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Ngai M, Chandrasekar T, Bratslavsky G, Goldberg H. The Current Role of Lymph Node Dissection in Nonmetastatic Localized Renal Cell Carcinoma. J Clin Med 2023; 12:jcm12113732. [PMID: 37297925 DOI: 10.3390/jcm12113732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/21/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
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.
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Affiliation(s)
- Megan Ngai
- Urology Department, SUNY Upstate Medical University, Syracuse, NY 13210, USA
| | | | - Gennady Bratslavsky
- Urology Department, SUNY Upstate Medical University, Syracuse, NY 13210, USA
| | - Hanan Goldberg
- Urology Department, SUNY Upstate Medical University, Syracuse, NY 13210, USA
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2
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Ray S, Dason S, Singer EA. Integrating Surgery in the Multidisciplinary Care of Advanced Renal Cell Carcinoma. Urol Clin North Am 2023; 50:311-323. [PMID: 36948674 DOI: 10.1016/j.ucl.2023.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
The role of surgery for patients with locally advanced and metastatic renal cell carcinoma (RCC) is not precisely defined in our contemporary era of systemic therapies. Research in this field is focused on the role of regional lymphadenectomy, along with indications and timing of cytoreductive nephrectomy and metastasectomy. As our understanding of the molecular and immunological basis of RCC continues to develop along with the advent of novel systemic therapies, prospective clinical trials will be critical in defining how surgery should be integrated into the treatment paradigm of advanced RCC.
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Affiliation(s)
- Shagnik Ray
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, 915 Olentangy River Road, 3rd Floor, Urology Suite 3100, Columbus, OH 43212, USA
| | - Shawn Dason
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, 915 Olentangy River Road, 3rd Floor, Urology Suite 3100, Columbus, OH 43212, USA
| | - Eric A Singer
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, 915 Olentangy River Road, 3rd Floor, Urology Suite 3100, Columbus, OH 43212, USA.
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3
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Małkiewicz B, Kiełb P, Kobylański M, Karwacki J, Poterek A, Krajewski W, Zdrojowy R, Szydełko T. Sentinel Lymph Node Techniques in Urologic Oncology: Current Knowledge and Application. Cancers (Basel) 2023; 15:cancers15092495. [PMID: 37173960 PMCID: PMC10177100 DOI: 10.3390/cancers15092495] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 04/23/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023] Open
Abstract
Lymph node (LN) metastases have a significant negative impact on the prognosis of urological malignancies. Unfortunately, current imaging modalities are insufficient when it comes to detecting micrometastases; thus, surgical LN removal is commonly used. However, there is still no established ideal lymph node dissection (LND) template, leading to unnecessary invasive staging and the possibility of missing LN metastases located outside the standard template. To address this issue, the sentinel lymph node (SLN) concept has been proposed. This technique involves identifying and removing the first group of draining LNs, which can accurately stage cancer. While successful in breast cancer and melanoma, the SLN technique in urologic oncology is still considered experimental due to high false-negative rates and lack of data in prostate, bladder, and kidney cancer. Nevertheless, the development of new tracers, imaging modalities, and surgical techniques may improve the potential of the SLN procedures in urological oncology. In this review, we aim to discuss the current knowledge and future contributions of the SLN procedure in the management of urological malignancies.
