Editing Management of Localized and Locally Advanced Disease (section)

==== Lymphadenectomy ====

* '''Main landing zones for RCC:'''
** '''Right side: interaortocaval'''
** '''Left side: para-aortic'''
*** '''The left kidney drains to the interaortocaval nodes only in advanced disease'''

===== Indications =====
*<span style="color:#ff00ff">'''EORTC 30881'''</span>
** '''Objective: evaluate oncologic benefit of lymphadenectomy in cN0 disease'''
** '''Population: 772 patients undergoing radical nephrectomy for cT1-3, N0 suspected RCC'''
** '''Randomized to nephrectomy +/- LND'''
** '''Results:'''
*** Only 4% of patients in the RN plus LND cohort had pN+ disease
****20% of patients with palpable nodes in RN plus LND group were N+ on final pathology; for patients without palpable nodes, 1% was pN+
***'''No difference in overall survival, progression-free survival, or time to progression of disease'''
*** While this is the only randomized trial to address this issue, concerns about EORTC 30881 include the relatively low risk of the patients randomized (≈70% of patients either T1 or T2) and many would be candidates for partial nephrectomy today. 
** [https://pubmed.ncbi.nlm.nih.gov/18848382/ Blom JH, van Poppel H, Maréchal JM, et al. 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 2009;55:28–34.]
* '''No randomized trials assessing the effect of lymphadenectomy for patients with cN+ disease.'''
** However, a subset of patients with regional lymph node metastases will be cured, or experience prolonged survival following surgery
*2018 systematic review and meta-analysis
**No benefit to LND for in either M0 or M1 RCC
**Suggested that high-risk M0 patient groups warrant further study, as a subset of patients with isolated nodal metastases experience long‐term survival after surgical resection.
** [https://pubmed.ncbi.nlm.nih.gov/29319926/ Bhindi, B, et al. "The role of lymph node dissection in the management of renal cell carcinoma: a systematic review and meta‐analysis." BJU international 121.5 (2018): 684-698.]
*'''Reasons for''' '''limited benefit of routine lymphadenectomy''' (3):
*# RCC metastasizes through the bloodstream independent of the lymphatic system in many patients
*# Lymphatic drainage of the kidney is highly variable.
*## Even an extensive retroperitoneal dissection may not remove all possible sites of metastasis.
*# Low overall incidence of lymph node disease (5%)

====== AUA ======

* '''2021 AUA'''
** '''cN+: recommended''' for clinically positive nodes (imaging or palpable surgical exploration), primarily for staging and prognostic purposes.
** '''cN0: does not routinely need to be performed''' for localized kidney cancer with clinically negative nodes

====== CUA ======
*'''2014 CUA'''
** '''cN0: not routinely recommended'''
**'''cN1M0 disease'''
** '''Lymphadenectomy may be performed for diagnostic purposes in patients with cN1M1 disease'''

====== Other sources (8): ======
#'''Enlarged lymph nodes on imaging (cN+)'''
#'''Cytoreductive surgery for metastatic disease'''
#'''Tumor size > 10 cm'''
#'''Nuclear grade 3 or 4'''
#'''Sarcomatoid component'''
#'''Tumor necrosis on imaging'''
#'''Extrarenal tumor extension'''
#'''Tumor thrombus'''
#'''Direct tumoral invasion of adjacent organs'''
* '''Regional lymphadenectomy should be considered in those patients who may have a reasonable chance of benefiting from the added surgery'''.
** Bulky lymphadenopathy carries a poor prognosis similar to metastatic disease, although surgical resection should be considered if feasible and if appropriate, given careful assessment of disease burden and patient age/comorbidities.