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Turajlic S, Xu H, Litchfield K, Rowan A, Chambers T, Lopez JI, Nicol D, O'Brien T, Larkin J, Horswell S, Stares M, Au L, Jamal-Hanjani M, Challacombe B, Chandra A, Hazell S, Eichler-Jonsson C, Soultati A, Chowdhury S, Rudman S, Lynch J, Fernando A, Stamp G, Nye E, Jabbar F, Spain L, Lall S, Guarch R, Falzon M, Proctor I, Pickering L, Gore M, Watkins TBK, Ward S, Stewart A, DiNatale R, Becerra MF, Reznik E, Hsieh JJ, Richmond TA, Mayhew GF, Hill SM, McNally CD, Jones C, Rosenbaum H, Stanislaw S, Burgess DL, Alexander NR, Swanton C. Tracking Cancer Evolution Reveals Constrained Routes to Metastases: TRACERx Renal. Cell 2018; 173:581-594.e12. [PMID: 29656895 PMCID: PMC5938365 DOI: 10.1016/j.cell.2018.03.057] [Citation(s) in RCA: 535] [Impact Index Per Article: 89.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 03/06/2018] [Accepted: 03/20/2018] [Indexed: 01/17/2023]
Abstract
Clear-cell renal cell carcinoma (ccRCC) exhibits a broad range of metastatic phenotypes that have not been systematically studied to date. Here, we analyzed 575 primary and 335 metastatic biopsies across 100 patients with metastatic ccRCC, including two cases sampledat post-mortem. Metastatic competence was afforded by chromosome complexity, and we identify 9p loss as a highly selected event driving metastasis and ccRCC-related mortality (p = 0.0014). Distinct patterns of metastatic dissemination were observed, including rapid progression to multiple tissue sites seeded by primary tumors of monoclonal structure. By contrast, we observed attenuated progression in cases characterized by high primary tumor heterogeneity, with metastatic competence acquired gradually and initial progression to solitary metastasis. Finally, we observed early divergence of primitive ancestral clones and protracted latency of up to two decades as a feature of pancreatic metastases.
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Affiliation(s)
- Samra Turajlic
- Translational Cancer Therapeutics Laboratory, the Francis Crick Institute, London NW1 1AT, UK; Renal and Skin Units, the Royal Marsden Hospital NHS Foundation Trust, London SW3 6JJ, UK
| | - Hang Xu
- Translational Cancer Therapeutics Laboratory, the Francis Crick Institute, London NW1 1AT, UK
| | - Kevin Litchfield
- Translational Cancer Therapeutics Laboratory, the Francis Crick Institute, London NW1 1AT, UK
| | - Andrew Rowan
- Translational Cancer Therapeutics Laboratory, the Francis Crick Institute, London NW1 1AT, UK
| | - Tim Chambers
- Translational Cancer Therapeutics Laboratory, the Francis Crick Institute, London NW1 1AT, UK
| | - Jose I Lopez
- Department of Pathology, Cruces University Hospital, Biocruces Institute, University of the Basque Country, Barakaldo, Spain
| | - David Nicol
- Department of Urology, the Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Tim O'Brien
- Urology Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - James Larkin
- Renal and Skin Units, the Royal Marsden Hospital NHS Foundation Trust, London SW3 6JJ, UK
| | - Stuart Horswell
- Department of Bioinformatics and Biostatistics, The Francis Crick Institute, London NW1 1AT, UK
| | - Mark Stares
- Translational Cancer Therapeutics Laboratory, the Francis Crick Institute, London NW1 1AT, UK; Renal and Skin Units, the Royal Marsden Hospital NHS Foundation Trust, London SW3 6JJ, UK
| | - Lewis Au
- Renal and Skin Units, the Royal Marsden Hospital NHS Foundation Trust, London SW3 6JJ, UK
| | - Mariam Jamal-Hanjani
- Cancer Research UK Lung Cancer Centre of Excellence London, University College London Cancer Institute, London WC1E 6DD, UK
| | - Ben Challacombe
- Urology Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Ashish Chandra
- Department of Cellular Pathology, Guy's & St Thomas' NHS Foundation Trust, London SE1 7EH, UK
| | - Steve Hazell
- Department of Pathology, the Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK
| | - Claudia Eichler-Jonsson
- Translational Cancer Therapeutics Laboratory, the Francis Crick Institute, London NW1 1AT, UK
| | - Aspasia Soultati
- Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Simon Chowdhury
- Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sarah Rudman
- Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Joanna Lynch
- Renal and Skin Units, the Royal Marsden Hospital NHS Foundation Trust, London SW3 6JJ, UK
| | - Archana Fernando
- Urology Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Gordon Stamp
- Experimental Histopathology Laboratory, the Francis Crick Institute, London NW1 1AT, UK
| | - Emma Nye
- Experimental Histopathology Laboratory, the Francis Crick Institute, London NW1 1AT, UK
| | - Faiz Jabbar
- Translational Cancer Therapeutics Laboratory, the Francis Crick Institute, London NW1 1AT, UK
| | - Lavinia Spain
- Renal and Skin Units, the Royal Marsden Hospital NHS Foundation Trust, London SW3 6JJ, UK
