Transcript Diapositiva 1

LINFOADENECTOMIA
Alessandro Volpe
Università del Piemonte Orientale
AOU Maggiore della Carità, Novara
LND IN RENAL CANCER
1.
1.
1.
The value of LND in patients with renal cell carcinoma
(RCC) still remains controversial
No data have clearly demonstrated which candidates
should undergo LND and which template should be used
for LND in RCC surgical management
Many urologists have abandoned systematic and
standardized LND at the time of nephrectomy because
of the lack of a proven benefit
6
7
8
383 RN+LND
vs.
389 RN alone
OUTCOMES
Time-to-progression
Overall survival
Progression-free survival
pN+ = 4%
Low-risk population
All cN0
patients
Prognostic implications of nodal metastasis
•
•
•
•
Positive nodes have been clearly shown to have an independent
adverse effect on oncologic outcome, regardless of other
prognostic factors
The estimated cancer specific survival rates at 1, 5, and 10 yr
following radical nephrectomy for patients with pN1 RCC are 52–
72%, 21–38%, and 11–29%, respectively
Patients with nodal involvement have a 7.8-fold greater chance of
dying from their disease than those without nodal involvement
Lymph node stage has even an impact on the survival of patients
with established metastatic RCC
Lughezzani G et al. Cancer 2009;115:5680–7
Blute ML et al. J Urol 2004;172: 465–9
LNI rates increase with tumor stage
Extended LND cN+ LND
No LND
n
531 (51%)
LN removed
18
6
3
p<0.001
Mean age (ys)
55
60
66
p<0.001
Mean tumor diameter (mm)
81
77
64
pT3ab (%)
56
47
64
Furhman G3 (%)
30
25
21
5 years CSS (%)
10 years CSS (%)
70
58
199 (19%) 305 (30%)
61
50
65
44
p<0.001
p<0.05
p<0.001
p<0.01
p<0.01
Can we predict LNI ?
- Non standardized LND in 415 cN0 patients
- 5 risk factors:
1.
Tumor size > 10 cm
169 high-risk
2.
Fuhrman 3-4
patients
3.
Sarcomatoid component
4.
pT3-pT4
LNI 38%
5.
Histologic tumor necrosis
cN+
patients
“Histologically positive nodes were found
in only 42% of patients with
enlarged nodes at preoperative CT”
M+
patients
“Patients who can potentially be cured by
LND
have early lymph node metastasis
and no systemic disease”
Canfield et al., J Urol 175:864-869, 2006
LND in RCC. Which template?
Predilection of RCC for early
haematogenic dissemination
≈57% TanyN0M1
Directly to the thoracic duct ≈30%
Many possible different lymphatic
routes in normal retroperitoneal
anatomy
Collateral lymphatic drainage and
invasion of tissue with different
lymphatic drainage (e.g. perinephric
fat)
Isolated metastases in the ipsilateral
iliac and supraclavicular nodes ≈10%
RCC: LYMPH NODE LANDING SITES
Distribution of first landing sites
with direct tracer injection
Some cases of sentinel nodes from RCC
outside the known templates
RCC = renal cell carcinoma.
LND IN RCC: TEMPLATE
Lymph node dissection (LND) should
include:
- (a) for the right kidney, the
paracaval, retrocaval, and precaval
nodes from the adrenal vein to the
level of the inferior mesenteric
artery
- (b) for the left kidney, the paraaortic and preaortic nodes from the
crus of the diaphragm to the
inferior mesenteric artery
- Interaortocaval nodes
(overlapping purple area) should
always be removed as well when
extended LND is sought
p=0.02
C.Terrone et al ,Eur Urol. 2006
BACKGROUND AND OBJECTIVES
The optimal classification for lymph node staging in RCC is still debated.
Aim of the study was to assess the prognostic value of the number of positive LNs using different
cut-offs (0 vs. 1 vs. >1 LN+; 0 vs. 1-4 vs >4 LN+).
PATIENTS AND METHODS




1550 patients underwent radical nephrectomy and lymphadenectomy for RCC
3 tertiary care centers (Milan, Turin, Novara)
November 1983 - December 2012
Prognostic value of the number of LNs:
2009 TNM classification (0 vs. 1 vs.>1 LN+) vs. new proposed classification (0 vs. 1-4 vs >4 LN+)
pN0
pN+
Tot
pT1a
196
1
197
pT1b
363
12
375
pT2a
172
15
187
pN1
61
3.9
pT2b
75
11
86
pN2
146
9.4
pT3a
335
79
414
pT3b
154
35
189
pT3c
23
17
pT4
25
Tot
1343
Age
Follow up
(months)
LNs
removed
LNs
involved
Median
60.0
57.6
7
3
IQR
52-68
18-130
4-12
1-6
%
Lymphadenectomy extension
pN0
pN+
Tot
cM0
1145
111
1256
40
cM1
198
96
294
37
62
Tot
1343
207
207
1550
Limited=552
Regional=533
Extended=465
RESULTS
The 2009 TNM classification correlates
significantly with 5-year CSS only in M1
pts, but not in Mall and M0 pts.
Regressor
HR
95% CI
p
pN (1 vs 0)
1.31
(0.93-1.86)
0.119
pN (2 vs 0)
2.76
(2.14-3.56)
<0.001
pT (2 vs 1)
2.04
(1.45-2.89)
<0.001
pT (3 vs 1)
3.20
(2.28-4.30)
<0.001
pT (4 vs 1)
6.30
(4.08-9.66)
<0.001
cM (1 vs 0)
4.91
(3.97-6.08)
<0.001
Grade (High vs Low)
1.60
(1.30-1.98)
<0.001
The proposed classification correlates
significantly with 5-year CSS for Mall and
M1 pts, but not for M0 pts.
Regressor
HR
95% CI
p
pN (1 vs 0)
1.90
(1.47-2.45)
<0.001
pN (2 vs 0)
2.58
(1.84-3.61)
<0.001
pT (2 vs 1)
2.07
(1.47-2.92)
<0.001
pT (3 vs 1)
3.17
(2.36-4.27)
<0.001
pT (4 vs 1)
6.11
(3.95-9.45)
<0.001
cM (1 vs 0)
4.71
(3.80-5.82)
<0.001
Grade (High vs Low)
1.62
(1.32-2.00)
<0.001
CONCLUSIONS
•
•
The number of positive lymph nodes correlates
with prognosis after RN in RCC, especially in
patients with distant metastases.
The current TNM classification of nodal
involvement should be modified.
n = 850; TanyN0–1Many RCC + LND (1987-2011)
90%
15
nodes