Lymph node excision for renal cancer

Templates of Lymph Node Dissection for Renal Cell Carcinoma: A Systematic Review of the Literature

Background: The role of lymph node dissection (LND) for renal cell carcinoma (RCC) is controversial. Notably, the conflicting evidence on the benefits and harms of LND is inherently linked to the lack of consensus on both anatomic templates and extent of lymphadenectomy. Herein, we provide a detailed overview of the most commonly dissected templates of LND for RCC, focusing on key anatomic landmarks and patterns of lymphatic drainage.

Methods: A systematic review of the English-language literature was performed without time filters in July 2018 in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement recommendations. The primary endpoint was to summarize the most commonly dissected templates of LND according to the side of RCC.

Results: Overall, 25 studies were selected for qualitative analysis. Of these, most were retrospective. The LND template was heterogeneous across studies. Indications and extent of LND were either not reported or not standardized in most series. The most commonly dissected template for right-sided tumors included hilar, paracaval, and precaval nodes, with few authors extending the dissection to the inter-aortocaval, retrocaval, common iliac or pre/paraaortic nodes. Similarly, the most commonly dissected template for left-sided tumors encompassed the renal hilar, preaortic and paraaortic nodes, with few authors reporting a systematic dissection of inter-aortocaval, retro-aortic, common iliac, or para-caval nodes.

Conclusions: In light of the unpredictable renal lymphatic anatomy and the evidence from available prospective mapping studies, the extent of the most commonly dissected templates might be insufficient to catch the overall anatomic pattern of lymphatic drainage from RCC.

Analysis of lymph node dissection in patients with ≥7-cm renal tumors

PURPOSE

To analyze the role of lymph node dissection (LND) in patients with large renal tumors.

METHODS

We performed a retrospective study of patients with renal cell carcinoma ≥7 cm in size undergoing surgery between 1990 and 2012. Primary outcome measures were recurrence-free and overall survival of patients who did and did not undergo LND. Cox proportional hazards regression models were created to account for known risk factors for recurrence and survival. Secondary outcomes were recurrence-free and overall survival by lymph node status, lymph node template and number of lymph nodes removed.

RESULTS

Of 524 patients, 164 had disease recurrence and 197 died. Median follow-up was 5 and 5.5 years for patients who did not die or have a recurrence, respectively. A total of 334 (64 %) patients underwent LND, and node-positive disease was identified in 26 (8 %). For patients who did and did not undergo LND, 5-year recurrence-free survival was 64 and 77 %, respectively. Five-year overall survival was 75 and 78 %, respectively. LND was not a predictor of recurrence or survival in multivariate analysis. Node-positive disease was associated with recurrence (p < 0.0005) and mortality (p = 0.032), although node-positive patients had a 5-year overall survival of 65 %.

CONCLUSIONS

We did not find a difference in recurrence-free or overall survival in patients with ≥7-cm tumors whether or not they underwent LND. Node-positive disease was associated with worse outcomes, suggesting that LND provides important staging information that can be important in the design of adjuvant clinical trials.

Renal leiomyosarcoma

Leiomyosarcoma (LMS) is a rare malignant tumor of smooth muscle origin that generally stems from soft tissues and uterine tissue. Although, a small percentage of these may originate from the smooth muscle or vessel walls, most of which are of venous origin. Renal leiomyosarcomas may arise from the smooth muscle fibers of renal pelvis, renal capsule or renal vessels, last one is the most frequent. We report a case of renal LMS that could be originated in the renal capsule.