| | - Sharanpreet Lall
- Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rosa Guarch
- Department of Pathology, Complejo Hospitalario de Navarra, 31008 Pamplona, Spain
| | - Mary Falzon
- Department of Pathology, University College London Hospitals, London WC1E 6DE, UK
| | - Ian Proctor
- Department of Pathology, University College London Hospitals, London WC1E 6DE, UK
| | - Lisa Pickering
- Renal and Skin Units, the Royal Marsden Hospital NHS Foundation Trust, London SW3 6JJ, UK
| | - Martin Gore
- Renal and Skin Units, the Royal Marsden Hospital NHS Foundation Trust, London SW3 6JJ, UK
| | - Thomas B K Watkins
- Translational Cancer Therapeutics Laboratory, the Francis Crick Institute, London NW1 1AT, UK
| | - Sophia Ward
- Translational Cancer Therapeutics Laboratory, the Francis Crick Institute, London NW1 1AT, UK; Cancer Research UK Lung Cancer Centre of Excellence London, University College London Cancer Institute, London WC1E 6DD, UK
| | - Aengus Stewart
- Department of Pathology, Cruces University Hospital, Biocruces Institute, University of the Basque Country, Barakaldo, Spain
| | - Renzo DiNatale
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maria F Becerra
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ed Reznik
- Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James J Hsieh
- Molecular Oncology, Department of Medicine, Siteman Cancer Center, Washington University, St. Louis, MO, USA
| | - Todd A Richmond
- Roche Sequencing Solutions, Madison, Research & Development, Madison, WI, 53719, USA
| | - George F Mayhew
- Roche Sequencing Solutions, Madison, Research & Development, Madison, WI, 53719, USA
| | | | | | - Carol Jones
- Ventana Medical Systems, Tucson, AZ 85755, USA
| | - Heidi Rosenbaum
- Roche Sequencing Solutions, Madison, Research & Development, Madison, WI, 53719, USA
| | | | - Daniel L Burgess
- Roche Sequencing Solutions, Madison, Research & Development, Madison, WI, 53719, USA
| | | | - Charles Swanton
- Translational Cancer Therapeutics Laboratory, the Francis Crick Institute, London NW1 1AT, UK; Cancer Research UK Lung Cancer Centre of Excellence London, University College London Cancer Institute, London WC1E 6DD, UK; Department of Medical Oncology, University College London Hospitals, London NW1 2BU, UK.
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52
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Nini A, Larcher A, Cianflone F, Trevisani F, Terrone C, Volpe A, Regis F, Briganti A, Salonia A, Montorsi F, Bertini R, Capitanio U. The Effect of Anatomical Location of Lymph Node Metastases on Cancer Specific Survival in Patients with Clear Cell Renal Cell Carcinoma. Front Surg 2018; 5:26. [PMID: 29740587 PMCID: PMC5931172 DOI: 10.3389/fsurg.2018.00026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/12/2018] [Indexed: 11/16/2022] Open
Abstract
Background Positive nodal status (pN1) is an independent predictor of survival in renal cell carcinoma (RCC) patients. However, no study to date has tested whether the location of lymph node (LN) metastases does affect oncologic outcomes in a population submitted to radical nephrectomy (RN) and extended lymph node dissection (eLND). Objective To describe nodal disease dissemination in clear cell RCC (ccRCC) patients and to assess the effect of the anatomical sites and the number of nodal areas affected on cancer specific mortality (CSM). Design, setting and partecipants The study included 415 patients who underwent RN and eLND, defined as the removal of hilar, side-specific (pre/paraaortic or pre/paracaval) and interaortocaval LNs for ccRCC, at two institutions. Outcome measurement and statistical analysis Descriptive statistics were used to depict nodal dissemination in pN1 patients, stratified according to nodal site and number of involved areas. Multivariable Cox regression analyses and Kaplan-Meier curves were used to explore the relationship between pN1 disease features and survival outcomes. Results and limitations Median number of removed LN was 14 (IQR 9–19); 23% of patients were pN1. Among patients with one involved nodal site, 54 and 26% of patients were positive only in side-specific and interaortocaval station, respectively. The most frequent nodal site was the interaortocaval and side-specific one, for right and left ccRCC, respectively. Interaortocaval nodal positivity (HR 2.3, CI 95%: 1.3–3.9, p < 0.01) represented an independent predictor of CSM. Conclusions When ccRCC patient harbour nodal disease, its spreading can occur at any nodal station without involving the others. The presence of interoartocaval positive nodes does affect oncologic outcomes. Patient summary Lymph node invasion in patients with clear cell renal cell carcinoma is not following a fixed anatomical pattern. An extended lymph node dissection, during treatment for primary kidney tumour, would aid patient risk stratification and multimodality upfront treatment.
