Year : 2011 | Volume
: 27 | Issue : 2 | Page : 297--298
Lymph node dissection during radical nephrectomy for clinical node negative, non-metastatic, clear cell renal cell carcinoma: Indications and extent
Amod Kumar Dwivedi, Deepak S Nagathan, Apul Goel
Department of Urology, CSM Medical University (Upgraded king George's Medical College), Lucknow, Uttar Pradesh, India
Department of Urology, CSM Medical University (Upgraded king George«SQ»s Medical College), Lucknow, Uttar Pradesh
|How to cite this article:|
Dwivedi AK, Nagathan DS, Goel A. Lymph node dissection during radical nephrectomy for clinical node negative, non-metastatic, clear cell renal cell carcinoma: Indications and extent.Indian J Urol 2011;27:297-298
|How to cite this URL:|
Dwivedi AK, Nagathan DS, Goel A. Lymph node dissection during radical nephrectomy for clinical node negative, non-metastatic, clear cell renal cell carcinoma: Indications and extent. Indian J Urol [serial online] 2011 [cited 2020 Oct 20 ];27:297-298
Available from: https://www.indianjurol.com/text.asp?2011/27/2/297/82866
Role of lymphadenectomy (LND) in radical nephrectomy is still debatable.  In a study, nuclear grade 3 or 4, sarcomatoid component, tumor size >10 cm, tumor stage pT3 or pT4, and presence of coagulative tumor necrosis were found to be independent predictors of regional lymph node involvement at the time of nephrectomy.  Patients were at a high risk for nodal metastasis if two or more of five pathologic features were noted in the primary tumor on the intra-operative frozen section and were recommended LND.
Purpose of this study was to assess the performance of these primary tumor pathologic features to predict lymph node-positive disease in high-risk patients undergoing radical nephrectomy and using these findings, propose a template for LND in high-risk patients at the time of radical nephrectomy.
Among 415 radical nephrectomy patients during the study period, 169 (41%) had two or more high-risk pathologic features and thus underwent LND at the time of radical nephrectomy. Metastases to retroperitoneal lymph nodes were detected in 64 of 169 patients (38%). The proportion of patients with lymph-node metastases was associated with the number of risk factors in the primary renal tumor. Lymph nodes involvement was noted in 20%, 37%, 49%, and 50% of patients with 2, 3, 4, and 5 of these features present, respectively. Finding that 45% of lymph-node positive patients had no metastases identified in the perihilar lymph nodes supports the notion that a mere sampling of the renal hilar lymph nodes is insufficient for pathologic staging. Based on the observed pattern of lymph node spread, author recommend that when performing LND in patients without palpable disease, paracaval and interaortocaval lymph nodes be removed in patients with right-sided tumors and the para-aortic and interaortocaval lymph nodes be removed in patients with left-sided tumors from the crus of the diaphragm to the common iliac artery. If disease is confirmed within the interaortocaval nodes, a complete retroperitoneal LND is recommended to define the full extent of metastatic lymph node involvement.
Surgical resection remains the only effective therapy for clinically localized renal cell cancer, with options including radical nephrectomy or nephron sparing surgery. Classical radical nephrectomy as described by Robson includes perifascial resection of kidney, perirenal fat, and regional lymph node dissection. LND may lead to more accurate staging, a decrease in local recurrence, and an increase in survival for those patients with metastatic disease limited to the resected lymph nodes. Clinical staging based on a CT scan is fraught with a risk of under staging in about 5% cases due to micrometastasis, and over staging in 58% due to enlarged lymph nodes caused by inflammation, especially in tumors with necrotic changes.  The main risks associated with LND are bleeding, persistent lymph leakage, and damage to surrounding tissues.
EORTC 30881 trial, the only prospective randomized trial addressing this issue, has found no significant increase in morbidity with addition of lymphadenectomy. Although this trial could not find any survival advantage by lymphadenectomy, definite conclusion cannot be drawn as study was underpowered due to small number of lymph node positive patient in the LND group. Most probable explanation for a small number of lymph node-positive patient is that the LND group was lack of patient with high risk tumor. ,
In this study authors have selected five high-risk factors for lymph-node metastasis based on their previous study.  These factors were based on intra-operative assessment as well as frozen section taken at time of surgery. Patients underwent LND if at least two factors were found to be positive. Number of pathological lymph node positivity increased as number of factors increased. Based on statistical analysis of lymph node positivity at different regions of retroperitoneum, author proposed a template of lymph-node dissection for both side tumors.
This article not only provides guidelines for lymph node dissection in non metastatic, clinically node negative, resectable clear cell renal carcinoma but also helps in making decision regarding the level of dissection. However, it is still questionable whether exempting lymphadenectomy in patient with less than two risk factors would be complete safe.
Based on radiological and intraoperative assessment, larger size (> 10 cm) T3 or T4 tumors can be directly proceeded for lymphadenectomy while tumor lower in stage need to undergo frozen section to look for other factors like nuclear grade, sarcomatoid component, and necrosis although many astute uroradiologist can predict latter two factors also.
Usefulness of this approach of lymphadenectomy can be best appreciated only after a prospective randomized study looking for survival analysis and local recurrences in such high-risk groups.
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