Lymphadenectomy for renal cell carcinoma: anatomical and therapeutic considerations

Management of colon-invading renal cell carcinoma: Operative technique and systematic review

Invasion into adjacent organs by non-metastatic renal cell carcinoma (RCC) occurs in 1% of patients suitable for resection. Colonic invasion is rare and presents technical challenges. No prospective data exists to guide management of these patients. We present the first reported case of a colon-invading RCC managed with simultaneous open right radical nephrectomy and extended right hemicolectomy. PubMed, Scopus and EMBASE databases were searched for relevant case reports reporting management of colon-invading renal cell carcinoma. Case reports, case series and cohort studies were eligible. A chart review was performed on a patient who presented with right-sided colon-invading RCC. Four previously reported cases were identified. The current case was managed with simultaneous open radical nephrectomy and extended right hemicolectomy. The patient remains well six months postoperatively with no evidence of disease recurrence. Histopathological evaluation of the resected specimen confirmed a T4 clear cell RCC with sarcomatoid differentiation. Colon-invading RCC is rare. This is the first reported case of right-sided, colon-invading RCC treated with radical resection. The current case confirms radical resection is a feasible management strategy for similar presentations. En bloc resection of involved organs remains the only potentially curative option for locally advanced disease.

Feasibility of sentinel node detection in renal cell carcinoma: a pilot study

PURPOSE

Lymphatic drainage from renal cell carcinoma is unpredictable and the therapeutic benefit and extent of lymph node dissection are controversial. We evaluated the feasibility of intratumoural injection of a radiolabelled tracer to image and sample draining lymph nodes in clinically non-metastatic renal cell carcinoma.

METHODS

Eight patients with cT1-2 cN0 cM0 (<6 cm) renal cell carcinoma prospectively received percutaneous intratumoural injections of (99m)Tc-nanocolloid under ultrasound guidance (0.4 ml, 225 MBq at one to four intratumoural locations depending on tumour size). Lymphoscintigraphy was performed 20 min, 2 h and 4 h after injection. After the delayed images a hybrid SPECT/CT was performed. SPECT was fused with CT to determine the anatomical localization of the sentinel node. Surgery with sampling was performed the following day using a gamma probe and a portable mini gamma camera.

RESULTS

Eight patients, seven with right-sided renal cell carcinoma, were included with a mean age of 55 years (range: 45-77). The mean tumour size was 4 cm (range: 3.5-6 cm). Six patients had sentinel nodes on scintigraphy (two retrocaval, four interaortocaval, including one hilar) with one extraretroperitoneal location along the internal mammary chain. All nodes could be mapped and sampled. In two patients no drainage was visualized. Renal cell carcinomas were of clear cell subtype with no lymph node metastases.

CONCLUSION

Sentinel node identification using preoperative and intraoperative imaging to locate and sample the sentinel node at surgery in renal cell carcinoma is feasible. Sentinel node biopsy may clarify the pattern of lymphatic drainage and extent of lymphatic spread which may have diagnostic and therapeutic implications.

The number of lymph nodes examined and staging accuracy in renal cell carcinoma

OBJECTIVE

To determine the number of lymph nodes that need to be examined to accurately stage the pN variable in patients undergoing radical nephrectomy (RN) for renal cell carcinoma (RCC).

PATIENTS AND METHODS

We reviewed the operative and pathology reports of 725 patients with RCC submitted for RN. All tumours were classified using the fifth edition of the Tumour-Nodes-Metastasis classification. For each patient the number of lymph nodes removed was recorded. The patients were divided into five different groups according to the number of nodes removed, i.e. group 1, 1-4; group 2, 5-8; group 3, 9-12; group 4, 13-16; and group 5, >or= 17. We evaluated the factors that affected the number of lymph nodes removed with nodal dissection and the variables that influenced the incidence of nodal involvement.

RESULTS

Lymphadenectomy was performed in 608 patients (83.8%); in these patients the rate of lymph node metastases was 13.6%. The median (range) number of nodes removed was 9 (1-43); there was a statistically significant correlation between the number of nodes removed and the percentage of nodal involvement (r = 0.6; P < 0.01). The rate of pN+ was significantly higher in the patients with >or= 13 than in those with < 13 nodes examined (20.8% vs 10.2%; P < 0.001). For organ-confined and locally advanced tumours there was a statistically significant difference in the pN+ rate between patients with < 13 or >or= 13 nodes examined (3.4% vs 10.5%, and 19.7% vs. 32.2%, respectively).