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Affiliation(s)
- Alessandro Nini
- Unit of Urology, University Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Division of Oncology, Urological Research Institute (URI), Renal Cancer Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Larcher
- Unit of Urology, University Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Division of Oncology, Urological Research Institute (URI), Renal Cancer Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Cianflone
- Unit of Urology, University Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Division of Oncology, Urological Research Institute (URI), Renal Cancer Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Trevisani
- Unit of Urology, University Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Division of Oncology, Urological Research Institute (URI), Renal Cancer Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Terrone
- Department of Urology, University Hospital Maggiore della Carità, University of Piemonte Orientale, Novara, Italy
| | - Alessandro Volpe
- Department of Urology, University Hospital Maggiore della Carità, University of Piemonte Orientale, Novara, Italy
| | - Federica Regis
- Department of Urology, University Hospital Maggiore della Carità, University of Piemonte Orientale, Novara, Italy
| | - Alberto Briganti
- Unit of Urology, University Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Division of Oncology, Urological Research Institute (URI), Renal Cancer Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Salonia
- Unit of Urology, University Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Division of Oncology, Urological Research Institute (URI), Renal Cancer Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Montorsi
- Unit of Urology, University Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Division of Oncology, Urological Research Institute (URI), Renal Cancer Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Roberto Bertini
- Unit of Urology, University Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Division of Oncology, Urological Research Institute (URI), Renal Cancer Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Umberto Capitanio
- Unit of Urology, University Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Division of Oncology, Urological Research Institute (URI), Renal Cancer Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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53
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Bhindi B, Wallis CJD, Boorjian SA, Thompson RH, Farrell A, Kim SP, Karam JA, Capitanio U, Golijanin D, Leibovich BC, Gershman B. The role of lymph node dissection in the management of renal cell carcinoma: a systematic review and meta-analysis. BJU Int 2018; 121:684-698. [PMID: 29319926 DOI: 10.1111/bju.14127] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Our objective was to evaluate the role of retroperitoneal lymph node dissection (LND) in non-metastatic (M0) and metastatic (M1) renal cell carcinoma (RCC). We searched Medline, EMBASE, Web of Science and Scopus from database inception to 29 August 2017 for studies of patients who underwent partial or radical nephrectomy for M0 or M1 RCC. Two investigators independently selected studies for inclusion. Risk of bias was assessed using the Newcastle-Ottawa scale, Cochrane Collaboration tool and National Heart, Lung and Blood Institute Quality Assessment Tool. Random effects meta-analysis was performed for all-cause-mortality. The GRADE approach was used to characterize quality of evidence. A total of 51 unique studies were included in the qualitative systematic review. Risk of bias was low in 41/51 (80%) studies. LND was not associated with all-cause mortality in either M0 (hazard ratio [HR] 1.02, 95% confidence interval [CI] 0.92-1.12; I2 = 0%; four studies), M1 (HR 1.04, 95% CI 0.83-1.29; I2 = 0%; two studies), or pooled M0 and M1 settings (HR 1.00, 95% CI 0.92-1.09; I2 = 0%; seven studies), with no statistically significant differences according to M stage subgroups (P = 0.50). In the three studies that examined M0 subgroups with a high risk of nodal metastasis, LND was not associated with improved oncological outcomes. Studies on the association of extent of LND with survival reported inconsistent results. Meanwhile, a small proportion of patients with pN1M0 disease demonstrate durable long-term oncological control after surgery, with 10-year cancer-specific survival of 21-31%. Nodal involvement is independently associated with adverse prognosis in both M0 and M1 settings. GRADE quality of evidence was moderate or low for the outcomes examined. Although LND yields independent prognostic information, the existing literature does not support a therapeutic benefit to LND in either M0 or M1 RCC. High-risk M0 patient groups warrant further study, as a subset of patients with isolated nodal metastases experience long-term survival after surgical resection.
