Lymph node dissection is not obsolete in clinically node-negative Renal Cell Carcinoma patients

Abstract

The place of lymph node dissection during radical nephrectomy for renal cell carcinoma (RCC) remains controversial. Crispen et al. [1] present the results of a retrospective study on a historical cohort of consecutive patients who received lymph node dissection when two or more risk factors were identified during intraoperative pathologic assessment of the primary tumor. Those factors included nuclear grade 3 or 4, sarcomatoid component, tumor size 10 cm, tumor stage pT3 or pT4, or coagulative tumor necrosis. Moreover, the authors suggested a template for lymph node dissection in these cases. From a methodological point of view, it is a pity that patients with clinically suspicious lymph nodes on computed tomography (CT) scan were included; in common urologic practice today, these patientswill get a lymph node dissection anyway. The authors still need to be congratulated for this work in which they attempt to indicate which patients should undergo lymph node dissection while undergoing nephrectomy, but the problem of the value of lymph node dissection in RCC is not solved. As second author and as a major recruiter for European Organization for Research and Treatment of Cancer (EORTC) protocol 30881, I wanted to demonstrate that lymph node dissection is beneficial in patients that have no lymph node invasion on CT scan, but I must admit that we failed to show this [2]. Still, in daily practice, I continue to do lymph node dissection in all patients that undergo radical nephrectomy (difficult T1b cases not amenable for partial nephrectomy or T2 tumors or larger) but also in larger T1b tumors treated with partial nephrectomy. This non-evidence-based surgical practice is used because although we all perform lymphadenectomies in patients with suspicious (ie, enlarged) nodes