CONCLUSIONS

The proportion of tumours classified as pN+ increased with the number of lymph nodes examined. In RCC,> 12 lymph nodes need to be assessed for optimal staging.

Laparoscopic nephrectomy for renal cell carcinoma

Since the first reported case of laparoscopic nephrectomy by Clayman et al. in 1991, laparoscopy is gaining acceptance as a viable alternative to open surgery for renal cell carcinoma. The benefits of laparoscopy include improved quality of life and lower incidence of perioperative morbidity. The perceived risks of laparoscopic nephrectomy for renal cell carcinoma include port-site metastasis, increased operative time, and the concern for inadequate surgical resection. The preliminary data concerning laparoscopy in renal cell carcinoma, however, indicate that rates of tumor recurrence are equivalent to open surgery while resulting in better cosmesis, decreased level of perioperative analgesic use, and decreased length of time to full convalescence.

Renal cell carcinoma: considerations for nephron-sparing surgery

OBJECTIVES

The performance of nephron-sparing surgery in patients with a normally functioning contralateral kidney is controversial. To explore the risk factors that may contribute to the success or failure of nephron-sparing surgery, we examined the radiology and pathology reports of 278 patients who underwent radical nephrectomy for the treatment of clinically localized renal cell carcinoma.

METHODS

We collated patient data from the records of 278 patients with Stage III renal cell carcinoma entered into the Eastern Cooperative Oncology Group protocol EST 2886 and compared preoperative clinical staging with postoperative pathologic results. Patients were considered potential candidates for nephron-sparing surgery if their preoperative radiographic studies indicated that the carcinoma was a single polar lesion 5 cm or less in diameter.

RESULTS

Of 278 radical nephrectomy specimens, 36 had primary lesions 5 cm or less in diameter. Preoperative radiographic studies showed 14 of 36 would not have been considered eligible for nephron-sparing surgery. Of the remaining 22 potential candidates, pathologic studies showed multifocal lesions in 11, renal vein disease in 4, and nodal disease in 2. Only 5 of 22 patients might have had specimen-confined disease (T3a lesion).

CONCLUSIONS

Capsular-penetrating (T3a) renal cell carcinoma is not often appreciated preoperatively and is associated frequently with multifocal lesions, renal vein or nodal disease. Frozen section studies to rule out T3a disease at the time of nephron-sparing surgery may help determine which patients need radical surgery.

Role of lymphadenectomy in the treatment of renal cell carcinoma

We evaluated the role of lymphadenectomy (LND) in the prevention of local recurrence following radical nephrectomy for renal cell carcinoma (RCC) by two retrospective studies. In one, the relative importance of various tumor characteristics to the subsequent development of local recurrence was investigated in 37 patients who underwent radical nephrectomy and later progressed. In 29 evaluable patients, only nodal metastasis was predictive of local recurrence, which developed in 6 of 7 node-positive patients. In our second study the records of 69 consecutive patients with RCC who underwent radical nephrectomy with or without simultaneous LND (N = 42 and 27, respectively) were reviewed. Local control after LND was excellent in node-positive disease; in no node-positive patient with unilateral RCC has a local recurrence developed (N = 5). LND did not extend hospitalization or add to the morbidity of radical nephrectomy.

Extended Lymphadenectomy during Radical Nephrectomy for Renal Cell Carcinoma. A Prospective Study

The role and extension of lymphadenectomy during radical nephrectomy for renal cell cancer still remain a matter of debate. From June 1989 to March 1992, 137 consecutive extended lymphadenectomies were performed in patients undergoing radical nephrectomy for renal cell cancer at the Department of Urology of Padua. Ten patients (7.3%) had a pathologically proved nodal involvement. Only 2 patients had a distant nodal involvement in the absence of metastases to hilar nodes. Both patients with microscopic metastases had massive involvement of hilar nodes. Due to short median follow-up no clinical consideration on survival can be drawn.