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Affiliation(s)
- Bimal Bhindi
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - Christopher J D Wallis
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Ann Farrell
- Mayo Clinic Libraries, Mayo Clinic, Rochester, MN, USA
| | - Simon P Kim
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jose A Karam
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Umberto Capitanio
- Unit of Urology, San Raffaele Scientific Institute, University Vita-Salute, Milan, Italy
| | - Dragan Golijanin
- Division of Urology, Rhode Island Hospital and The Miriam Hospital, Providence, RI, USA.,Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Boris Gershman
- Division of Urology, Rhode Island Hospital and The Miriam Hospital, Providence, RI, USA.,Warren Alpert Medical School of Brown University, Providence, RI, USA
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54
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González J, Gaynor JJ, Alameddine M, Esteban M, Ciancio G. Indications, complications, and outcomes following surgical management of locally advanced and metastatic renal cell carcinoma. Expert Rev Anticancer Ther 2018; 18:237-250. [PMID: 29353520 DOI: 10.1080/14737140.2018.1431530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Surgery may set the basis for a potential cure or would provide the best achievable quality of life in locally advanced or metastatic renal cell carcinoma (mRCC). However, survival extension with this approach would be scarce and not exempt from adverse events, thus preventing its recommendation in an already frail patient. An evidence based analysis on the role of surgery in each of the possible clinical scenarios involved under this heading may provide a clear picture on this issue and would be of value in the decision making process. Areas covered: Current literature was queried in PubMed/Medline in a systematic fashion. Manuscripts included were selected according to the quality of the data provided. A narrative review strategy was adopted to summarize the evidence acquired. Expert commentary: A surgery-based multimodal treatment approach should be strongly considered after adequate counseling in locally advanced and mRCC, since it may provide for additional benefits in terms of survival. However, a critical reevaluation of its adequacy, optimal timing, and selection of ideal candidates is currently ongoing.
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Affiliation(s)
- Javier González
- a Servicio de Urología , Hospital Central de la Cruz Roja San José y Santa Adela , Madrid , Spain
| | - Jeffrey J Gaynor
- b Department of Surgery (Division of Transplantation), Department of Urology and the Miami Transplant Institute , University of Miami Miller School of Medicine, Jackson Memorial Hospital , Miami , FL , USA
| | - Mahmoud Alameddine
- b Department of Surgery (Division of Transplantation), Department of Urology and the Miami Transplant Institute , University of Miami Miller School of Medicine, Jackson Memorial Hospital , Miami , FL , USA
| | - Manuel Esteban
- c Servicio de Urología , Hospital Nacional de Parapléjicos , Toledo , Spain
| | - Gaetano Ciancio
- b Department of Surgery (Division of Transplantation), Department of Urology and the Miami Transplant Institute , University of Miami Miller School of Medicine, Jackson Memorial Hospital , Miami , FL , USA
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55
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Kuusk T, De Bruijn R, Brouwer OR, De Jong J, Donswijk M, Grivas N, Hendricksen K, Horenblas S, Prevoo W, Valdés Olmos RA, Van Der Poel HG, Van Rhijn BWG, Wit EM, Bex A. Lymphatic Drainage from Renal Tumors In Vivo: A Prospective Sentinel Node Study Using SPECT/CT Imaging. J Urol 2017; 199:1426-1432. [PMID: 29223390 DOI: 10.1016/j.juro.2017.11.112] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE Lymphatic drainage from renal tumors is unpredictable. In vivo drainage studies of primary lymphatic landing sites may reveal the variability and dynamics of lymphatic connections. The purpose of this study was to investigate the lymphatic drainage pattern of renal tumors in vivo with single photon emission/computerized tomography after intratumor radiotracer injection. MATERIALS AND METHODS We performed a phase II, prospective, single arm study to investigate the distribution of sentinel nodes from renal tumors on single photon emission/computerized tomography. Patients with cT1-3 (less than 10 cm) cN0M0 renal tumors of any subtype were enrolled in analysis. After intratumor ultrasound guided injection of 0.4 ml 99mTc-nanocolloid we performed preoperative imaging of sentinel nodes with lymphoscintigraphy and single photon emission/computerized tomography. Sentinel and locoregional nonsentinel nodes were resected with a γ probe combined with a mobile γ camera. The primary study end point was the location of sentinel nodes outside the locoregional retroperitoneal templates on single photon emission/computerized tomography. Using a Simon minimax 2-stage design to detect a 25% extralocoregional retroperitoneal template location of sentinel nodes on imaging at α = 0.05 and 80% power at least 40 patients with sentinel node imaging on single photon emission/computerized tomography were needed. RESULTS Of the 68 patients 40 underwent preoperative single photon emission/computerized tomography of sentinel nodes and were included in primary end point analysis. Lymphatic drainage outside the locoregional retroperitoneal templates was observed in 14 patients (35%). Eight patients (20%) had supradiaphragmatic sentinel nodes. CONCLUSIONS Sentinel nodes from renal tumors were mainly located in the respective locoregional retroperitoneal templates. Simultaneous sentinel nodes were located outside the suggested lymph node dissection templates, including supradiaphragmatic sentinel nodes in more than a third of the patients.
