The rationale and the role of lymph node dissection in renal cell carcinoma

Purpose: Although the role of lymph node dissection (LND) is well defined in many urological settings, uncertainty regarding need for LND still exists for patients with renal cell carcinoma (RCC). The aim of the current review is to highlight the rationale for performing or omitting LND at the time of renal surgery. Methods: Data were identified through a search of PubMed and Web of Science, including studies published in the last 20 years in core clinical journals. The review is based on evidence synthesis from a peer-review process of the two authors after a structured data search. Results: Neither imaging, nor predictive tools or molecular/genetic markers accurately identify which patients may warrant a LND. In patients with clinical T1abN0 and absence of unfavorable clinical and pathological characteristics, LND does not appear to offer benefit in terms of staging and cancer control. Conversely, LND can be considered in selected cases (larger tumors, locally advanced diseases or when unfavorable pathological characteristics are likely, as high Fuhrman grade, sarcomatoid features or tumor necrosis) due to the non-negligible risk of associated nodal metastases and possible benefit in terms of cancer control. Conclusions: Although LND does not provide any benefit in the majority of RCC cases (mainly T1abN0M0 cases), it remains an important consideration in intermediate-/high-risk patients for staging purposes, given an increased risk of LNI, and for potential benefit in terms of cancer control. Additional data are urgently needed to improve the accuracy of nodal staging tools and to evaluate the potential role of salvage LND.