Perioperative Morbidity of Lymph Node Dissection for Renal Cell Carcinoma: A Propensity Score-based Analysis

Should Patients with Renal Cell Carcinoma and Pathological Nodal Invasion Be Classified As Having Stage IV Disease?

BACKGROUND

Lymph node invasion is associated with poor outcome in patients with renal cell carcinoma (RCC).

PATIENTS AND METHODS

Patients with RCC within a single center from 2001 to 2018 were retrospectively obtained from the Chang Gung Research Database. Patient gender, physical status, Charlson Comorbidity Index, tumor side, histology, age at diagnosis, and body mass index (BMI) were compared. The overall survival (OS) and cancer-specific survival (CSS) of each group were estimated using the Kaplan-Meier method. Log-rank tests were used to compare between the subgroups.

RESULTS AND CONCLUSIONS

A total of 335 patients were enrolled, of whom 76 had pT3N0M0, 29 had pT1-3N1M0, 104 had T1-4N0M1, and 126 had T1-4N1M1 disease. Significant OS difference was noted between pT3N0M0 and pT1-3N1M0 groups with 12.08 years [95% confidence interval (CI), 8.33-15.84] versus 2.58 years (95% CI, 1.32-3.85), respectively (P < 0.005). No significant difference was observed in OS between pT1-3N1M0 and T1-4N0M1 groups with 2.58 years (95% CI, 1.32-3.85) versus 2.50 years (95% CI, 1.85-3.15, P = 0.72). The OS of N1M1 group was worse than that of N0M1 group with 1.00 year (95% CI, 0.74-1.26) versus 2.50 years (95% CI, 1.85-3.15, P < 0.05). Similar results were also observed in CSS. In summary, we claim that RCC with lymph node (LN) invasion should be reclassified as stage IV disease in terms of survival outcome.

Role of lymphadenectomy during primary surgery for kidney cancer

PURPOSE OF REVIEW

Lymph node dissection (LND) during radical nephrectomy (RN) for renal cell carcinoma (RCC) is not considered as a standard. The emergence of robot-assisted surgery and effective immune checkpoint inhibitors (ICI) in recent years may change this and lymph node (LN) staging has become easier and has a clinical impact. In this review, we aimed to reconsider the role of LND today.

RECENT FINDINGS

Although the extent of LND has still not been well established, removal of more LN seems to provide better oncologic outcomes for a select group of patients with high-risk factors such as clinical T3-4. Adjuvant therapy using pembrolizumab has been shown to improve disease free survival if complete resection of metastatic lesions as well as the primary site is obtained in combination. Robot assisted RN for localized RCC has been widespread and the studies regarding LND for RCC has been recently appeared.

SUMMARY

The staging and surgical benefits and its extent of LND during RN for RCC remains unclear, but it is becoming increasingly important. Technologies that allow an easier LND and adjuvant ICI that improve survival in LN-positive patients are engaging the role of LND, a procedure that was needed, but almost never done, is now indicated sometimes. Now, the goal is to identify the clinical and molecular imaging tools that can help identify with sufficient accuracy who needs a LND and which LNs to remove in a targeted personalized approach.

The Current Role of Lymph Node Dissection in Nonmetastatic Localized Renal Cell Carcinoma

PURPOSE

To explore the current role of lymph node dissection (LND) in the management of nonmetastatic localized renal cell carcinoma (RCC).

BACKGROUND

There is currently no proven benefit of LND in the setting of RCC, and its role remains controversial because of conflicting evidence. Patients who may benefit from LND are those at greatest risk of nodal disease, but the tools used to predict nodal involvement are limited due to unpredictable retroperitoneal lymphatics. The indications, templates, and extent of LND are also not standardized, adding to the ambiguity of current guidelines surrounding its use.

EVIDENCE ACQUISITION

A PubMed search of the literature from January 2017 to December 2022 was conducted using the search terms "renal cell carcinoma" or "renal cancer" in combination with "lymph node dissection" or "lymphadenectomy". Case studies and editorials were excluded, whereas studies investigating the therapeutic effect of LND were classified as either demonstrating a benefit or no benefit. References of the studies and review articles were also searched for notable studies and findings that were outside the five-year literature search. The studies in this review were restricted to the English language.