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Affiliation(s)
- Teele Kuusk
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Roderick De Bruijn
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Oscar R Brouwer
- Department of Radiology, Interventional Molecular Imaging Laboratory and Nuclear Medicine Section, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen De Jong
- Department of Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Maarten Donswijk
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Nikolaos Grivas
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Kees Hendricksen
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Simon Horenblas
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Warner Prevoo
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Renato A Valdés Olmos
- Department of Radiology, Interventional Molecular Imaging Laboratory and Nuclear Medicine Section, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk G Van Der Poel
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Bas W G Van Rhijn
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Esther M Wit
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Axel Bex
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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56
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Gershman B, Moreira DM, Thompson RH, Boorjian SA, Lohse CM, Costello BA, Cheville JC, Leibovich BC. Perioperative Morbidity of Lymph Node Dissection for Renal Cell Carcinoma: A Propensity Score-based Analysis. Eur Urol 2017; 73:469-475. [PMID: 29132713 DOI: 10.1016/j.eururo.2017.10.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 10/23/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND There are little data regarding the morbidity of lymph node dissection (LND) for renal cell carcinoma (RCC) to assess its risk-benefit ratio. OBJECTIVE To evaluate the association of LND with 30-d complications among patients undergoing radical nephrectomy (RN) for RCC. DESIGN, SETTING, AND PARTICIPANTS A total of 2066 patients underwent RN for M0 or M1 RCC between 1990 and 2010, of whom 774 (37%) underwent LND. INTERVENTION RN with or without LND. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Associations of LND with 30-d complications were examined using logistic regression with several propensity score techniques. Extended LND, defined as removal of ≥13 lymph nodes, was examined in a sensitivity analysis. RESULTS AND LIMITATIONS A total of 184 (9%) patients were pN1 and 302 (15%) were M1. Thirty-day complications occurred in 194 (9%) patients, including Clavien grade ≥3 complications in 81 (4%) patients. Clinicopathologic features were well balanced after propensity score adjustment. In the overall cohort, LND was not statistically significantly associated with Clavien grade ≥3 complications, although there was an approximately 40% increased risk of any Clavien grade complication that did not reach statistical significance. Likewise, LND was not significantly associated with any Clavien grade or Clavien grade ≥3 complications when separately evaluated among M0 or M1 patients. Extended LND was not significantly associated with any Clavien grade or Clavien grade ≥3 complications. LND was not associated with length of stay or estimated blood loss. Limitations include a retrospective design. CONCLUSIONS LND is not significantly associated with an increased risk of Clavien grade ≥3 complications, although it may be associated with a modestly increased risk of minor complications. In the absence of increased morbidity, LND may be justified in a predominantly staging role in the management of RCC. PATIENT SUMMARY Lymph node dissection for renal cell carcinoma is not associated with increased rates of major complications.