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Affiliation(s)
- Bartosz Małkiewicz
- University Center of Excellence in Urology, Department of Minimally Invasive and Robotic Urology, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Paweł Kiełb
- University Center of Excellence in Urology, Department of Minimally Invasive and Robotic Urology, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Maximilian Kobylański
- University Center of Excellence in Urology, Department of Minimally Invasive and Robotic Urology, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Jakub Karwacki
- University Center of Excellence in Urology, Department of Minimally Invasive and Robotic Urology, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Adrian Poterek
- University Center of Excellence in Urology, Department of Minimally Invasive and Robotic Urology, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Wojciech Krajewski
- University Center of Excellence in Urology, Department of Minimally Invasive and Robotic Urology, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Romuald Zdrojowy
- University Center of Excellence in Urology, Department of Urology, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Tomasz Szydełko
- University Center of Excellence in Urology, Department of Minimally Invasive and Robotic Urology, Wroclaw Medical University, 50-556 Wroclaw, Poland
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4
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Wu R, Wang K, Gai Y, Li M, Wang J, Wang C, Zhang Y, Xiao Z, Jiang D, Gao Z, Xia X. Nanomedicine for renal cell carcinoma: imaging, treatment and beyond. J Nanobiotechnology 2023; 21:3. [PMID: 36597108 PMCID: PMC9809106 DOI: 10.1186/s12951-022-01761-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 12/26/2022] [Indexed: 01/04/2023] Open
Abstract
The kidney is a vital organ responsible for maintaining homeostasis in the human body. However, renal cell carcinoma (RCC) is a common malignancy of the urinary system and represents a serious threat to human health. Although the overall survival of RCC has improved substantially with the development of cancer diagnosis and management, there are various reasons for treatment failure. Firstly, without any readily available biomarkers, timely diagnosis has been greatly hampered. Secondly, the imaging appearance also varies greatly, and its early detection often remains difficult. Thirdly, chemotherapy has been validated as unavailable for treating renal cancer in the clinic due to its intrinsic drug resistance. Concomitant with the progress of nanotechnological methods in pharmaceuticals, the management of kidney cancer has undergone a transformation in the recent decade. Nanotechnology has shown many advantages over widely used traditional methods, leading to broad biomedical applications ranging from drug delivery, prevention, diagnosis to treatment. This review focuses on nanotechnologies in RCC management and further discusses their biomedical translation with the aim of identifying the most promising nanomedicines for clinical needs. As our understanding of nanotechnologies continues to grow, more opportunities to improve the management of renal cancer are expected to emerge.
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Affiliation(s)
- Ruolin Wu
- grid.33199.310000 0004 0368 7223Department of Nuclear Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022 Hubei People’s Republic of China ,grid.412839.50000 0004 1771 3250Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Biological Targeted Therapy, The Ministry of Education, Wuhan, China
| | - Keshan Wang
- grid.33199.310000 0004 0368 7223Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Yongkang Gai
- grid.33199.310000 0004 0368 7223Department of Nuclear Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022 Hubei People’s Republic of China ,grid.412839.50000 0004 1771 3250Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Biological Targeted Therapy, The Ministry of Education, Wuhan, China
| | - Mengting Li
- grid.33199.310000 0004 0368 7223Department of Nuclear Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022 Hubei People’s Republic of China ,grid.412839.50000 0004 1771 3250Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Biological Targeted Therapy, The Ministry of Education, Wuhan, China
| | - Jingjing Wang
- grid.33199.310000 0004 0368 7223Department of Nuclear Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022 Hubei People’s Republic of China ,grid.412839.50000 0004 1771 3250Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Biological Targeted Therapy, The Ministry of Education, Wuhan, China
| | - Chenyang Wang
- grid.33199.310000 0004 0368 7223Department of Nuclear Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022 Hubei People’s Republic of China ,grid.412839.50000 0004 1771 3250Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Biological Targeted Therapy, The Ministry of Education, Wuhan, China
| | - Yajing Zhang
- grid.33199.310000 0004 0368 7223Department of Nuclear Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022 Hubei People’s Republic of China ,grid.412839.50000 0004 1771 3250Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Biological Targeted Therapy, The Ministry of Education, Wuhan, China
| | - Zhiwei Xiao
- grid.413247.70000 0004 1808 0969Department of Nuclear Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Dawei Jiang
- grid.33199.310000 0004 0368 7223Department of Nuclear Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022 Hubei People’s Republic of China ,grid.412839.50000 0004 1771 3250Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Biological Targeted Therapy, The Ministry of Education, Wuhan, China
| | - Zairong Gao
- grid.33199.310000 0004 0368 7223Department of Nuclear Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022 Hubei People’s Republic of China ,grid.412839.50000 0004 1771 3250Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Biological Targeted Therapy, The Ministry of Education, Wuhan, China
| | - Xiaotian Xia
- grid.33199.310000 0004 0368 7223Department of Nuclear Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan, 430022 Hubei People’s Republic of China ,grid.412839.50000 0004 1771 3250Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China ,grid.419897.a0000 0004 0369 313XKey Laboratory of Biological Targeted Therapy, The Ministry of Education, Wuhan, China
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5
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Patel HV, Srivastava A, Singer EA. To Be or "Node" to Be: Nodal Disease and the Role of Lymphadenectomy in the Treatment of Renal Cell Carcinoma. ACTA ACUST UNITED AC 2020; 8. [PMID: 32582841 DOI: 10.18103/mra.v8i5.2091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Lymph node involvement in renal cell carcinoma (RCC) correlates with poor oncologic outcomes. However, current RCC staging guidelines may not fully reflect the survival impact of lymph node positive disease. Recent data demonstrates that nodal disease has significant impact on survival and modifications to current staging guidelines have been proposed. Lymph node dissection (LND) at the time of surgical intervention for RCC remains controversial. While clinical trial data have demonstrated conflicting evidence for LND, some institutional studies suggests that carefully selected patients at high-risk for recurrence may benefit from LND. Prospectively, clinical trials are examining treating nodal disease and disease at high-risk of recurrence in the neoadjuvant and/or adjuvant setting at the time of nephrectomy. These promising trials are poised, if successful, to influence the treatment paradigm for localized RCC.
