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Título

SHOULD WE PERFORM LYMPH NODE DISSECTION IN PATIENTS WITH RENAL CELL CARCINOMA WITHOUT SUSPECT LYMPH NODES ON IMAGING?

Introdução, Material, Método, Resultados, Discussão e Conclusões

Introduction: The role of Lymph Node Dissection (LND) in patients with Renal Cell Carcinoma (RCC) with nonmetastatic disease to date is controversial. Although surgeons tend to remove enlarged LN suggestive of metastasis, there remains controversy on the benefit of LND in patients without enlarged LN on preoperative staging.

Objective: To evaluate, in a systematic review, the evidence of benefit of perfoming LND in Patients with RCC without evidence of lymph node enlargement on preoperative staging.

Methods: We performed a review of the literature published in English language on PubMed and Google Scholar databases from 1990 to 2019. Keywords selected were (“renal cell carcinoma” or “renal cancer”) and (“lymphadenectomy” or “lymph node dissection”). After abstract evaluation, we included publications concerning performance of LND in the context of RCC without evidence of LN metastasis on preoperative staging.

Results: For patients at low risk of LN metastasis (pT1-2, Fuhrman grades 1-2 and no sarcomatoid component or coagulative necrosis), there is level I evidence showing no benefit in survival with LND. The EORTC 30881 trial randomized 732 patients to radical nephrectomy with or without LND. After a median follow-up of 12 years, no significant difference was observed between groups in overall, time-to-progression, and progression-free survival.

However, Bekema et al. re-examined the EORTC 30881 trial data and found a 15% difference in overall survival at 5 years for the subgroup of cT3N0M0 patients who underwent LND, even though without statistical significance, and this difference was not sustained at 15 years. Wei et al. (2019) report superior survival rates for LND in the subgroup of pT3N0M0 patients, which were not observed for the study population as a whole. The largest retrospective series (Gershman, 2017; Ristau, 2018) did not find improved outcomes in patients undergoing LND for cN0 RCC. Even when assessing high-risk populations such as those with tumors ≥ 7cm (Feuerstein, 2014) or pT2-3 (Marchioni, 2017), no significant advantage for LND is observed.

Conclusion: Patients with cN0 nonmetastatic RCC do not appear to benefit from LND in low-risk disease. A possible benefit of LND in high-risk cases (T3, high grade) was shown in some studies but not confirmed in others, leaving LND in this setting still controversial.

Palavras Chave

kidney cancer; lymph node dissection

Área

Câncer de Rim

Instituições

HOSPITAL DAS CLÍNICAS DA FACULDADE DE MEDICINA DA UNIVERSIDADE DE SAO PAULO - Sao Paulo - Brasil, HOSPITAL ISRAELITA ALBERT EINSTEIN - Sao Paulo - Brasil

Autores

Pedro Felipe Silva de Freitas, Joao Arthur Brunhara Alves Barbosa, Augusto Quaresma Coelho, Sergio Andurte Carvalho Duarte, William C Nahas, Miguel Srougi, Leonardo Lima Borges