Lymphadenectomy for Renal Cell Carcinoma

Patterns of enlarged lymph nodes in patients with metastatic renal cell carcinoma

OBJECTIVE

We reviewed the imaging studies of patients with known metastatic renal cell carcinoma (RCC) in order to more accurately assess where retroperitoneal lymphadenopathy occurs.

METHODS

The database of patients with metastatic RCC was reviewed and 101 patients were found from 2002 to 2006. Each patient's CT scans were then reviewed. Twenty-seven retroperitoneal sections were defined for each patient, with 3 positions in each of the x-, y-, and z-axis. Lymph nodes greater than 1 cm were then counted for each section.

RESULTS

Of the 101 patients, 31, of whom 28 qualified, were found to have retroperitoneal lymphadenopathy of a least 1 cm or greater. Two-thirds of nodes (87 out of 124) exhibited a suprahilar, intra-aortocaval, and retro-aortocaval trend of lymph node enlargement. Three patients (11%) had isolated infrahilar nodes, while 8 patients (29%) exhibited a skip lesion pattern by imaging criteria. Only 4 patients (14%) were noted to have lymph nodes that were confined to the ipsilateral (paraaortic or paracaval) nodes in the perihilar and infrahilar region, which would be readily accessible during renal surgery.

CONCLUSIONS

Lymphatic drainage in RCC is ill-defined, likely due to multiple lymphatic outflow channels. However, after a review of retroperitoneal lymphadenopathy imaging in patients with known metastatic RCC, there does seem to be a cephalad, posterior, and medial drainage pattern.

Clinical significance of lymph node dissection in renal cell carcinoma

OBJECTIVE

To identify the role of lymph node dissection in renal cell carcinoma (RCC).

MATERIAL AND METHODS

A total of 100 patients (66 males, 34 females) were enrolled in the study. The mean age and tumor size were 61.4 years and 5.8 cm, respectively. A total of 41 patients (41%) had tumors <4 cm in diameter. The pathological status was pT1, pT2 and pT3 in 60, 11 and 29 patients, respectively.

RESULTS

In total, lymph node metastases were found in seven cases (7%). Of 40 patients with pT1a tumors (tumor size <4 cm), one (2.5%) had lymph node metastasis. Patients with lymph node metastases had significantly larger tumors than those without (8.9 vs 5.5 cm; p<0.05). Regarding patient outcome, 33 (33%) had tumor progression (alive with disease, n=14; disease-specific death, n=19) after a median follow-up period of 54.0 months. In univariate analysis, 15/18 prognostic markers [tumor size, tumor grade, pT, pN and M categories, stage, microscopic venous invasion (V category), microscopic lymphatic invasion (Ly category), pathological tumor infiltration pattern (INF category), plasma fibrinogen, C-reactive protein, immunosuppressive acidic protein, alpha-2 globulin and erythrocyte sedimentation rates at 1 and 2 h] were common significant predictors of tumor progression. A Cox hazard model revealed tumor size, tumor grade and pathological stage to be independent prognostic factors.

CONCLUSIONS

Tumor size is a crucial prognostic factor for tumor progression, and lymph node dissection may be omitted in T1a tumors.

The role of lymphadenectomy in the surgical management of renal cell carcinoma

After decades of evaluation, the role of lymphadenectomy in the management of renal cell carcinoma remains a controversy. Contemporary series suggest that the true incidence of isolated lymph node metastases in clinically localized disease is small, and the location of such metastases is unpredictable. While several institutional series have suggested a therapeutic benefit for extended lymphadenectomy, there remains a lack of randomized data to support its routine use. Despite this, there remains a role for lymphadenectomy in individuals with high risk of lymph node metastasis or known lymphadenopathy in whom few other options exist for aggressive, potentially curative therapy.

The role of lymphadenectomy in renal cell carcinoma

The standard of care for localized and metastatic renal cell carcinoma includes a nephrectomy. The potential benefits for lymphadenectomy include more accurate staging, decreased risk of local recurrence, and improved survival. However, the benefits of lymph node dissection have not been proven.

