LAUSR

The widespread use of cross-sectional imaging in the past two decades has increased the detection of incidental renal tumors. Furthermore, up to 30% of patients who underwent curative treatment for localized renal cell carcinoma (RCC) developed tumor recurrence or metastases. RCC is highly vascularized with a rich lymphatic return, and during hematogenous or lymphatic metastasis, tumor cells invade the surrounding tissue and enter the hematogenous/lymphatic stream. RCC patients with pathologically confirmed lymph node (LN) metastases at the time of surgery were found to have a poor prognosis, with a twofold increased likelihood of progression and overall mortality than LN-negative cases. However, there is a lack of consensus regarding the prognostic value of LN involvement among patients with LN-positive RCC at the time of surgery, and the utility of LN dissection (LND) remains controversial. In this study, Yang et al. investigated the timing and distribution of first RCC metastasis postoperatively according to nodal status. The authors reviewed the clinical and pathological records of 4290 patients, including 178 LN-positive patients (4.1%), who underwent surgical treatment for RCC, and enrolled 1049 patients (24.5%) who developed metastases. Just 43 (1.0%) LN-positive patients were cured after surgery, and the remaining 135 (3.1%) N1 patients developed metastasis. Furthermore, the recurrence-free survival of RCC patients with clinical/pathological N1 was significantly shorter than that of patients with N0 (P < 0.001), and the recurrence patterns in the pN1 patients were found to be unique. The authors reported bone, liver and lung metastases in patients within 2 years after surgery. Generally, these metastatic sites seem to occur by hematogenous metastasis in RCC patients. Therefore, LN-positive RCC is considered to have vital aggressive behavior. The European Organization for Research and Treatment of Cancer randomized trial 30881, which is one of the most impactful trials carried out on this topic, reported no association of LND with oncological outcomes; likewise, several observational studies failed to show a survival benefit with LND. This study had several limitations, and further large-scale clinical or observational studies are warranted. However, this study presents information on oncological outcomes in LN-positive RCC patients and might help clinicians to decide the treatment strategy with nephrectomy, whether it is with or without LND.