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Affiliation(s)
- Hiren V Patel
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Arnav Srivastava
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Eric A Singer
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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6
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John NT, Blum KA, Hakimi AA. Role of lymph node dissection in renal cell cancer. Urol Oncol 2019; 37:187-192. [DOI: 10.1016/j.urolonc.2018.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 02/21/2018] [Accepted: 03/06/2018] [Indexed: 12/20/2022]
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7
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Kuusk T, Donswijk ML, Valdés Olmos RA, De Bruijn RE, Brouwer OR, Hendricksen K, Horenblas S, Jóźwiak K, Prevoo W, Van Der Poel HG, Van Rhijn BWG, Wit EM, Bex A. An analysis of SPECT/CT non-visualization of sentinel lymph nodes in renal tumors. EJNMMI Res 2018; 8:105. [PMID: 30511175 PMCID: PMC6277398 DOI: 10.1186/s13550-018-0460-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 11/20/2018] [Indexed: 11/24/2022] Open
Abstract
Background Sentinel lymph node biopsy (SLNB) after intratumoral injection of 99mTc labeled nanocolloid and imaging with scintigraphy and SPECT/CT in renal tumors is feasible. However, sentinel lymph node (SN) non-detection rate with scintigraphy and SPECT/CT is high. The aim of the study was to determine factors affecting non-visualization (NV) of SN imaging in renal tumors. Seventy-eight patients with cT1–3 renal tumors received intratumoral injection of 225 MBq 99mTc-labeled nanocolloid 1 day before (partial) nephrectomy. Radiotracer injection was followed by anterioposterior and lateral scintigraphy in combination with SPECT/CT 20 min and 2–4 h after. Surgical treatment of the tumor with sentinel lymph node biopsy by aid of γ-probe and-camera was performed the next day. Scintigraphy and SPECT/CT images were evaluated and patient, tumor, and procedure characteristics were collected for 73 eligible patients used in uni- and multivariable analysis of a potential association with NV. Results A total of 80 (mean 1.1, IQR 0–2, max 6) sentinel lymph nodes in 46 patients were detected with scintigraphy and SPECT/CT. Preoperative visualization rate and intraoperative detection rate was 63% [95% CI 50–73%] and 61% [95% CI 49–72%], respectively. In uni- and multivariable analysis, the only factor associated with non-visualization was age, showing higher odds of non-visualization with higher age. Conclusion Our study demonstrated that non-visualization of SNs in renal tumors is relatively high and is associated with patient age. Furthermore, kidneys and also its tumors are highly vascularized which may cause a wash-out effect that could be identified with decreased kidney-liver ratios. However, in our data, the effect was statistically inconclusive. Further studies are needed to improve visualization and standardize the procedure of SLNB in renal tumors. The percentage of NV limits the use of SLNB for research and clinical purposes in renal cancer. Electronic supplementary material The online version of this article (10.1186/s13550-018-0460-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Teele Kuusk
- Department of Urology, The Netherlands Cancer Institute, Postbus 90203, 1006 BE, Amsterdam, The Netherlands
| | - Maarten L Donswijk
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Postbus 90203, 1006 BE, Amsterdam, The Netherlands
| | - Renato A Valdés Olmos
- Department of Nuclear Medicine, The Netherlands Cancer Institute, Postbus 90203, 1006 BE, Amsterdam, The Netherlands.,Department of Radiology, Interventional Molecular Imaging Laboratory and Nuclear Medicine Section, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Roderick E De Bruijn
- Department of Urology, The Netherlands Cancer Institute, Postbus 90203, 1006 BE, Amsterdam, The Netherlands
| | - Oscar R Brouwer
- Department of Urology, The Netherlands Cancer Institute, Postbus 90203, 1006 BE, Amsterdam, The Netherlands.,Department of Radiology, Interventional Molecular Imaging Laboratory and Nuclear Medicine Section, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Kees Hendricksen
- Department of Urology, The Netherlands Cancer Institute, Postbus 90203, 1006 BE, Amsterdam, The Netherlands
| | - Simon Horenblas
- Department of Urology, The Netherlands Cancer Institute, Postbus 90203, 1006 BE, Amsterdam, The Netherlands
| | - Katarzyna Jóźwiak
- Department of Epidemiology and Biostatistics, The Netherlands Cancer Institute, Postbus 90203, 1006 BE, Amsterdam, The Netherlands
| | - Warner Prevoo
- Department of Radiology, The Netherlands Cancer Institute, Postbus 90203, 1006 BE, Amsterdam, The Netherlands
| | - Henk G Van Der Poel
- Department of Urology, The Netherlands Cancer Institute, Postbus 90203, 1006 BE, Amsterdam, The Netherlands