RESULTS

Only a number of studies in recent years have found an association between the extent of LND and increased survival. Most studies do not indicate an associated benefit, and some even suggest a negative effect on survival. Most of these studies are retrospective.

CONCLUSION

The therapeutic value of LND in RCC is still unclear, and although prospective data are needed, its declining rates and emerging new therapies make this unlikely. A better understanding of renal lymphatics and improved detection of nodal disease may help determine the role of LND in nonmetastatic localized RCC.

Retroperitoneal Laparoscopic Radical Nephrectomy for Renal Cell Carcinoma: Indications and Long-term Outcome of a Cohort Study in Vietnam

OBJECTIVE: Laparoscopic radical nephrectomy (LRN) has been suggested as the standard care for cancer patients in the T1-2 stage. However, whether this advanced technique is most indicated suitable for renal tumors higher than T3a and N1 is unclear, especially in different regions and countries, such as the difference between European and Asia. METHODS: From 2013 to 2021, the data of pathologically diagnosed renal cell carcinoma (RCC) patients who received laparoscopic retroperitoneal radical nephrectomy was subjected to the present study. RESULTS: Overall, all the registered Vietnamese patients were eligible for the study. The average operative time was 86.8 ± 21.2 min and the percentage number of patients in stages 1, 2, and 3 were 134 (70.2%), 30 (15.7%), and 27 (14.1%), respectively. Patients in the 3rd stage had a significantly longer operative time than stages 1–2 (p = 0.0001). No Lymph-node dissection (LND) was recorded in 10 patients (5.2%), limited LND in 163 patients (85.3%), regional LND in 13 patients (6.8%), extended LND (eLND) in 5 patients (2.6%). eLND showed only prolongation of operative time (p = 0.000), however, did not increase intraoperative complications as well as prolonged the duration of analgesia and hospital stay when compared with the other 2 groups (p = 0.82, 0.85, 0.91). Mean follow-up time: 42.3 ± 24.7 months. The 5-year recurrent free survival and 5-year overall survival of the stage 1, 2, 3 were: 98.3%, 100%, 87.8%, and 98.9%, 100%, and 91.3%, respectively. (p = 0.0011, p = 0.0082). CONCLUSION: Retroperitoneal LRN could be an important technique in improving long-term oncological outcomes for Vietnamese patients, especially in the stage of T1-3N0-1M0 tumors. Radical retroperitoneal nephrectomy is safe and technically feasible as well as providing favorable long-term oncological outcomes for stage T1-2-3aN1M0 RCC.

Complications and their management following retroperitoneal lymph node dissection in conjunction with retroperitoneal laparoscopic radical nephroureterectomy

OBJECTIVES

To describe the detailed perioperative complications and their management after retroperitoneal lymph node dissection with retroperitoneal laparoscopic radical nephroureterectomy for patients with upper tract urothelial carcinoma at three institutions.

METHODS

Retroperitoneal lymph node dissection was performed on patients with upper tract urothelial carcinoma located at the pelvis and/or upper or middle ureter, and its template included the renal hilar and para-aortic lymph nodes (left side) and the renal hilar, paracaval, retrocaval, and intra-aortocaval lymph nodes (right side). The lymph nodes and kidneys were removed en bloc. The primary endpoint was postoperative complication rates, and the secondary endpoints were intraoperative findings and chylous leakage management. The associations of retroperitoneal lymph node dissection with postoperative complications were examined using logistic regression with propensity score techniques.

RESULTS

Eighty-eight (31%) and 195 (69%) patients underwent and did not undergo retroperitoneal lymph node dissection, respectively. There was no significant difference in postoperative complications and other perioperative findings in the entire cohort, except for prolonged operation time. Retroperitoneal lymph node dissection was not statistically significantly associated with total and serious complications in propensity score analyses. Postoperative chylous leakage could be conservatively managed even though it is common in patients with retroperitoneal lymph node dissection (14/88 (16%)). The incidence of chylous leakage was significantly lower in patients whose lymphatic vessels were meticulously clipped completely during retroperitoneal lymph node dissection (5.3% vs 24%; P = 0.017).