Renal cell carcinoma with retroperitoneal lymph nodes: role of lymph node dissection

PURPOSE

We better defined the benefits and morbidity of lymph node dissection in patients with localized renal cell carcinoma using the experience of patients treated at our institution.

MATERIALS AND METHODS

A retrospective cohort study was performed with outcome assessment based on the chart review of demographic, clinical and pathological data in 1,087 patients with renal cell carcinoma treated at our institution. Patients with renal cell carcinoma who did not undergo nephrectomy as part of cancer treatment, those with bilateral disease and those for whom nodal status was unknown were not included in this study. A total of 900 patients meeting these criteria who underwent nephrectomy for unilateral renal cell carcinoma at our medical center form the principal study population.

RESULTS

Positive lymph nodes were associated with larger, higher grade, locally advanced primary tumors that were more commonly associated with sarcomatoid features. Positive nodes were 3 to 4 times more common in patients with metastatic disease and the majority of these patients could be identified preoperatively. The survival of patients with regional lymph node involvement only was identical to that of patients with distant metastatic disease only. Patients with regional nodes and distant metastases had significantly inferior survival to those with either condition alone. In node negative cases lymph node dissection can be performed with no additional morbidity but it confers no survival advantage. In node positive cases lymph node dissection can also be performed safely but it is associated with improved survival and a trend toward an improved response to immunotherapy.

CONCLUSIONS

Regional lymph node dissection is unnecessary in patients with clinically negative lymph nodes since it offers extremely limited staging information and no benefit in terms of decreasing disease recurrence or improving survival. In patients with positive lymph nodes lymph node dissection is associated with improved survival when it is performed in carefully selected patients undergoing cytoreductive nephrectomy and postoperative immunotherapy. When lymph nodes are present, they should be resected when technically feasible.

Novel concepts in the staging of renal cell carcinoma

The incidence of renal cell carcinoma (RCC) continues to rise steadily; unfortunately, our ability to cure patients with metastatic RCC remains limited. When developing and evaluating new treatment protocols, it is important to consider the role of prognostic factors, often defined as pretreatment features, that are predictive of outcome. The complexity and variability of patients' individual clinical outcome and the recently recognized limitation of conventional staging systems have lead to the formulation of integrated prognostic staging systems. In this review, we discuss the evolution of various clinically relevant integrated staging systems for RCC.

Regional lymph node dissection in the treatment of renal cell carcinoma: is it useful in patients with no suspected adenopathy before or during surgery?

OBJECTIVES

To evaluate the role of regional lymph node dissection (LND) in a series of patients with renal cell carcinoma (RCC) with no suspicion of nodal metastases before or during surgery.

PATIENTS AND METHODS

A series of 167 patients with RCC, free from distant metastases at diagnosis, and who underwent radical nephrectomy at our hospital between January 1990 and October 1997, was reviewed. The mean (median, range) follow-up was 51 (45, 19-112) months. Of the 167 patients, 108 underwent radical nephrectomy alone and 59 had radical nephrectomy with regional LND limited to the anterior, posterior and lateral sides of the ipsilateral great vessel, from the level of the renal pedicle to the inferior mesenteric artery. Of these 59 patients, 49 had no evidence of nodal metastases before or during surgery. The probability of survival was estimated by the Kaplan-Meier method, using the log-rank test to estimate differences among levels of the analysed variables.

RESULTS

The overall 5-year survival was 79%; the 5-year survival rate for the 108 patients who underwent radical nephrectomy alone was 79% and for the 49 who underwent LND was 78%. Of the 49 patients with no suspicion of lymph node metastases, one (2%) was found to have histologically confirmed positive nodes.

CONCLUSION

These results suggest that there is no clinical benefit in terms of overall outcome in undertaking regional LND in the absence of enlarged nodes detected before or during surgery.