| | - Bas W G Van Rhijn
- Department of Urology, The Netherlands Cancer Institute, Postbus 90203, 1006 BE, Amsterdam, The Netherlands
| | - Esther M Wit
- Department of Urology, The Netherlands Cancer Institute, Postbus 90203, 1006 BE, Amsterdam, The Netherlands
| | - Axel Bex
- Department of Urology, The Netherlands Cancer Institute, Postbus 90203, 1006 BE, Amsterdam, The Netherlands. .,Division of Surgical Oncology, Department of Urology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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8
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The side and the location of the primary tumor does not affect the probability of lymph node invasion in patients with renal cell carcinoma. World J Urol 2018; 37:1623-1629. [PMID: 30474699 DOI: 10.1007/s00345-018-2573-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 11/20/2018] [Indexed: 10/27/2022] Open
Abstract
PURPOSE To evaluate the role of side and location of the primary renal cell carcinoma (RCC) on the risk of lymph node invasion (LNI) and/or nodal progression (NP) during follow-up. MATERIALS AND METHODS We evaluated 2485 patients with unilateral RCC, surgically treated in a single tertiary care referral center. Outcomes were LNI at surgery and/or NP during follow-up. We studied if RCC side (left vs. right) and location (upper vs. middle vs. hilar vs. lower area vs. more than one area) affected the probability of LNI and/or NP at follow-up. RESULTS Overall, 43 and 15% of patients underwent lymph node dissection and had LNI at surgery, respectively. During follow-up, 2.2% of patients had NP. Higher rates of LNI and NP were observed for patients with primary tumor located in more than one anatomical kidney area relative to patients with tumor in a single area (upper 11% vs. middle 10% vs. hilar 0%, vs. lower 12% vs. more than one area 26%, p < 0.01). cM1, cN1, pT2/pT3/pT4 disease and Fuhrman grade 3/4 were independent predictors of the study outcome (all p ≤ 0.01). Neither the RCC side nor the location reached the independent predictor status (all p > 0.1). CONCLUSIONS Patients with single-side and more than one anatomical kidney area affected by RCC have higher rate of LNI at surgery and/or NP at follow-up. Neither side nor location of primary RCC tumor is related to the risk of harboring LNI at surgery and/or developing NP at follow-up.
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9
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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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10
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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: 25] [Impact Index Per Article: 3.6] [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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Lymph node dissection should not be dismissed in case of localized renal cell carcinoma in the presence of larger diseases. Urol Oncol 2017; 35:662.e9-662.e15. [PMID: 28801027 DOI: 10.1016/j.urolonc.2017.07.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 06/03/2017] [Accepted: 07/10/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To assess whether even in the group of localized renal cell carcinoma (RCC), some patients might harbor a disease with a predilection for lymph node invasion (LNI) and/or lymph node (LN) progression and might deserve lymph node dissection (LND) at the time of surgery. MATERIALS AND METHODS Between 1990 and 2014, 2,010 patients with clinically defined T1-T2N0M0 RCC were treated with nephrectomy and standardized LND at a single tertiary care referral center. The endpoint consists of the presence of LNI and/or nodal progression, defined as the onset of a new clinically detected lymphadenopathy (>10mm) in the retroperitoneal lymphatic area with associated systemic progression or histological confirmation or both. We tested the association between clinical characteristics and the endpoint of interest. Predictors consisted of age at surgery, clinical tumor size, preoperative hemoglobin, and platelets levels. Multivariable logistic regression model and smoothed Lowess method were used. RESULTS LNI was recorded in 14 cases (2.2%). The median follow-up after surgery was 68 months. During the study period, 23 patients (1.1%) experienced LN progression; 91% of those patients experienced LN progression within 3 years after surgery. Combining the 2 endpoints, 36 patients (1.8%) had LNI and/or LN progression. Clinical tumor size was the only independent predictors of LNI and/or LN progression (OR = 1.25). A significant increase of the risk of LNI and/or LN progression was observed in RCC larger than 7cm (cT2a or higher). CONCLUSIONS LNI and/or LN progression is a rare entity in patients with localized RCC. Nonetheless, patients with larger tumors might still benefit from LND because of a non-negligible risk of LNI and/or LN progression.
