title: Lymphadenectomy at the time of nephroureterectomy for upper tract urothelial cancer.
abstract: BACKGROUND
  The role of lymph node dissection (LND) in patients treated with radical nephroureterectomy (RNU) for upper tract urothelial cancer (UTUC) is still controversial.
  
  
  OBJECTIVE
  To analyze the impact of lymph node invasion on the outcome of patients, the staging, and the possible therapeutic role of LND in UTUC.
  
  
  METHODS
  A Medline search was conducted to identify original articles, review articles, and editorials addressing the role of LND in UTUC. Keywords included upper tract urothelial neoplasms, lymphadenectomy, lymph node excision, lymphatic metastases, nephroureterectomy, imaging, and survival.
  
  
  RESULTS
  Regional nodes are frequently involved in UTUC and represent the most common metastatic site. Regional nodal status is a significant predictor of patient outcomes, especially in invasive disease. Therefore, select patients treated with RNU at high risk for regional nodal metastases should undergo LND to improve disease staging, which would identify those who could benefit from adjuvant systemic therapy. Several retrospective studies suggested the potential therapeutic role of LND in UTUC. An accurate LND could remove some nodal micrometastases not identified on routine pathologic examination, thus improving local control and cancer-specific survival. Radical surgery and LND might be curative in a subpopulation with limited nodal disease, as described in bladder cancer. A clear knowledge of the limits of LND and a template of LND for UTUC are still needed.
  
  
  CONCLUSIONS
  An extended LND can provide better disease staging and may be curative in patients with limited nodal disease. However, current evidence is based on retrospective studies, which limits the ability to standardize either the indication or the extent of LND. Prospective trials are required to determine the impact of LND on survival in patients with UTUC and identify patients for a risk-adapted approach such as close follow-up or adjuvant chemotherapy.
authors.affiliation: Department of Urology, Ospedali Riuniti di Bergamo, Bergamo, Italy. roscigno.marco@gmail.com
authors.forename: Marco
authors.initials: M
authors.lastname: Roscigno
authors.forename: Maurizio
authors.initials: M
authors.lastname: Brausi
authors.forename: Axel
authors.initials: A
authors.lastname: Heidenreich
authors.forename: Yair
authors.initials: Y
authors.lastname: Lotan
authors.forename: Vitaly
authors.initials: V
authors.lastname: Margulis
authors.forename: Shahrokh F
authors.initials: SF
authors.lastname: Shariat
authors.forename: Hendrik
authors.initials: H
authors.lastname: Van Poppel
authors.forename: Richard
authors.initials: R
authors.lastname: Zigeuner
mesh_terms: D002277:Carcinoma / Q000188:drug therapy / Q000601:surgery*; D017024:Chemotherapy, Adjuvant; D006801:Humans; D008197:Lymph Node Excision; D009367:Neoplasm Staging; D009392:Nephrectomy; D018579:Patient Selection; D016896:Treatment Outcome; D014513:Ureter / Q000187:drug effects / Q000601:surgery*; D001749:Urinary Bladder Neoplasms / Q000188:drug therapy / Q000601:surgery*