Year : 2006 | Volume
: 22 | Issue : 2 | Page : 167--168
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
Rajiv Goyal, Aneesh Srivastav
Departments of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
Departments of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow
|How to cite this article:|
Goyal R, Srivastav A. 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.Indian J Urol 2006;22:167-168
|How to cite this URL:|
Goyal R, Srivastav A. 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. Indian J Urol [serial online] 2006 [cited 2020 Sep 30 ];22:167-168
Available from: http://www.indianjurol.com/text.asp?2006/22/2/167/26587
Nodal disease in the setting of metastatic renal cell carcinoma, is associated with poor prognosis. However, the biology of nodal metastases in the absence of metastatic disease, is unknown. Authors reviewed their experience, with treating this subset of patients with aggressive surgical resection. A total of 2,643 patients underwent nephrectomy between 1993 and 2003, including 40 with positive lymph nodes, but no systemic metastases. All 40 patients underwent nephrectomy with extended retroperitoneal lymphadenectomy and they were the subjects of this study. Pathological characteristics and clinical outcomes were assessed. Median patient age was 58 years and 62% of the patients were male. Median tumor size was 11 cm. Local stage was T 1 in 3% of cases, T 2 in 17%, T 3a in 30%, T 3b in 47% and T 4 in 3%. Perinephric fat invasion was present in 77% of patients and positive margins were identified in 17%. Nodal status was N1 in 30% of patients and N2 in 70%, including 10 with masses of matted nodes. Histology was conventional in 63% of cases and papillary in 17%. The remaining 20% of patients had sarcomatoid dedifferentiation. Excluding the 10 patients with matted nodes, the median number of nodes harvested per patient was 7 with a median of 2, that were positive. Extranodal extension was present in 70% of cases, while in 70%, disease recurred at a median of 4.9 months. Median actuarial disease specific survival was 20.3 months. At a median follow-up of 17.7 months, 30% of patients had no evidence of disease, 8% had disease and 62% had died. On multivariate analysis, more than1 positive node was predictive of decreased recurrence-free survival (HR 2.83, 95% CI 1.06 to 7.61, p _ 0.039) and overall survival (HR 9.33, 95% CI 1.85 to 47.09, p _ 0.007).
Nodal metastasis with renal cell carcinoma, is an independent predictor of prognosis in patients with M0 disease. Even in the absence of distant metastatic disease, patients with positive nodes should be targeted for aggressive surgical resection, followed by clinical trials of adjuvant therapy to improve the outcome.
There has been considerable controversy concerning the necessity for and importance of regional lymphadenectomy (LA). Early hematogenous spread, lack of effective adjuvant therapy and morbidity associated with LA, are arguments against regional LA. Others have suggested that staging is better with LA and risk of local recurrence might be lower. In patients with no clinical evidence of nodal disease, an increasing body of evidence suggests that it may be unnecessary, whereas in the presence of metastatic disease, modern series demonstrate that patients with simultaneous nodal disease have worse outcomes. This series evaluates the role of extended lymphadenectomy in a select subgroup of patients having node- positive disease, in the absence of distant metastasis. Complete lymphadenectomy in this subgroup offers survival advantage. Patients with only 1 positive node survived significantly longer than patients with more than 1 positive node (median 35.7 vs 14.5 months). Recurrences appeared rapidly (median 4.9 months), suggesting the need for immediate adjuvant therapy, if and when effective adjuvant therapy is identified. These patients are candidates for adjuvant therapy trials and they should be aggressively targeted for such trials.
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