Neglected Lymph Nodal Metastases in Patients with Renal Cancer: When to Extend the Anatomical Template of Lymph Node Dissection During Nephrectomy

In our recently published article, we state that performing an eLND during Kidney surgery con Renal Cell Carcinoma (RCC) might be justified in patients with large suspicious LN metastases, both to improve staging and to allow adequate postoperative treatment management. The idea to submit this study comes from the discussion about lymph node dissection during Radical Nephrectomy (RN) and Partial Nephrectomy (PN) still ongoing among the urological community.

The guidelines suggest that the indication of LN dissection is still controversial and only based on the enlargement at CT/MRI scan or intra- operative palpability of enlarged nodes. Therefore, to this date, more data is needed.

Moreover, a standardized Lymph node dissection template on cN1 patients is missing. Very often LN dissection is performed based on the single surgeon's experience and on intraoperative evaluation of the Lymph nodes; this may often lead to wrong cancer staging as less than 20% of the palpably enlarged nodes during surgery are positive on histopathological examination.

In patients undergoing RN or PN with eLND from 2000 to 2020 at our center, up to 50% of cN1 detection harbored LN metastases, also outside the radiological area and the length of the diameter related to an increased risk of LN metastases. In addition to the information given in our paper, worth noting that patients included underwent both robot-assisted and open surgery and either partial or radical nephrectomy, therefore our population is heterogenic.

In accordance with our findings, we believe that LN dissection may represent the most accurate staging system for RCC. These findings may have an important impact on RCC staging and treatment as the actual cross-sectional imaging to identify lymph node involvement has shown low accuracy.

We are aware of the limitations within the study, which are already listed in the paper (its retrospective nature, different number of lymph nodes removed during surgery, and the variability of LN dissection in cN0 patients) despite that, we hope that our work may raise awareness among the urological community of the very important role of LN dissection in RCC staging.

This statement acquires even more importance when discussing about the application of adjuvant therapy in patients who might benefit from it, as the decision-making is based on staging, in which LN invasion has a key role.

More prospective data will be needed to confirm our findings and better understand the role of LND in kidney cancer surgery. In the future a standardized LND template based on risk assessment could improve cancer staging, changing the management and the outcomes of RCC.

Written by: Pietro Scilipoti, MD & Giuseppe Rosiello, MD

Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy

Read the Abstract

Login