Guidelines not being followed for lymph node dissection in renal cancer

By Will Boggs MD

NEW YORK (Reuters Health) - 27/5/2019

"We were surprised by the discordance between the American and European guidelines and actual practice," Dr. J. Stuart Wolf Jr. of the University of Texas, in Austin, told Reuters Health by email. "Specifically, among patients in whom LND is recommended, 32% did not undergo LND and among patients for whom LND is not recommended 13% of patients nonetheless underwent LND. Thus, there is evidence of both under-treatment and over-treatment in the same disease."

"Follow the American and European Guidelines on LND in association with surgery for renal cancer: don't do LND in association with radical nephrectomy for <cN1 disease and do perform LND in association with radical nephrectomy for cN1 or higher disease," Dr. Wolf said.

As reported online April 19 in Urology, Dr. Wolf and colleagues evaluated factors associated with the performance and quality of LND at the time of radical nephrectomy for RCC using data from an international registry.

Among 1,742 patients who underwent radical nephrectomy for renal cancer, 18% underwent LND.

In univariate analysis, increasing cT and cN stage, open surgery and institutions with high or moderate levels of experience were associated with higher rates of LND. Open surgery and moderate institutional experience were associated with higher nodal yield.

After adjusting for confounding factors, open surgery was associated with significantly higher odds of performing lymph node dissection and with greater lymph node yield, although the association was not significant for malignant lymph node yield.

In the subgroup with cN1 or higher, the population in whom LND is recommended, no factors except open surgery were associated with performing LND.

"These findings might be useful to educators attempting to promulgate the Guidelines, because clearly the Guidelines are not being as impactful as they could be," Dr. Wolf said.

Dr. Michele Marchioni from SS Annunziata Hospital, 'G. D'Annunzio' University of Chieti, Italy, who has studied the link between LND and RCC outcomes, told Reuters Health by email, "I think that physicians should take into consideration these results, pushing more the use of partial nephrectomy without LND in those with clinically localized tumors."

"Indeed," said Dr. Marchioni, who was not involved in the research, "several studies have shown that in this group of patients LND does not confer any oncological advantage in the long term, while partial nephrectomy guarantees higher rates of kidney-function sparing. In those with more advanced tumors the use of LND may be recommended; however no strong evidences are available about its use in all patients to reduce cancer-related mortality."

"I think that, as for other surgeries, surgeons should use the best technique, open or minimally invasive, to obtain the best oncological and surgical results," Dr. Marchioni said. "Usually the best technique is the one with which the surgeon is more confident."

SOURCE: https://bit.ly/2V5uRRa

Urology 2019

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