Partial nephrectomy for renal cell carcinoma: indications, results and implications

Of 52 patients who underwent partial nephrectomy for tumor 44 were found to have renal cell carcinoma. The indications for this parenchyma-sparing procedure were categorized according to the initial status of the contralateral kidney and included bilateral tumors or tumor in a solitary kidney in 16 patients (mandatory indications), unilateral carcinoma with compromise of the contralateral kidney by a benign disease process in 9 (relative indications) and small peripheral tumor with a normal contralateral kidney in 19 (elective indications). There were 4 recurrences that accounted for 3 deaths, all in patients with mandatory indications. All patients who underwent partial nephrectomy for relative or elective indications were without definite evidence of recurrent disease at last followup (over-all mean 36 months). Our results suggest that conservative surgery can often provide effective and advantageous therapy for renal cancer and we encourage further consideration of the role of partial nephrectomy as an alternative to radical nephrectomy in selected patients with small peripheral tumors and normal contralateral kidneys.

Enlargement of regional lymph nodes in renal cell carcinoma is often not due to metastases

Preoperative axial computerized tomography scans in 163 patients with renal cell carcinoma were reviewed to assess the predictive value for the diagnosis of regional lymph node metastases. Computerized tomography was falsely negative in 5 patients: 2 had metastatic lymph nodes in the renal hilus adjacent to the primary tumor measuring 2 and 2.5 cm., and 3 had micrometastases in nodes of less than 1 cm. In 43 patients enlarged lymph nodes with a diameter of 1 to 2.2 cm. (median 1.4 cm.) were diagnosed on the preoperative scan and this was confirmed at nephrectomy and pathologically. In 18 of these 43 patients (42%) histological study showed metastases of the renal cell carcinoma in the enlarged lymph nodes. In the other 25 patients (58%) the enlarged nodes showed only inflammatory changes and/or follicular hyperplasia. This finding was significantly more frequent in patients with tumor involvement of the renal vein and tumor necrosis (p = 0.0044). We conclude that the sensitivity of preoperative computerized tomography is good for the detection of enlarged lymph nodes in patients with renal cell cancer (95%). However, significant lymph node enlargement frequently may be caused by inflammatory changes, especially in the presence of tumor necrosis. This radiological finding should not be misinterpreted as metastatic disease, unless it has been proved cytologically by fine needle aspiration.

Five-year survival following excision of renal cell carcinoma extending into inferior vena cava

Fifteen consecutive patients having radical nephrectomy and excision of tumor extension from the inferior vena cava for pathologic Stage 3A renal cell carcinoma were followed up for a minimum of five years. Survival was compared with patients having radical nephrectomy for Stage 2 or Stage 3 renal cell carcinoma in the same time interval. Five-year survival in the Stage 3A group (47%) was similar to that for patients with Stage 2 tumors (54%) and significantly better than Stage 3 patients with positive lymph nodes at surgery (12%). Renal cell carcinoma with venous extension has a reasonable prognosis after surgical excision and warrants an aggressive surgical approach.

Conservative surgical treatment of renal cell carcinoma: clinical experience and reappraisal of indications

During a 14-year period 36 patients who presented with renal cell carcinoma underwent conservative surgical treatment. The patients were divided into 3 groups according to treatment indications and condition of the contralateral kidney: group 1 included patients with a solitary kidney or bilateral tumors, group 2 patients had a damaged contralateral kidney and group 3 patients were without abnormalities of the contralateral kidney. Cumulative 6-year survival rates were 58 per cent for group 1, and 90 per cent for groups 2 and 3 combined. The over-all cumulative 6-year survival rate was 74 per cent. Based on these data extension of the indication for conservative surgical treatment seems to be justified in patients who present with low stage tumors and partial or potential damage to the contralateral organ.

Surgical management of renal cell carcinoma with intracaval neoplastic extension above the hepatic veins

Cardiopulmonary bypass, hypothermia, temporary cardiac arrest and exsanguination represent the next logical step in the evolutionary management of intracaval neoplastic extension with renal cell carcinoma. This method of management provides control of the circulation of the entire body and allows for careful dissection in a bloodless field with less risk of embolization. From 1981 to 1986, 15 patients were treated with intracaval neoplastic extension of renal cell carcinoma above the level of the most inferior hepatic veins. In 6 patients mobilization of the vena cava with division of the hepatic veins to the caudate lobe allowed excision of the tumor and tumor thrombus without cardiopulmonary bypass (group 1). The remaining 9 patients underwent cardiopulmonary bypass and hypothermia (group 2). There was 1 postoperative mortality in the entire group. Most patients had advanced regional disease but the feasibility of this technique has been demonstrated. Survival appeared to be less in the bypass group. Although some of the patients have had metastatic disease, the quality of life and survival have been prolonged in many of these acutely ill patients.

