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Re: Extent of Lymph Node Dissection at Nephrectomy Affects Cancer-Specific Survival and Metastatic Progression in Specific Sub-Categories of Patients with Renal Cell Carcinoma (RCC)
Urological Survey Urological Oncology: Adrenal, Renal, Ureteral and Retroperitoneal Tumors Re: Extent of Lymph Node Dissection at Nephrectomy Affects Cancer-Specific Survival and Metastatic Progression in Specific Sub-Categories of Patients with Renal Cell Carcinoma (RCC) U. Capitanio, N. Suardi, R. Matloob, M. Roscigno, F. Abdollah, E. Di Trapani, M. Moschini, A. Gallina, A. Salonia, A. Briganti, F. Montorsi and R. Bertini Department of Urology, San Raffaele Scientific Institute, Milan, Italy BJU Int 2014; 114: 210e215.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2014.11.043 available at http://jurology.com/ Editorial Comment: Unlike in other cancers, lymph node dissection (LND) in renal cell carcinoma (RCC) has been controversial. LND is still rarely performed, either due to technical reasons (diffusion of laparoscopy, lack of standard templates), migration to early stages or uncertainty about the therapeutic value. Unfortunately the only randomized controlled trial (EORTC 30881) providing level of evidence 1b did not support the additional value of LND. This study presented some limitations, and a recent subgroup analysis suggests a beneficial effect of LND in cT3 disease. Meanwhile, retrospective series have shown that LND offers a benefit in high risk patients, and define tumor diameter greater than 10 cm, presence of sarcomatoid features and T3 to T4 disease as predictors of lymph node involvement. The present retrospective series analysis adds to the growing evidence that not only LND, but also the extent, namely the number of lymph nodes removed, has a protective effect against cancer specific mortality. Besides reproducing the results of other series in pT3 to pT4 disease, bulky tumors and tumors with sarcomatoid features, surprisingly the benefit was also found in pT2a disease but not in the well represented group of pT3a to pT3b disease. This apparent discordance may be driven by the selection bias for LND (gross nodes on imaging) or the different LND templates in previous series or in the present study. If a rationale for LND is to eliminate nodal macrometastasis and micrometastasis, candidates for LND should be determined a priori. Thus, efforts should focus on defining high risk patients for nodal metastasis at clinical staging. Furthermore, to balance the benefits/complications, determining which template should be applied in a given patient needs to be defined, and the possible advantage of LND in patients who already have metastasis (protective effect regarding median progression-free survival), as advocated by the authors, needs to be validated since it is well known that some distant metastases, especially pulmonary metastases, may evolve slowly. M. Pilar Laguna, MD, PhD
Suggesting Reading Whitson JM, Harris CR, Reese AC et al: Lymphadenectomy improves survival of patients with renal cell carcinoma and nodal metastases. J Urol 2011; 185: 1615. Blute ML, Leibovich BC, Cheville JC et al: A protocol for performing extended lymph node dissection using primary tumor pathological features for patients treated with radical nephrectomy for clear cell renal cell carcinoma. J Urol 2004; 172: 465. Vasselli JR, Yang JC, Linehan WM et al: Lack of retroperitoneal lymphadenopathy predicts survival of patients with metastatic renal cell carcinoma. J Urol 2001; 166: 68.
0022-5347/15/1932-0457/0 THE JOURNAL OF UROLOGY® © 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2014.11.043 Vol. 193, 457-459, February 2015 Printed in U.S.A.
www.jurology.com
j
457
Abstract for this article http://dx.doi.org/10.1016/j.juro.2014.11.043 available at http://jurology.com/ Editorial Comment: Unlike in other cancers, lymph node dissection (LND) in renal cell carcinoma (RCC) has been controversial. LND is still rarely performed, either due to technical reasons (diffusion of laparoscopy, lack of standard templates), migration to early stages or uncertainty about the therapeutic value. Unfortunately the only randomized controlled trial (EORTC 30881) providing level of evidence 1b did not support the additional value of LND. This study presented some limitations, and a recent subgroup analysis suggests a beneficial effect of LND in cT3 disease. Meanwhile, retrospective series have shown that LND offers a benefit in high risk patients, and define tumor diameter greater than 10 cm, presence of sarcomatoid features and T3 to T4 disease as predictors of lymph node involvement. The present retrospective series analysis adds to the growing evidence that not only LND, but also the extent, namely the number of lymph nodes removed, has a protective effect against cancer specific mortality. Besides reproducing the results of other series in pT3 to pT4 disease, bulky tumors and tumors with sarcomatoid features, surprisingly the benefit was also found in pT2a disease but not in the well represented group of pT3a to pT3b disease. This apparent discordance may be driven by the selection bias for LND (gross nodes on imaging) or the different LND templates in previous series or in the present study. If a rationale for LND is to eliminate nodal macrometastasis and micrometastasis, candidates for LND should be determined a priori. Thus, efforts should focus on defining high risk patients for nodal metastasis at clinical staging. Furthermore, to balance the benefits/complications, determining which template should be applied in a given patient needs to be defined, and the possible advantage of LND in patients who already have metastasis (protective effect regarding median progression-free survival), as advocated by the authors, needs to be validated since it is well known that some distant metastases, especially pulmonary metastases, may evolve slowly. M. Pilar Laguna, MD, PhD
Suggesting Reading Whitson JM, Harris CR, Reese AC et al: Lymphadenectomy improves survival of patients with renal cell carcinoma and nodal metastases. J Urol 2011; 185: 1615. Blute ML, Leibovich BC, Cheville JC et al: A protocol for performing extended lymph node dissection using primary tumor pathological features for patients treated with radical nephrectomy for clear cell renal cell carcinoma. J Urol 2004; 172: 465. Vasselli JR, Yang JC, Linehan WM et al: Lack of retroperitoneal lymphadenopathy predicts survival of patients with metastatic renal cell carcinoma. J Urol 2001; 166: 68.
0022-5347/15/1932-0457/0 THE JOURNAL OF UROLOGY® © 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2014.11.043 Vol. 193, 457-459, February 2015 Printed in U.S.A.
www.jurology.com
j
457