CONCLUSION

There was no association between retroperitoneal lymph node dissection with laparoscopic radical nephroureterectomy and postoperative complications. However, chylous leakage is often observed after retroperitoneal lymph node dissection and careful management is highly required. The use of clips during retroperitoneal lymph node dissection is recommended to minimize chylous leakage risk.

Lymph node yield in pediatric, adolescent and young adult Renal Cell Carcinoma - How many are enough?

PURPOSE

Pediatric, adolescent and young adult (PAYA) patients with renal cell carcinoma (RCC) have a high rate of LN involvement, yet data to guide surgical lymph node (LN) management in this group is limited. The objective is to describe a LN yield threshold to quantify the chance of missing occult LN involvement at ≤10% in PAYAs with RCC.

MATERIALS & METHODS

The National Cancer Database was queried for patients aged ≤30 y with unilateral, non-metastaticRCC from 2004 to 2013. The probability of a false negative LN sampling was determined on the cohort of patients who had at least one positive LNand ≥ 2 LNs examined. For a given LN yield, the probability that a positive LN exists but none were found was estimated using a beta-binomial model.

RESULTS

We identified 112 patients meeting study criteria. Median age was 24 y and median tumor size was 9.5 cm (IQR 5.8-14). The median number of LNs sampled was 7 (IQR 4-12) and the median number of LNs positive was 4 (IQR 2-7). To achieve ≤10% probability of a false-negativeLN sampling, the beta-binomial model estimated that 5 LNs (95% CI4-7) must be sampled.

CONCLUSIONS

The desired LN yield to reduce the risk of a false-negativeLN sampling in PAYAs with RCC to ≤10% is 5. This is in keeping with prior studies identifying a LN yield of 6-10 to achieve the same. These data may be used to standardize surgical guidelines when treating PAYAs with renal tumors.

LEVEL OF EVIDENCE

II.

The Role of Lymphadenectomy in Patients with Advanced Renal Cell Carcinoma

The role of lymph node dissection (LND) in the management of renal cell carcinoma (RCC) is controversial. LND serves an indisputable staging role by providing pathologic nodal stage. However, while earlier observational studies had suggested a survival benefit to LND, more recent observational evidence and a randomized trial do not support a survival benefit. The majority of patients with isolated lymph node involvement appear to harbor occult metastatic disease. Still, LND is not associated with increased perioperative morbidity when performed in experienced centers. LND may therefore play a predominantly staging role in patients at increased risk of lymph node metastases.

Valuation of lymph node dissection in localized high-risk renal cell cancer using X-tile software

PURPOSE

Attempt to group the number of lymph nodes in a more ideal way to assess the value of lymph node dissection (LND) in the treatment of localized high-risk renal cell cancer (LH-RCC).

METHODS

The Surveillance, Epidemiology, and End Result database (SEER) was used to analyze LH-RCC patients who undergoing radical nephrectomy (RN) from 2011 to 2015. The X-tile software was performed to calculate the optimal grouping cut-off points for the number of removed lymph nodes and positive lymph nodes. The Nomogram model was constructed by R language to visually present survival rates of patients.

RESULTS

Among 4917 cases of LH-RCC patients undergoing RN, there were 1835 patients treated with LND (37.32%) with the average survival time (AST) of 43.10 months (95% CI 41.91-44.29), which was superior than 40.52 months of patients who did not have LND (95% CI 39.26-41.78) (P < 0.01). The mortality risk of patients with ≥ 3 removed nodes was 0.75 times that of patients with 1-2 removed nodes (95% CI 0.62-0.99, P < 0.01). For overall survival (OS), the hazard ratio of ≥ 5 positive nodes, 1-4 positive nodes, and 0 positive node was 3.04, 2.37, and 1.00, respectively. The Nomogram model can evaluate the 1 year, 2 year, and 3 year survival rates of LH-RCC patients undergoing RN with the internal validation C-index of 0.73.

CONCLUSION

LH-RCC patients with ≥ 3 removed lymph nodes and fewer positive lymph nodes are expected to have better long-term survival. LND is not only helpful for tumor staging of LH-RCC, but also valuable for long-term survival.