EURURO Vol. 71 No. 4

568 692

Platinum Priority – Editorial
Referring to the article published on pp. 560–567 of this issue
The Role of Lymphadenectomy for Renal Cell Carcinoma:
Are we any Closer to an Answer?
James[2_TD$DIFF] R. Porter
Swedish Urology Group, Seattle, WA, USA
[1_TD$DIFF]As a cancer, renal cell carcinoma (RCC) is unique in that it is
relatively resistant to radiotherapy and does not respond to
standard chemotherapy. So when the current study
reported by Gershman et al in this month’s issue of
European Urology found that removal of lymph nodes in
patients undergoing radical nephrectomy had no appreci-
able impact on cancer outcomes, this was in keeping with
the recalcitrant nature of RCC.
The authors retrospectively analyzed 1797 patients
undergoing radical nephrectomy over a 20-yr time frame,
and 606 (34%) underwent a concurrent lymph node
dissection (LND). Importantly, the indications for LND
and the extent of dissection could not be determined and
were at the discretion of the surgeon. Despite the large
cohort and greater than 10-yr median follow-up, perform-
ing LND during radical nephrectomy was not associated
with any improvement in cancer specific mortality or all-
cause mortality.
This same issue was addressed in a prospective manner
by the European Organization for Research and Treatment
of Cancer (EORTC) trial 30881 published in European
Urology in 2009 The trial compared 389 patients
undergoing radical nephrectomy alone with 383 patients
undergoing radical nephrectomy combined with LND.
Similar to the current study by Gershman et al , there
was no difference between the two groups with regard to
overall survival, progression-free survival, or time to
progression of disease. While this is the only randomized
trial to address this issue, concerns have been raised about
EORTC 30881 and its ability to determine the role of LND
during nephrectomy . The major limitation of the study is
the relatively low risk of the patients randomized with 70%
of patients either T1 or T2 and many would be candidates
for partial nephrectomy today. In addition, only 4% of
patients undergoing LND were found to have positive nodes
again indicating a low-risk cohort. Because of the many low-
risk patients and the low rate of positive lymph nodes, the
trial was inadequately powered to determine if LND during
nephrectomy is of benefit in patients with RCC.
Both the current study and the EORTC trial found no
oncologic benefit of LND in patients undergoing nephrec-
tomy. Both studies have a relatively low positive node rate
with the current study at 6.2%. One methodologic issue in
the current study that should be noted is that 153 high-risk
patients were excluded from the propensity matching
analysis because there were no suitable matches in the non-
LND group. This could have the effect of lowering the overall
risk of the LND group and make any difference in cancer
outcomes harder to detect.
What the two studies also have in common is that the
boundaries or the extent of the LND are unknown and this
commonality may be important to the reported outcomes.
The extent of lymph nodes removed has become increas-
ingly recognized as an important factor in patients
undergoing LND for bladder and testis cancer. An inade-
quate LND during radical nephrectomy could result in some
patients being reported as N0 when they are really N1, and
they could paradoxically have worse oncologic outcomes
than the patients who did not receive LND.
In fact, a similar finding was identified in a study by
Feuerstein et al In a retrospective review of 258 patients
undergoing cytoreductive nephrectomy, 177 (69%) received
LND and 59 (33%) were found to have positive lymph nodes.
The 5-yr overall survival was 21% for patients undergoing
LND as compared with 31% for patients who did not receive
LND. They found that overall survival was worse for patients
available at
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DOI of original article: .
* Swedish Urology Group, 1101 Madison, Suite 1400, Seattle, WA 98104, USA. Tel.+1-206-386-6266; Fax: +1-206-622-1052.
E-mail address:
0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.