Renal neoplasm: The prognostic significance of nodal involvement

– Histologically-proven positive nodal involvement has a markedly negative affect on the prognosis of patients subjected to surgery for renal neoplasm. The incidence of nodal metastases reported in literature is wide-ranging and depends on various factors. A critical retrospective evaluation of literature in terms of survival curves and prognostic factor analysis highlights a particularly heterogeneous picture, due to much methodological bias and frequent violation of assumptions of the statistical analyses used. All these factors prevent a precise, independent prognostic value from being assigned to nodal involvement. The results of the single randomised prospective study (protocom EORTC 30881) on the therapeutic effectiveness of lymphadenectomy have been weakened by the low reported incidence of nodal involvement (about 5%). One of the most plausible explanations for this is the change in the natural history of renal tumours, which are currently diagnosed at low volume and stage, with a consequently low rate of nodal and/or distant metastases. This change in the natural history of the disease has increased the frequency of non-elective nephron-sparing surgery with optional nodal dissection over the last few years. This new approach has weakened the traditionally recognised role of lymphadenectomy in staging the disease.

Renal cell carcinoma metastases. Review of unusual clinical metastases, metastatic modes and patterns and comparison between clinical and autopsy metastatic series

We reviewed all cases of unusual clinical metastases of renal cell carcinoma found in the English literature. The percentages of usual and unusual clinical metastases are compared with data of some large autopsy series. The involvement of various organs is considered and some metastatic modes and patterns are reported. The analysis shows that clinical metastases are obviously underdiagnosed. Correct staging based on careful clinical investigations is paramount for optimal management of metastatic renal cancer.

Laparoscopy-assisted radical nephrectomy in combination with minilaparotomy: report of initial 7 cases

We recently developed a new procedure for laparoscopy-assisted radical nephrectomy in combination with minilaparotomy to remove kidneys with renal cell carcinoma. A pararectal incision approximately 7 cm in length was performed from the subcostal region. A 12-mm trocar was placed at the mid-clavicular line at the level of the umbilicus. An 11-mm trocar was placed at the tip of the 12th rib. Under laparoscopic and trans-minilaparotomic observation, intra-abdominal manipulation was begun. The contents of Gerota's fascia were freed from the surrounding tissues and removed through the abdominal incision. Seven patients have been successfully treated with this procedure. The operating time for this procedure was shorter than the time of laparoscopic nephrectomy. There were none of the adverse hemodynamic or ventilatory effects associated with pneumoperitoneum in this procedure. This procedure also resulted in less postoperative pain and a shorter convalescence period when compared with open nephrectomy.

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.

Renal carcinoma in patients undergoing nephrectomy: analysis of survival and prognostic factors

A series of 155 patients who underwent nephrectomy for renal carcinoma between 1965 and 1985 at Manchester Royal Infirmary were analysed for survival in relationship to presenting features, surgical staging and histopathology. Univariate and multivariate analyses were carried out. Five-year survival estimates for stage 1 disease were 81%, for stage 2 disease 65%, for stage 3 disease 39% and for stage 4 disease 6%. An erythrocyte sedimentation rate (ESR) greater than 30 mm/h was associated with worse survival and a history of hypertension was associated with better survival. Renal vein invasion alone was related to worse survival. Perinephric fat invasion was also associated with worse survival and this association in the multivariate analysis was more significant than expected, suggesting that the principles of radical surgery should be observed. The presence of granular cells as opposed to clear cells worsened survival. Patients with papillary tumours had a better survival than those with solid tumours.

Modified cruciate incision for transabdominal radical nephrectomy

Experience with multiple organ harvesting procedures as well as orthotopic liver transplantation has provided for excellent extensive upper abdominal surgical exposure. We report use of a modified cruciate incision for transabdominal radical nephrectomy.

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.

Bilateral renal cell carcinoma with metastasis to thyroid

A case of bilateral synchronous renal cell carcinomas with metastases to the regional lymph nodes and later to the thyroid gland was treated with aggressive surgical extirpation and adjuvant gamma interferon. The patient continues to have an excellent performance status sixteen months after initial diagnosis despite a large tumor burden at presentation.

