Year : 2012 | Volume
: 28 | Issue : 4 | Page : 463--464
Current controversies and consensus on extended lymphadenectomy in renal cell carcinoma
|How to cite this article:|
Sathishkumar R M. Current controversies and consensus on extended lymphadenectomy in renal cell carcinoma.Indian J Urol 2012;28:463-464
|How to cite this URL:|
Sathishkumar R M. Current controversies and consensus on extended lymphadenectomy in renal cell carcinoma. Indian J Urol [serial online] 2012 [cited 2019 Dec 8 ];28:463-464
Available from: http://www.indianjurol.com/text.asp?2012/28/4/463/105794
The objective of this collaborative review article was to establish a consensus on the role of lymphadenectomy in renal cell carcinoma (RCC) and recommend guidelines on the extent of and indications for lymphadenectomy.  The authors had used Medline search and have accumulated evidence and analyzed only articles which amounted to creditable evidence. Authors recommend extended lymphadenectomy in higher stage tumors (T3-T4) and higher grade tumors. Preoperative risk assessments by various algorithms were used to guide lymphadenectomy. Role of sentinel node biopsy was considered investigational as were the recent innovations like diffusion-weighted magnetic resonance imaging (MRI), nano-particle-based imaging, and genetic analysis of tumor tissue. Preoperative diagnosis of enlarged nodes was limited to size of 2 cm. Any node less than this were not conclusively diagnosed as metastatic. The authors have in detail explained the advantages of extended lymphadenectomy and template dissection so as to increase the yield of nodes which may increase cancer-specific survival in select patients. The contemporary indications were poor prognostic factors like presence of necrosis, sarcomatoid component, higher Fuhrman grade, size more than 10 cm, and obviously enlarged nodes at the time of surgery. No improvement in cancer-specific survival was achieved in patients with small tumors. The advantage of lymphadenectomy in patients with metastatic disease with grossly enlarged nodes was found in patients started on oral tyrosine kinase inhibitors.
With the advent of tyrosine kinase inhibitors, improved disease-free survival and overall survival has been found in patients of metastatic RCC. But the management in patients of RCC with lymph nodes is largely controversial. The benefit of lymphadenectomy (with extended templates) in prostate and bladder cancer has been more or less standardized. Extrapolating this to the management of RCC, there is renewed interest and a felt need about the management of lymph nodes in RCC. The authors have made a decent attempt to address this issue.
Many urologists feel that there is no role of extended lymphadenectomy in RCC. The main reason cited is that RCC metastasizes through the blood stream first rather than the lymphatic route. Studies performed since the 1980s have been for and against performing lymphadenectomy in clear cell carcinoma of kidney. A large-scale retrospective study by Joslyn et al., observes that there is no demonstrable increase in cancer-specific survival by performing extended lymphadenectomy. On the other hand retrospective studies by Herlinger et al., and Schausfer et al., predict extended cancer-specific survival in patients with localized RCC. Benefit of extended lymphadenectomy applies to patients with microscopic metastases and not for obvious positive nodes, according to their observations. No long-term prospective studies are available to comment upon the same.
Compounded to this problem is the advent of minimal access surgery (laparoscopic and robotic partial/radical nephrectomy) which is largely done without lymphadenectomy. This amounts to valuable data loss which translates into absence of prospective data. Though the authors have tried to justify the role and extent of lymphadenectomy in Stage T3 and T4 tumors, the role of lymphadenectomy in patients undergoing partial nephrectomy for Stage T2 tumors is still not conclusive. There are no definite preoperative criteria which may conclusively define the need for lymph node dissection. Boundaries of dissection which may prove helpful in achieving cure or improvement in cancer-specific survival still remain doubtful.
The final call will be taken only after availability of randomized controlled trials comparing nephrectomy, nephrectomy with removal of enlarged nodes, nephrectomy with extended node dissection without enlarged nodes.
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