 2007 Wiley-Liss, Inc.

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“…3 Of these patients with metastatic disease, historically 40% have distant metastases only without evidence of lymph node involvement, 50% have both distant metastases and lymph node involvement, and about 3% to 10% present with lymph node involvement only. [4][5][6][7] When lymph node dissection is performed, a number of studies have shown that positive lymph nodes have an independent adverse effect on outcome, irrespective of other variables. [8][9][10] Patients with node-positive disease have 5-year survival rates ranging from 5% to 35%.…”

Section: Discussionmentioning

confidence: 99%

Concurrent RCC with tuberculous para aortic lymphadenopathy: A pleasant surprise

Pushkar¹,

Agarwal²,

Sarin³

et al. 2015

CUAJ

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A middle-aged man with end-stage renal disease presented with biopsy-proven left renal cell carcinoma (RCC) and extensive lymphadenopathy on ultrasound/magnetic resonance image. He and his family were counselled on his poor prognosis based on imaging findings, which showed multiple enlarged lymph nodes, appearing metastatic. He underwent laparoscopic radical nephrectomy along with lymph node dissection. Biopsy revealed RCC with all tuberculous lymph nodes. It was a surprise for the patient and treating clinician as the lymph node involvement was a poor prognostic factor for RCC.

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Renal Cell Carcinoma With Nodal Metastases in the Absence of Distant Metastatic Disease (Clinical Stage TxN1-2M0): The Impact of Aggressive Surgical Resection on Patient Outcome

Cited by 109 publications

References 19 publications

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

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

Patients with renal cell carcinoma nodal metastases can be accurately identified: External validation of a new nomogram

Concurrent RCC with tuberculous para aortic lymphadenopathy: A pleasant surprise

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