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Affiliation(s)
- Boris Gershman
- Division of Urology, Rhode Island Hospital and The Miriam Hospital, Providence, RI, USA.
| | | | | | | | - Christine M Lohse
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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57
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Tilki D, Chandrasekar T, Capitanio U, Ciancio G, Daneshmand S, Gontero P, Gonzalez J, Haferkamp A, Hohenfellner M, Huang WC, Linares Espinós E, Lorentz A, Martinez-Salamanca JI, Master VA, McKiernan JM, Montorsi F, Novara G, Pahernik S, Palou J, Pruthi RS, Rodriguez-Faba O, Russo P, Scherr DS, Shariat SF, Spahn M, Terrone C, Vera-Donoso C, Zigeuner R, Libertino JA, Evans CP. Impact of lymph node dissection at the time of radical nephrectomy with tumor thrombectomy on oncological outcomes: Results from the International Renal Cell Carcinoma-Venous Thrombus Consortium (IRCC-VTC). Urol Oncol 2017; 36:79.e11-79.e17. [PMID: 29129353 DOI: 10.1016/j.urolonc.2017.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 09/11/2017] [Accepted: 10/09/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To study the effect of lymph node dissection (LND) at the time of nephrectomy and tumor thrombectomy on oncological outcomes in patients with renal cell carcinoma (RCC) and tumor thrombus. PATIENTS AND METHODS The records of 1,978 patients with RCC and tumor thrombus who underwent radical nephrectomy and tumor thrombectomy from 1985 to 2014 at 24 centers were analyzed. None of the patients had distant metastases. Extent and pathologic results of LND were compared with respect to cancer-specific survival (CSS). Multivariable Cox regression models were used to quantify the effect of multiple covariates. RESULTS LND was performed in 1,026 patients. In multivariable analysis, the presence of LN metastasis, the number of positive LNs, and LN density were independently associated with cancer-specific mortality (CSM). Clinical node-negative (cN-) disease was documented in 573 patients, 447 of them underwent LND with 43 cN- patients (9.6%) revealing positive LNs at pathology. LN positive cN- patients showed significantly better CSS when compared to LN positive cN+ patients. In multivariable analysis, positive cN status in LN positive patients was a significant predictor of CSM (HR, 2.923; P = 0.015). CONCLUSIONS The number of positive nodes harvested during LND and LN density was strong prognostic indicators of CSS, while number of removed LNs did not have a significant effect on CSS. The rate of pN1 patients among clinically node-negative patients was relatively high, and LND in these patients suggested a survival benefit. However, only a randomized trial can determine the absolute benefit of LND in this setting.
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Affiliation(s)
- Derya Tilki
- Department of Urology, University of California, Davis School of Medicine, Sacramento, CA
| | - Thenappan Chandrasekar
- Department of Urology, University of California, Davis School of Medicine, Sacramento, CA
| | - Umberto Capitanio
- Department of Urology, Hospital San Raffaele, University Vita-Salute, Milano, Italy
| | - Gaetano Ciancio
- Department of Urology, Miami Transplant Institute, University of Miami, Miami, FL
| | - Siamak Daneshmand
- Department of Urology, USC/Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Paolo Gontero
- Department of Urology, A.O.U. San Giovanni Battista, University of Turin, Turin, Italy
| | - Javier Gonzalez
- Department of Urology, Hospital Central de la Cruz Roja San José y Santa Adela, Madrid, Spain
| | - Axel Haferkamp
- Department of Urology, University of Frankfurt, Frankfurt, Germany
| | | | - William C Huang
- Department of Urology, New York University School of Medicine, New York City, NY
| | | | - Adam Lorentz
- Department of Urology, Emory University, Atlanta, GA
| | - Juan I Martinez-Salamanca
- Department of Urology, Hospital Universitario Puerta de Hierro-Majadahonda, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - James M McKiernan
- Department of Urology, Columbia University College of Physicians and Surgeons, New York City, NY
| | - Francesco Montorsi
- Department of Urology, Hospital San Raffaele, University Vita-Salute, Milano, Italy
| | - Giacomo Novara
- Department of Urology, University of Padua, Padua, Italy
| | - Sascha Pahernik
- Department of Urology, University of Heidelberg, Heidelberg, Germany
| | - Juan Palou
- Department of Urology, Fundació Puigvert, Barcelona, Spain
| | - Raj S Pruthi
- Department of Urology, UNC at Chappel Hill, Chapel Hill, NC
| | | | - Paul Russo
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Douglas S Scherr
- Department of Urology, Weill Cornell Medical Center, New York City, NY
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Martin Spahn
- Department of Urology, University of Würzburg, Würzburg, Germany; Department of Urology, University Hospital Bern, Bern, Switzerland
| | - Carlo Terrone
- Division of Urology, Maggiore della Carita Hospital, University of Eastern Piedmont, Novara, Italy
| | - Cesar Vera-Donoso
- Department of Urology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Richard Zigeuner
- Department of Urology, Medical University of Graz, Graz, Austria
| | | | - Christopher P Evans
- Department of Urology, University of California, Davis School of Medicine, Sacramento, CA.
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