Lymph Node Dissection in Renal Cancer and Upper Tract Urothelial Cancer

Abstract

The role of lymph node dissection (LND) in the treatment of renal cell carcinoma remains controversial and the therapeutic benefit is unproven. The available evidence is mainly retrospective, often of poor quality, and predates the era of effective systemic therapy. The lymphatic drainage from the kidneys is highly variable and LND templates are not standardised or defined. Lymph node involvement at the time of nephrectomy is usually associated with systemic disease and is independently associated with poor prognosis in clinical M0 and M1 patients. Neither imaging nor predictive tools accurately identify which patients warrant LND. The incidence of lymph node involvement in low risk localised renal cell carcinoma (RCC) T1abN0 is low and the added potential morbidity associated with LND is not justified. LND does provide valuable staging information in intermediate and high risk or locally advanced disease and may be of therapeutic benefit in some patients. Several retrospective studies support the hypothesis that LND may be beneficial in high risk patients such as clinical T3-T4, high grade, those with sarcomatoid features or coagulative tumour necrosis. A subset of patients with pN1 disease demonstrates longer term cancer control after surgery. LND is justified if lymph nodes are visibly enlarged on imaging or palpable during surgery. Molecular and genetic markers have the potential to replace clinical characteristics and cross sectional imaging in determining which patients if any might benefit from LND.