Management of primary and metastatic renal cell carcinoma by transcatheter embolization with iodine 125

The long-term results of the management of metastatic renal cell carcinoma by a radioactive interstitial implant seated by a transcatheter embolization technique were evaluated in 85 patients at risk at 2 years and 37 at 5 years. The 2-year survival rate was 33% and the 5-year survival rate was 32%. Patients with isolated skeletal metastases showed the best survival rate (2-year survival rate, 69%; 5-year survival rate, 60%). Isolated pulmonary, other parenchymal, and central nervous system (CNS) metastases showed a lower 2-year survival rate of 15%. Regardless of the site of metastases and the size of the primary, histologic grade appeared to have a substantial impact on the survival of our patients. The beneficial results of interstitial radiation therapy are attributed to reduction of tumor burden and possibly the stimulation of the host immune response that may initiate remission. The noticeably better results in patients with osseous metastases are attributed to the resolute treatment of all osseous metastases by additional interstitial iodine 125 (125I) infarct implants. Conversely, the poor results in patients with CNS and other parenchymal metastases may be based on the inability to treat such metastases with 125I interstitial infarct implants. In addition to clinical observations of weight gain and the cessation of pain and hematuria if present, remissions are heralded by normalization of the erythrocyte sedimentation rate, disappearance of tumor markers if present, and rise of beta interferon levels. The technique is advocated for the management of inoperable renal cell carcinoma with distant metastases.

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.

Transplantation of human renal cell carcinoma into NMRI nu/nu mice. III. Effect of irradiation on tumor acceptance and tumor growth

Irradiation of human renal cell carcinoma before radical tumor nephrectomy resulted in a significantly lower acceptance rate (1 of 7) in nude mice than for nonirradiated tumors (all of 13). The tumor tissue was transplanted into NMRI nu/nu mice immediately after nephrectomy. In this experimental system we demonstrated the reduced vitality of human tumor cells after irradiation. In a second series of experiments, 3 morphologically different human renal cell carcinomas were irradiated at various doses after establishment in nude mice. The irradiated tumor tissue was transplanted to the next passage. The morphology, proliferation rate and growth of these tumors were compared with those of nonirradiated controls. Radiation effect was dose dependent in the responding tumor types. The characteristics correlated with radiosensitivity were high proliferation rate (measured by flow cytometry), low cytologic grading and fast growth rate in the nude mice.

Comparison of dynamic and conventional computed tomography, angiography, and ultrasonography in the staging of renal cell carcinoma

A prospective study was carried out on 22 patients to assess the diagnostic ability to stage renal cell carcinoma by computed tomography, dynamic computed tomography, arteriography, ultrasonography, and radionuclide scanning. Dynamic computed tomography remedied the most consequential diagnostic shortcomings of conventional computed tomography and proved the most sensitive, specific, and accurate technique for staging of all types of contiguous extension of renal cell carcinoma. For the identification of bone metastases, radionuclide scintiscanograms were found most accurate and cost-effective.

Problems of the indications of radiotherapy in renal tumours after radical nephrectomy

The complex therapy of renal tumours is discussed. While pointing to the advances in this field over the last decade, the fact is emphasized that it is primarily in the radicality of the operations were progress has been achieved. Radiotherapy is viewed with a critical eye. Its hazards are illustrated by observations of four lethal cases consecutive to complications of postoperative irradiations, which had been administered without any need when malignant changes were no longer present.

Renal cell carcinoma: the Ochsner Medical Institution experience (1945-1978)

We reviewed 161 patients operated upon for renal cell carcinoma between 1945 and 1978. Life table and survival analyses were computed to compare the effects of stage, tumor differentiation, cell type, surgical technique, renal vein involvement and sex on the years of survival. Patients with stage I and well differentiated tumors had the best prognosis. All patients surviving 10 years or more had well differentiated tumors. The type of nephrectomy did not affect survival and lymphadenectomy was only of value in staging the disease. The stage and differentiation of the tumor were more important to outcome than choice of therapy.

Clinically unrecognised renal carcinoma: aspects of tumor morphology, lymphatic and haematogenous metastatic spread

In a series comprising 235 clinically unrecognised renal carcinoma, metastatic spread was found in 56 cases (24%). In 82% of cases with metastases the spread involved more than one site. Lymphatic spread was diagnosed in 37 patients. Lymph node metastases were usually multiple and multifocal and were almost as common in the mediastinum as in the retroperitoneal space. In cases with involvement of these sites and/or supraclavicular nodes, concomitant metastases in the lungs were observed in 86% and in other organs in 11%. Since lymph node invasion is a strong indicator of systemic spread, the therapeutic benefit of radical lymphadenectomy seems very low, whereas a limited unilateral dissection is justified mainly for its value as a staging procedure.

