Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Valuation of lymph node dissection in localized high-risk renal cell cancer using X-tile software



Attempt to group the number of lymph nodes in a more ideal way to assess the value of lymph node dissection (LND) in the treatment of localized high-risk renal cell cancer (LH-RCC).


The Surveillance, Epidemiology, and End Result database (SEER) was used to analyze LH-RCC patients who undergoing radical nephrectomy (RN) from 2011 to 2015. The X-tile software was performed to calculate the optimal grouping cut-off points for the number of removed lymph nodes and positive lymph nodes. The Nomogram model was constructed by R language to visually present survival rates of patients.


Among 4917 cases of LH-RCC patients undergoing RN, there were 1835 patients treated with LND (37.32%) with the average survival time (AST) of 43.10 months (95% CI 41.91–44.29), which was superior than 40.52 months of patients who did not have LND (95% CI 39.26–41.78) (P < 0.01). The mortality risk of patients with ≥ 3 removed nodes was 0.75 times that of patients with 1–2 removed nodes (95% CI 0.62–0.99, P < 0.01). For overall survival (OS), the hazard ratio of ≥ 5 positive nodes, 1–4 positive nodes, and 0 positive node was 3.04, 2.37, and 1.00, respectively. The Nomogram model can evaluate the 1 year, 2 year, and 3 year survival rates of LH-RCC patients undergoing RN with the internal validation C-index of 0.73.


LH-RCC patients with ≥ 3 removed lymph nodes and fewer positive lymph nodes are expected to have better long-term survival. LND is not only helpful for tumor staging of LH-RCC, but also valuable for long-term survival.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5


  1. 1.

    Blom JH, van Poppel H, Maréchal JM et al (2009) Radical nephrectomy with and without lymph-node dissection: final results of European Organization for Research and Treatment of Cancer (EORTC) randomized phase 3 trial 30881. Eur Urol 55:28–34

  2. 2.

    Gershman B, Thompson RH, Moreira DM et al (2017) Radical nephrectomy with or without lymph node dissection for nonmetastatic renal cell carcinoma: a propensity score-based analysis. Eur Urol 71:560–567

  3. 3.

    Capitanio U, Stewart GD, Larcher A et al (2017) European temporal trends in the use of lymph node dissection in patients with renal cancer. Eur J Surg Oncol 43(11):2184–2192

  4. 4.

    Van Poppel H (2011) Lymph node dissection is not obsolete in clinically node-negative renal cell carcinoma patients. Eur Urol 59:24–25

  5. 5.

    Capitanio U, Suardi N, Matloob R et al (2014) 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). BJU Int 114:210–215

  6. 6.

    Ristau BT, Manola J, Haas NB et al (2018) Retroperitoneal lymphadenectomy for high risk, nonmetastatic renal cell carcinoma: an analysis of the ASSURE (ECOG-ACRIN 2805) adjuvant trial. J Urol 199:53–59

  7. 7.

    Marchioni M, Bandini M, Pompe RS et al (2018) The impact of lymph node dissection and positive lymph nodes on cancer-specific mortality in contemporary pT2-3 non-metastatic renal cell carcinoma treated with radical nephrectomy. BJU Int 121:383–392

  8. 8.

    Crispen PL, Breau RH, Allmer C et al (2011) Lymph node dissection at the time of radical nephrectomy for high-risk clear cell renal cell carcinoma: indications and recommendations for surgical templates. Eur Urol 59:18–23

  9. 9.

    Capitanio U, Abdollah F, Matloob R et al (2013) When to perform lymph node dissection in patients with renal cell carcinoma: a novel approach to the preoperative assessment of risk of lymph node invasion at surgery and of lymph node progression during follow-up. BJU Int 112:E59–E66

  10. 10.

    Bekema HJ, MacLennan S, Imamura M et al (2013) Systematic review of adrenalectomy and lymph node dissection in locally advanced renal cell carcinoma. Eur Urol 64:799–810

  11. 11.

    Gershman B, Moreira DM, Thompson RH et al (2017) Renal cell carcinoma with isolated lymph node involvement: long-term natural history and predictors of oncologic outcomes following surgical resection. Eur Urol 72:300–306

  12. 12.