Surgical staging of genitourinary tumors

Regional retroperitoneal lymphadenectomy usually is performed with radical nephrectomy for renal cell carcinoma and sometimes is performed with nephroureterectomy for upper tract urothelial tumors; however, no therapeutic benefit has been proven. Pelvic lymphadenectomy usually is performed with radical cystectomy for bladder cancer and may confer therapeutic benefit on patients having only minimal nodal involvement. A limited extraperitoneal pelvic lymphadenectomy, including only the nodes surrounding the obturator nerves, is performed in prostate cancer patients who are considered to be potential candidates for radical prostatectomy, but is of doubtful therapeutic benefit. The effectiveness of chemotherapy for germ-cell testicular tumors has diminished the utilization of routine surgical staging and also has decreased the scope of lymphadenectomy when performed. The substantial complications associated with traditional ilioinguinal lymphadenectomy for carcinoma of the penis and the unreliability of aspiration or excisional node biopsy have militated against routine surgical staging of patients having clinically negative nodes. This policy should be reconsidered in light of suboptimal treatment results and newer surgical techniques.

Selection of initial therapy for renal cell carcinoma

Complete surgical excision is the only effective method of treatment for renal cell carcinoma (RCC) and patients with extensive regional or distant metastases are incurable by any means. Accurate preoperative staging is therefore of critical importance, and computerized tomography and magnetic resonance imaging are the most accurate staging modalities. The traditional operative procedure for RCC has been the radical nephrectomy with excision of Gerota's fascia and its contents, resulting in a 60% to 70% 5-year survival of patients with localized tumors (T1-2 and N0 and M0). Extensive lymphadenectomy has not appreciably improved the cure rate. Indeed, less aggressive surgery has been recently proposed by some authors, based on the excellent results achieved after partial nephrectomy or for tumors in solitary kidneys, with survival after partial nephrectomy or enucleation similar to that after radical nephrectomy. Preoperative adjuvants such as angioinfarction or radiotherapy have not increased survival or local tumor control, and no regional or systemic postoperative adjuvant has proven to be of value. Until further data is accumulated, radical nephrectomy remains the treatment of choice for localized RCC.

In situ management of renal tumors: renal cell carcinoma and transitional cell carcinoma

In the last 8 years 15 patients with malignant neoplasms in functionally solitary kidneys underwent in situ excision of the tumor with preservation of renal parenchyma. Of 10 patients with renal cell carcinoma 8 underwent partial nephrectomy, 1 had a central wedge resection and 1 had enucleation of 3 tumors. After followup of 6 months to 4.7 years 6 patients are free of disease. One patient died of metastatic cancer and 1 of cardiovascular disease. Of 5 patients with transitional cell carcinoma of the kidney (including 2 with parenchymal invasion) 2 underwent partial nephrectomy and 3 underwent extensive resection of renal pelvic lesions. After followup of 6 months to 7 years 2 patients are alive, 2 died of metastatic disease and 1 died of metastatic bladder carcinoma. Only 1 of the 5 patients had locally recurrent tumor. These data demonstrate the efficacy of in situ management of renal tumors in selected patients with solitary kidneys or compromised renal function.

Prognostic Factors in Renal Carcinoma. An Evaluation of Operative Findings

A consecutive series of 257 patients with renal carcinoma treated by radical nephrectomy is presented. The crude 5-year and 10-year survival rates for all patients were 47 and 31% respectively and for patients without distant metastases 62 and 50%. The importance of factors relating to prognosis was investigated with multivariate survival analysis. Metastases, nodal involvement and histological grade were strongly and independently associated with survival, but the influence of venous invasion was less important. When these factors are taken into consideration, direct extension, size and cell type of the tumour or sex and age of the patient give no significant additional prognostic information.