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| Potential benefit of lymph node dissection during radical nephrectomy for kidney cancer: A review and critical analysis of current literature |
Michele Marchionia,*( ),Daniele Amparoreb,Igino Andrea Maglia,Riccardo Bertoloc,Umberto Carbonarad,Selcuk Erdeme,Alexandre Ingelsf,Constantijn H.J. Muselaersg,Onder Karah,Marco Mascittia,Tobias Klattei,Maximilian Kriegmairj,Nicola Pavank,Eduard Roussell,Angela Pecorarob,Laura Marandinom,Riccardo Campin,Luigi Schipsa,on behalf of the European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer group
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aDepartment of Urology, SS Annunziata Hospital, “G. D’Annunzio” University of Chieti, Chieti, Italy
bDivision of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy
cDepartment of Urology, San Carlo Di Nancy Hospital, Rome, Italy
dDepartment of Emergency and Organ Transplantation-Urology, Andrology and Kidney Transplantation Unit, University of Bari, Bari, Italy
eDivision of Urologic Oncology, Department of Urology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
fDepartment of Urology, University Hospital Henri Mondor, APHP, Créteil, France
gDepartment of Urology, Radboud University Medical Center, Nijmegen, the Netherlands
hDepartment of Urology, Kocaeli University School of Medicine, Kocaeli, Turkey
iDepartment of Urology, Royal Bournemouth Hospital, Bournemouth, UK
jDepartment of Urology, University Medical Centre Mannheim, Mannheim, Germany
kUrology Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
lDepartment of Urology, University Hospitals Leuven, Leuven, Belgium
mDepartment of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
nUnit of Urological Robotic Surgery and Renal Transplantation, University of Florence, Careggi Hospital, Florence, Italy |
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Abstract Objective: The role of lymph node dissection (LND) is still controversial in patients with renal cell carcinoma undergoing surgery. We aimed to provide a comprehensive review of the literature about the effect of LND on survival, prognosis, surgical outcomes, as well as patient selection and available LND templates.
Methods: Recent literature (from January 2011 to December 2021) was assessed through PubMed and MEDLINE databases. A narrative review of most relevant articles was provided.
Results: The frequencies in which LNDs are being carried out are decreasing due to an increase in minimally invasive and nephron sparing surgery. Moreover, randomized clinical trials and meta-analyses failed to show any survival advantage of LND versus no LND. However, retrospective studies suggest a survival benefit of LND in high-risk patients (bulky tumors, T3-4 stage, and cN1 patients). Moreover, extended LND might provide important staging information, which could be of interest for adjuvant treatment planning.
Conclusion: No level 1 evidence of any survival advantage deriving from LND is currently available in literature. Thus, the role of LND is limited to staging purposes. However, low grade evidence suggests a possible role of LND in high-risk patients. Randomized clinical trials are warranted to corroborate these findings.
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Received: 08 December 2021
Available online: 20 July 2022
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Corresponding Authors:
Michele Marchioni
E-mail: mic.marchioni@gmail.com
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| Reference | Study design | Patient, n (no LND/LND) | Primary endpoint | Tumor stage, (n, no LND/LND) | | Localized | | Gershman et al. 2017, [16] | Monocentric retrospective | 1797 (1191/606) | CSM and ACM | -pT1a (340/36);
pT1b (352/84);
pT2a (152/81);
pT2b (65/66);
pT3a (210/218);
pT3b (41/91);
pT3c (11/13);
pT4 (9/16)
Missing (12) | | Farber et al. 2019, [21] | Monocentric retrospective | 19 500 (9750/9750) | OS | -pT1 (3327/3120);
pT2 (2838/3294);
pT3 (3328/3048);
pT4 (257/288) | | Feuerstein et al. 2014, [22] | Monocentric retrospective | 524 (190/334) | 5-year RFS and 5-year OS | -pT2 (84/95);
pT3 (101/227);
pT4 (5/12);
-pN0 (0/308);
pN1 (0/26) | | Gershman et al. 2018, [20] | Multicentric retrospective | 2437 (1398/1039) | CSM and ACM | -pT1a (299/195);
pT1b (401/301);
pT2a (182/136);
p T2b (96/71);
pT3a (321/253);
pT3b (64/54);
pT3c (23/18);
pT4 (12/11);
-cN1 (47/47) | | Advanced and metastatic | | Tilki et al. 2018, [27] | Multicentric retrospective | 1978 (952/1026) | CSS | -pNx 952 (NA);
pN0 803 (NA);
pN1 223 (NA) | | Faiena et al. 2018, [28] | Monocentric retrospective | 1780 (514/1266) | OS | -pT1-2 (41/101);
pT3a (263/656);
pT3b-c (78/255);
pT4 (59/212);
pTx (73/42);
-pN0 (NA/163);
pN1 (NA/1036);
pNx (514/41);
Missing (0/26) | | Chipollini et al. 2018, [31] | Multicentric retrospective | 293 (106/187) | CSS | -pT3a 84 (NA);
pT3b 137 (NA);
pT3c 34 (NA);
pT4 38 (NA);
-pN0 68 (NA);
pN1 119 (NA);
pNx 106 (NA) | | Capitanio et al. 2012, [13] | Multicentric retrospective | 1983 (1109/874) | CSS | -pT1a 760 (NA);
pT1b 487 (NA);
pT2a 152 (NA);
pT2b 68 (NA);
pT3a 375 (NA);
pT3b 61 (NA);
pT3c 38 (NA);
pT4 42 (NA);
-pN0 754 (NA)
pN1 120 (NA);
pNx 1109 (NA) | | Marchioni et al. 2018, [17] | Monocentric retrospective | 25 357 (19 057/6300) | CSS | -pT2 (8268/2275);
pT3 (10 789/4025) | | Feuerstein et al. 2014, [29] | Monocentric retrospective | 258 (81/177) | OS | -pT1 (25/11);
pT2 (5/19);
≥pT3 (51/147) | | Gershman et al. 2017, [30] | Monocentric retrospective | 305 (117/188) | CSM and ACM | -pT1a 3 (1/2);
pT1b 26 (12/14);
pT2a 31 (15/16);
pT2b 22 (10/12);
pT3a 143 (53/90);
pT3b 40 (12/28);
pT3c 10 (3/7);
pT4 28 (10/18)
Missing (2) | | Salvage | | Barboza et al. 2020, [33] | Monocentric retrospective | 19 (0/19) | RFS and CSS | -pT1/pT2 6 (NA);
pT3 10 (NA);
pT4 1 (NA);
Unknown 2 (NA)
-pN0 4 (NA);
pN1 4 (NA);
pNx 9 (NA);
Unknown 2 (NA) | | Russell et al. 2015, [34] | Monocentric retrospective | 50 (0/50) | RFS and CSS | -pT1a 4 (NA);
pT1b 6 (NA);
pT2a 7 (NA);
pT2b 3 (NA);
pT3a 25 (NA);
pT3b 5 (NA);
-pN0/Nx 35 (NA);
pN1 15 (NA) |
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Main patients’ characteristics of included studies.
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Schematic representation of mainly used lymph node dissection templates. (A) Schematic representation of main kidney lymphatic drainage. In blue are the most common lymphatic stations involved in standard lymph node dissection for the right (B) and left kidney (C). In yellow are lymphatic stations involved in extended lymph node dissection for the right (B) and left (C) kidney.
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