The role of lymph node dissection in renal cell carcinoma: the pendulum swings back

The incidence of regional lymph node metastases in patients with renal cell carcinoma ranges from 13% to over 30%, and portends a poor prognosis in both locally advanced and metastatic settings. Patients with small, organ confined tumors are at low risk for regional lymph node metastases and lymph node dissection can be omitted in these patients. In contrast, patients with clinical evidence of regional lymph node metastases may derive therapeutic benefit from aggressive removal of all affected lymph nodes within the retroperitoneum. Patients with locally advanced primary tumors but no clinical evidence of lymphadenopathy can be selectively targeted for aggressive lymph node dissection as an adjunct to radical nephrectomy, based on their individual risk of harboring micrometastatic lymph node disease. Several predictive tools have been developed for prediction of occult retroperitoneal nodal metastases. Although early identification of micrometastatic nodal disease in this group of patients has not conclusively been shown to improve survival, accurate pathologic nodal staging allows for early implementation of adjuvant systemic therapies in these high-risk patients. No formal guidelines exist regarding the extent and boundaries of lymph node dissection at the time of radical nephrectomy; however, overwhelming evidence suggests that the staging accuracy of lymph node dissection can be markedly improved if extended template dissections, rather than limited node sampling, is implemented.