Poor evidence occludes locally advanced RCC surgery recommendations
By Lucy Piper, Senior medwireNews Reporter
26 June 2013
Eur Urol 2013; Advance online publication

medwireNews: Researchers have failed to find sufficient evidence to conclude whether concomitant lymph node dissection (LND) or ipsilateral adrenalectomy with radical nephrectomy improves oncologic outcomes for patients with locally advanced renal cell carcinoma (RCC).

"The quality of evidence is generally low and the results biased and uncertain," says the team, led by Thomas Lam (University of Aberdeen, UK).

"Important prognostic variables are rarely reported, and outcomes are reported and measured in heterogeneous ways; these characteristics limit interpretation and applicability."

Screening 3658 abstracts and 252 full-text articles, the researchers found only eight that met their inclusion criteria - six on LNDs and two on adrenalectomies.

With regard to LND, there was no significant difference in survival between patients who had concomitant LND and those who had radical nephrectomy alone. But survival curves in one study did suggest a 15% improved 5-year overall survival with concomitant LND surgery.

Lam et al suggest that this survival benefit with LND could be because of a therapeutic benefit of removing cancerous lymph nodes; however, they add that this is probably not the case due to the low prevalence of lymph node involvement in this group of patients with T3 disease.

Rather, they propose that the possible survival benefit is due to a prophylactic effect, "whereby the removal of disease-free lymph nodes may prevent the subsequent spread of the disease by removing the means of cancer spread through the lymphatic channels."

Event rates in this study were generally low overall and there were no marked differences between those receiving concomitant surgery and nephrectomy alone. Otherwise, no studies reported any perioperative or quality-of-life (QoL) data.

Similarly, no perioperative or QoL outcome data were reported in studies of ipsilateral adrenalectomy. Only one study reported on cancer-specific survival and this showed no difference between concomitant adrenalectomy and nephrectomy alone.

The lack of QoL outcomes is an important issue, say Lam and team in European Urology. "These outcomes are important for patient decision making in locally advanced disease."

They also note that "it was not possible to perform meta-analyses for any outcomes of interest because of insufficient data and inconsistencies in outcome definition, measurement, and reporting."

They conclude: "Further research, preferably in the form of randomized and adequately powered trials, must be undertaken to address the issues of whether LND or adrenalectomy should be performed concurrently with [radical nephrectomy] in locally advanced RCC patients."

medwireNews (www.medwirenews.com) is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2013

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