    Capitanio U, Leibovich BC (2017) The rationale and the role of lymph node dissection in renal cell carcinoma. World J Urol 35:497–506

  13. 13.

    Faiena I, Salmasi A, Lenis AT et al (2018) Overall survival in patients with metastatic renal cell carcinoma and clinical N1 disease undergoing cytoreductive nephrectomy and lymph node dissection. Urol Oncol 36:79.e19–79.e26

  14. 14.

    Culp SH, Karam JA, Wood CG (2014) Population-based analysis of factors associated with survival in patients undergoing cytoreductive nephrectomy in the targeted therapy era. Urol Oncol 32:561–568

  15. 15.

    Lin HP, Li SW, Liu Y et al (2018) Prognostic value of lymph nodes count on survival of patients with distal cholangiocarcinomas. World J Gastroenterol 24:1022–1034

  16. 16.

    Pan Z, Bu Q, You H et al (2019) Determining the optimal cutoff point for lymph node density and its impact on overall survival in children with wilms’ tumor. Cancer Manag Res 11:759–766

  17. 17.

    Qian K, Sun W, Guo K et al (2019) The number and ratio of positive lymph nodes are independent prognostic factors for patients with major salivary gland cancer: results from the surveillance, epidemiology, and end results dataset. Eur J Surg Oncol 45:1025–1032

  18. 18.

    Babaian KN, Kim DY, Kenney PA et al (2015) Preoperative predictors of pathological lymph node metastasis in patients with renal cell carcinoma undergoing retroperitoneal lymph node dissection. J Urol 193:1101–1107

  19. 19.

    Bhindi B, Wallis CJD, Boorjian SA et al (2018) The role of lymph node dissection in the management of renal cell carcinoma: a systematic review and meta-analysis. BJU Int 121:684–698

  20. 20.

    Dell’Oglio P, Larcher A, Muttin F et al (2017) Lymph node dissection should not be dismissed in case of localized renal cell carcinoma in the presence of larger diseases. Urol Oncol 35:662.e9–662.e15

  21. 21.

    Capitanio U, Jeldres C, Patard JJ et al (2009) Stage-specific effect of nodal metastases on survival in patients with non-metastatic renal cell carcinoma. BJU Int 103:33–37

  22. 22.

    Gershman B, Thompson RH, Boorjian SA et al (2018) Radical nephrectomy with or without lymph node dissection for high risk nonmetastatic renal cell carcinoma: a multi-institutional analysis. J Urol 199:1143–1148

  23. 23.

    Feuerstein MA, Kent M, Bazzi WM et al (2014) Analysis of lymph node dissection in patients with ≥ 7-cm renal tumors. World J Urol 32:1531–1536

  24. 24.

    Camp RL, Dolled-Filhart M, Rimm DL (2004) X-tile: a new bio-informatics tool for biomarker assessment and outcome-based cut-point optimization. Clin Cancer Res 10:7252–7259

  25. 25.

    Capitanio U, Deho’ F, Dell’Oglio P et al (2016) Lymphadenopathies in patients with renal cell carcinoma: clinical and pathological predictors of pathologically confirmed lymph node invasion. World J Urol 34:1139–1145

  26. 26.

    Zareba P, Rosenzweig B, Winer AG et al (2017) Association between lymph node yield and survival among patients undergoing radical nephroureterectomy for urothelial carcinoma of the upper tract. Cancer 123:1741–1750

  27. 27.

    Gershman B, Moreira DM, Thompson RH et al (2017) Perioperative morbidity of lymph node dissection for renal cell carcinoma: a propensity score-based analysis. Eur Urol 73:469–475

Download references


The authors would like to thank SEER program for public access to the database.



Author information

Correspondence to Weihui Liu.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. We obtained the authorization to access the SEER database, with the number 14260-Nov2016.

Informed consent

The SEER database does not reveal patient privacy, so patient informed consent is not required.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Zhuang, W., Chen, J., Li, Y. et al. Valuation of lymph node dissection in localized high-risk renal cell cancer using X-tile software. Int Urol Nephrol 52, 253–262 (2020).

Download citation


  • Localized high-risk renal cell cancer
  • Lymph node dissection
  • SEER database
  • X-tile
  • Survival