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Brouwer OR, van der Poel HG, Bevers RF, van Gennep EJ, Horenblas S. Beyond penile cancer, is there a role for sentinel node biopsy in urological malignancies? Clin Transl Imaging 2016; 4:395-410. [PMID: 27738628 PMCID: PMC5037151 DOI: 10.1007/s40336-016-0189-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 05/30/2016] [Indexed: 11/30/2022]
Abstract
This review aims to discuss the current state-of-the-art of sentinel node (SN) mapping in urological malignancies. The principles and methodological aspects of lymphatic mapping and SN biopsy in urological malignancies are reviewed. Literature search was restricted to English language. The references of the retrieved articles were examined to identify additional articles. The review also includes meta-analyses published in the past 5 years. SN biopsy for penile cancer is recommended by the European Association of Urology as the preferred staging tool for clinically node-negative patients with at least T1G2 tumours (level of evidence 2a, Grade B). The feasibility of SN biopsy in prostate cancer has been repeatedly demonstrated and its potential value is increasingly being recognised. However, conclusive prospective clinical data as well as consensus on methodology and patient selection are still lacking. For bladder, renal and testicular cancer, only few studies have been published, and concerns around high false-negative rates remain. Throughout the years, the uro-oncological field has portrayed a pivotal role in the development of the SN concept. Recent advances such as hybrid tracers and novel intraoperative detection tools such as fluorescence and portable gamma imaging will hopefully encourage prospectively designed clinical trials which can further substantiate the potential of the SN approach in becoming an integral part of staging in urological malignancies beyond penile cancer.
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Affiliation(s)
- O R Brouwer
- Department of Urologyand Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands ; Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - H G van der Poel
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - R F Bevers
- Department of Urologyand Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - E J van Gennep
- Department of Urologyand Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - S Horenblas
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
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14
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Capitanio U, Leibovich BC. The rationale and the role of lymph node dissection in renal cell carcinoma. World J Urol 2016; 35:497-506. [DOI: 10.1007/s00345-016-1886-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 06/23/2016] [Indexed: 01/29/2023] Open
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15
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Jakobsen JK. Sentinel node biopsy in uro-oncology: A history of the development of a promising concept. Urol Oncol 2015; 33:486-93. [DOI: 10.1016/j.urolonc.2015.08.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 08/17/2015] [Accepted: 08/19/2015] [Indexed: 02/06/2023]
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16
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Valdés Olmos RA, Rietbergen DDD, Vidal-Sicart S. SPECT/CT and sentinel node lymphoscintigraphy. Clin Transl Imaging 2014. [DOI: 10.1007/s40336-014-0087-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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17
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Karmali RJ, Suami H, Wood CG, Karam JA. Lymphatic drainage in renal cell carcinoma: back to the basics. BJU Int 2014; 114:806-17. [PMID: 24841690 DOI: 10.1111/bju.12814] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Lymphatic drainage in renal cell carcinoma (RCC) is unpredictable, however, basic patterns can be observed in cadaveric and sentinel lymph node mapping studies in patients with RCC. The existence of peripheral lymphovenous communications at the level of the renal vein has been shown in mammals but remains unknown in humans. The sentinel lymph node biopsy technique can be safely applied to map lymphatic drainage patterns in patients with RCC. Further standardisation of sentinel node biopsy techniques is required to improve the clinical significance of mapping studies. Understanding lymphatic drainage in RCC may lead to an evidence-based consensus on the surgical management of retroperitoneal lymph nodes.
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Affiliation(s)
- Riaz J Karmali
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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