Complications of transabdominal radical nephrectomy for renal cell carcinoma

Our data from 193 patients demonstrate that most renal cell carcinomas can be removed with acceptable mortality and morbidity by transabdominal, transperitoneal radical nephrectomy through an upper midline incision. During this study only 12 tumors were removed via a different approach. Four patients, all with stage IV disease, died postoperatively, for an operative mortality of 2.1 per cent. The intraoperative and postoperative complication rates were 20.7 and 19.1 per cent, respectively. The most common complication was injury to the spleen, which occurred in 24 patients (12.4 per cent) and probably represents the greatest potential disadvantage of this approach.

Renal cell carcinoma in children

Data from four pediatric hospitals concerning 20 children treated for renal cell carcinoma (RCC) from 1964-1978 were reviewed. Median age of the patients (pts) was 11.8 years (range, 14 months-19 years). Twelve were male and eight female; 17 were white and three black. Most patients presented with pain and hematuria with or without a palpable mass. An intrarenal tumor was detected at IV urography (17 pts), arteriography (2 pts), or at surgery (1 pt). Treatment consisted of nephrectomy in 15 pts, renal biopsy (4 pts), or no surgery (1 pt), followed by chemotherapy (5 pts), radiation therapy (1 pt), or both (7 pts). Ten pts died of distant metastases at a median of one year (range, 0.2 to two years) after diagnosis. The other 10 pts (50%) survive free of relapse at a median of 4 years (range, two to ten years) from diagnosis. Proportions surviving free of recurrent disease two or more years by National Wilms' Tumor Study (NWTS) Group were 5/5 in Group I, 3/7 in Group II, 1/3 in Group III, and 1/5 in Group IV; by age at diagnosis, 6/6 in those under 11 years old and 4/14 in those 11 or older; and by type of surgery, 10/15 who had nephrectomy and 0/5 with limited or no surgery. The data indicate that radiation and chemotherapy had only minor if any influences on relapse-free survival. We conclude that (1) RCC in children is similar to its counterpart in adults; (2) RCC has a worse prognosis than Wilms' tumor except for the earliest stage; (3) nephrectomy alone is adequate treatment for Group I RCC, and (4) young age (less than 11 years old) may be prognostically favorable.

Accuracy of computed tomography in staging of kidney tumors

Computed tomography was performed in 125 patients with kidney tumors for pretreatment staging. The accuracy of CT staging was then determined by correlating the CT findings with the pathologic findings (111 patients) or with the angiographic findings (14 patients). Perirenal extension was correctly predicted in 79 per cent of all the patients, lymph node involvement in 87, main renal vein involvement in 91, infiltration of the inferior vena cava in 97 and invasion of neighboring organs in 96 per cent. It is concluded that CT should be the baseline procedure for the assessment of the extent of spread of renal tumors.

Metastatic processes and a potential indication of treatment for metastatic lesions of renal adenocarcinoma

Renal adenocarcinoma findings from 307 autopsied cases with metastasis to 1 and 2 organs were investigated concerning the mode of metastasis. The lung was the most frequent site of metastasis to 1 organ, although the frequency was rather low (30 per cent), followed by bones (over-all), lymph nodes (over-all) and brain, and involving frequently the thoracic spine and retroperitoneal lymph nodes. In patients with metastases to 2 organs a significant correlation was found between the pulmonary-tracheal lymph nodes and those to the lungs. Potential indications for treatment of metastatic lesions were 1) lymphadenectomy and/or radiation therapy for the retroperitoneal and para-aortic lymph nodes and 2) resection of metastatic lesions in the lungs combined with lymphadenectomy and/or radiation therapy for the pulmonary-tracheal lymph nodes. In patients without lung metastasis lymphadenectomy and/or radiation therapy for the pulmonary-tracheal lymph nodes is not always necessary.