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ANATOMICAL TEMPLATE FOR RENAL CELL CARCINOMA LYMPH NODE DISSECTION - WHAT IS THE CURRENT EVIDENCE?
Introdução, Material, Método, Resultados, Discussão e Conclusões
Introduction: Although there is strong evidence that patients with low risk renal cell carcinoma (RCC) do not benefit from lymph node dissection (LND), the role of this procedure in high risk patients remains controversial. In this setting, LND improves disease staging and may improve survival. However, there is still no consensus on the anatomical template for LND in such cases.
Objective: To evaluate, in a systematic review, the current evidence regarding anatomical templates for LND in RCC .
Methods: We performed a review of the literature published in English on PubMed and Google Scholar databases from 1990 to 2019. Keywords selected were (“kidney”, “renal” and “lymph node dissection”, “lymphadenectomy” “lymphatic drainage”, “lymphatics”). After abstract evaluation, studies discussing anatomical templates for LND in RCC and lymphatic drainage of the kidney were included.
Results: 18 studies were selected for proper review. Although Cadaveric dye dissection revealed most of what is known over renal lymphatic drainage, given the complexity of lymphovascular connections and frequency of supradiaphragmatic direct drainage, several in vivo and functional lymphatic studies have been proposed. The functional evaluation with SPECT-CT shows that renal lymph node drainage has a high individual variability. Sentinel node studies suggest a direct pathway via thoracic duct to the lungs and mediastinum in up to 20% of RCC. Retrospective data suggests that contralateral lymph node involvement is usually observed with metastases in other ipsilateral retroperitoneal lymph nodes. Several studies report that hilar nodes may underestimate metastatic disease beyond hilar region. There are no prospective randomized studies regarding an anatomical template in the literature reviewed.
Conclusion: Although there is still no strong evidence to elect a single template in LND for RCC, there is evidence that dissection restricted to the ipsilateral hilar region could miss metastases to contralateral and distant nodes. In most of the studies LND was performed at surgeon’s discretion without standard anatomical templates. Therefore, we still lack randomized controlled trials with detailed standardized templates for LND in high risk RCC patients.
kidney cancer; lymph node dissection
Câncer de Rim
Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Sao Paulo - Brasil, Hospital Israelita Albert Einstein - Sao Paulo - Brasil
Augusto Quaresma Coelho, João Arthur Brunhara Alves Barbosa, Sergio Andurte Carvalho Duarte, Pedro Felipe Silva de Freitas, William Carlos Nahas, Miguel Srougi, Leonardo Lima Borges