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Pattern and implication of lymphatic
drainage in renal tumors Axel Bex, MD, PhD
The Netherlands Cancer Institute
FOIU Tel Aviv,
July 4, 2018
Financial and Other Disclosures Off-label use of drugs, devices, or other agents: None or FILL IN HERE; including your
local regulatory agency, such as FDA, EMA, etc.
Data from IRB-approved human research is presented [or state: “is not”]
2
I have the following financial interests or
relationships to disclose: Disclosure code
Pfizer C, S
Roche C
Genentech C
Ipsen C
Novartis C
BMS C
Recommendations from EAU guidelines on
RCC – updated 2014
• For T1 RCCs, nephron-sparing surgery should be performed whenever possible.
Open partial nephrectomy currently remains the standard. A
• Laparoscopic radical nephrectomy is recommended in T2 renal cell cancer when nephron-
sparing surgery is not suitable B
• Extended lymphadenectomy does not improve survival and can be restricted to staging purposes. A
• Adrenalectomy is generally not recommended except when a normal adrenal gland cannot be excluded
by imaging and palpation. B
• Patients with small tumours and/or significant comorbidity who are unfit for surgery should be considered
for an ablative approach
(eg, cryotherapy and radiofrequency ablation). A
EAU Guidelines on RCC – 2014 update, Ljungberg et al, Eur Urol 67:913-24, 2015
• For T1 RCCs, nephron-sparing surgery should be performed whenever possible.
Open partial nephrectomy currently remains the standard. A
• Laparoscopic radical nephrectomy is recommended in T2 renal cell cancer when nephron-
sparing surgery is not suitable B
• Extended lymphadenectomy does not improve survival and can be restricted to staging purposes. A
• Adrenalectomy is generally not recommended except when a normal adrenal gland cannot be excluded
by imaging and palpation. B
• Patients with small tumours and/or significant comorbidity who are unfit for surgery should be considered
for an ablative approach
(eg, cryotherapy and radiofrequency ablation). A
But……..
• The patient who can potentially be
cured by LND has very early lymph
node metastasis and no systemic
disease
Canfield et al., J Urol 175:864-869, 2006
Capitanio et al., BJU Int 112: E59-66, 2013
• 1983 patients with cT any cNany cMany
• Prevalence of nodal metastases 6.1 %
• Accuracy 86.9 %
Preoperative nomogram to predict nodal metastases
Is there a template for lymph node
dissection in RCC ?
Hadley et al, Urologic Oncology 2009
N=31 patients with N+ >1 cm
MATERIALS & METHODS
• OBJECTIVES: To study the lymphatic drainage of renal tumours
• 40 patients
• Local cT1-3 (<10 cm) cN0cM0
• US guided p/c injection of 0.4 ml 99mTc-nanocolloid into the tumour
• Preoperative lymphoscintigraphy with SPECT/CT
• Surgical treatment with intraoperative SN identification and sampling using a gamma probe
and mobile gamma camera
• SN and non-SN dissection
Supraclavicular lymph node metastases
4/22 patients with SPECT-
SN identification (18.2 %)
Brouwer et al., Lymph Res Biol 11:233-38, 2013
1969 - A lymphographic and
histopathological investigation in RCC
• N=22 patients undergoing nephrectomy
• 7 (32 %) metastasis in lumbar and
ipsilateral iliac nodes
• 1 supraclavicular node
• Poor correlation of lymphography with
nodal metastasis but contrast filling of
mediastinal nodes observed
Hulten et al., Scand J Urol Nephrol 3:129-33, 1969
5 of 13 right side, 3 of 13 left side
Assouad et al., Lymphology 39:26-32, 2006
Direct drainage into the thoracic duct without
intervening lymph nodes
Distribution of lymph node metastases –
an autopsy study
• n= 1001 patients with metastatic RCC
Location %
neck + clavicle 20.7 %
mediastinum 10.3 %
hilus of lungs 66.2 %
hilus of kidney 7 %
paraaortal 26.8 %
retroperitoneal 36 %
mesenterial 14.4 %
Saitoh et al. J Urol 1982
Distribution of lymph node metastasis
• Imaging study on 28 patients with cN1 identified from
101 with RCC
Location Percentage (left/right
combined
Distant lymphadenopathy
without hilar
lymphadenopathy
29 %
Interaortocaval 42 %
retroaortocaval 46 %
suprahilar 30 %
Hadley et al. Urol Oncol 2009