3 years ago

The Role of Lymph Node Dissection in the Management of Renal Cell Carcinoma: A Systematic Review and Meta-Analysis

Jose A. Karam, Bimal Bhindi, Umberto Capitanio, Ann Farrell, R. Houston Thompson, Boris Gershman, Simon P. Kim, Stephen A. Boorjian, Dragan Golijanin, Christopher J. D. Wallis, Bradley C. Leibovich
Objectives To evaluate the role of retroperitoneal lymph node dissection (LND) in non-metastatic (M0) and metastatic (M1) renal cell carcinoma (RCC). Patients and Methods We searched Medline, EMBASE, Web of Science, and Scopus from database inception to August 29, 2017 for studies of patients who underwent partial or radical nephrectomy for M0 or M1 RCC. Two investigators independently selected studies for inclusion. Risk of bias was assessed using the Newcastle-Ottawa scale, Cochrane Collaboration tool, and NHLBI Quality Assessment Tool. Random effects meta-analysis was performed for all-cause-mortality. The GRADE approach was used to characterize quality of evidence. Results Fifty-one unique studies were included in the qualitative systematic review. Risk of bias was low in 41/51 (80%) studies. LND was not associated with all-cause mortality (ACM) in either M0 (HR 1.02;95% CI 0.92,1.12;I2=0%;4 studies), M1 (HR 1.04;95% CI 0.83,1.29;I2=0%;2 studies), or pooled M0 and M1 (HR 1.00;95% CI 0.92, 1.09; I2=0%;7 studies) settings, with no statistically significant differences according to M stage subgroups (p=0.50). In the three studies that examined M0 subgroups with a high-risk of nodal metastasis, LND was not associated with improved oncologic outcomes. Studies on the association of extent of LND with survival reported inconsistent results. Meanwhile, a small proportion of patients with pN1M0 disease demonstrate durable long-term oncologic control following surgery, with 10-year cancer-specific survival of 21-31%. Nodal involvement is independently associated with adverse prognosis in both M0 and M1 settings. GRADE quality of evidence was moderate or low for the outcomes examined. Conclusion Although LND yields independent prognostic information, the existing literature does not support a therapeutic benefit to LND in either M0 or M1 RCC. High-risk M0 patient groups warrant further study, as a subset of patients with isolated nodal metastases experience long-term survival following surgical resection. This article is protected by copyright. All rights reserved.

Publisher URL: http://onlinelibrary.wiley.com/resolve/doi

DOI: 10.1111/bju.14127

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