Page 8 - Kidney Cancer Research Network of Canada (KCRNC) consensus statement on the role of cytoreductive nephrectomy for patients with metastatic renal cell carcinoma

CUAJ – Consensus Statement Mason et al
KCRNC consensus: Cytoreductive nephrectomy for mRCC

Is there a role for concomitant regional lymph node dissection during cytoreductive
nephrectomy?

1. In patients with mRCC undergoing CN who do not have clinical evidence of
nodal disease, retroperitoneal lymph node dissection is not recommended.
2. Surgical resection of clinically positive lymph nodes may be considered at the
time of CN after weighing the potential for increased surgical morbidity and the
uncertain clinical benefit.

The role of regional lymph node dissection (LND) in patients with RCC continues to
be debated, including its role in patients undergoing CN. Neither of the trials performed
before the introduction of targeted therapy included standardized LND as part of CN[1,
2]. In addition, the modern phase III trials have not mandated LND as a component of
CN[3, 4, 48]. Nonetheless, five retrospective observational studies and one meta-analysis
have investigated whether LND during CN is associated with an improvement in overall
survival among patients with mRCC[55-60]. The common finding between these studies
is that LND does not appear to impart a survival advantage in mRCC patients. Similar
findings have been noted in patients with and without clinically positive lymph
nodes[55].
While existing data does not suggest a benefit to LND during CN, several limitations
warrant caution before drawing definitive conclusions, most importantly the lack of
standardized LND template in all of these studies. Currently, for patients without
evidence of clinically positive regional nodes, we do not recommend performing a LND.
However, observational studies have identified that the degree of tumor debulking at the
time of CN may be associated with an improvement in survival[22, 61]. The burden of
extra-renal metastases should also be taken into account when considering nodal
dissection during CN. Thus, recognizing the lack of evidence to guide this decision, we
submit that regional LND may be considered at the time of CN for patients with
clinically positive nodes, at the discretion of the treating surgeon after considering the
potential for increased morbidity associated with LND along with the uncertain clinical
benefit.

Is there a preferred surgical approach for cytoreductive nephrectomy?

1. Cytoreductive nephrectomy can be performed through both minimally invasive
and open surgical approaches at the discretion of the treating surgeon.

Several observational studies have shown that minimally invasive CN can be safely
performed in select patients with the potential for reduced morbidity, decreased blood