title: The extent of lymphadenectomy does affect cancer specific survival in pathologically confirmed T4 renal cell carcinoma.
abstract: BACKGROUND
  Controversies exist regarding the effect of lymphadenectomy (LND) in renal cell carcinoma (RCC). We hypothesized that patients with locally advanced cancer invading beyond Gerota's fascia (pT4 Nany Many RCC) might benefit from an extended LND not only for staging but also for survival purposes.
  
  
  METHODS
  Clinical and pathologic data were prospectively gathered in 1.847 patients treated at a single Academic Center, between 1987 and 2011. Only patients with pT4 RCC (TNM 2009, n=44, 2.4%) were included. Univariable (UVA) and multivariable (MVA) Cox regression analyses targeted the association between the number of lymph nodes removed and cancer specific mortality (CSM). Analyses were adjusted for age, Fuhrman grade, symptoms at presentation, metastases at diagnosis, ECOG performance status, tumor size, number of positive nodes, and presence of necrosis or sarcomatoid features.
  
  
  RESULTS
  Mean number of nodes removed was 11.8 (median 8, range 1-37). Mean number of positive nodes was 4.8 (median 2, range 0-36). Cancer-specific survival rates at 1, 2 and 3 years of follow-up were 39.3%, 25.0% and 8.6%, respectively. When stratified for nodal status, cancer-specific survival rates at 1, 2 and 3 years of follow-up were 65.0, 36.1, and 9.0% vs. 13.3, 13.0, and 6.7%, for pN0 vs. pN+ cases, respectively (p=0.004). At MVA, after adjusting for all the possible confounders, the number of positive nodes resulted independently associated with CSM (HR 1.25, p=0.001). Interestingly, at MVA, the number of nodes removed achieved the independent predictor status, as well (HR 0.84, p=0.007) showing a protective effect on survival. The risk of dying increased of 16% every positive node found (p<0.001), and decreased of 8% every node removed (p=0.02) (Table II).
  
  
  CONCLUSIONS
  A more extended retroperitoneal lymphadenectomy at the time of nephrectomy statistically significantly decreased CSM in pT4 cases.
authors.affiliation: Department of Urology, University Vita-Salute, San Raffaele Hospital, Milan, Italy. capitanio.umberto@hsr.it
authors.forename: Umberto
authors.initials: U
authors.lastname: Capitanio
authors.forename: Rayan
authors.initials: R
authors.lastname: Matloob
authors.forename: Nazareno
authors.initials: N
authors.lastname: Suardi
authors.forename: Firas
authors.initials: F
authors.lastname: Abdollah
authors.forename: Fabio
authors.initials: F
authors.lastname: Castiglione
authors.forename: Dario
authors.initials: D
authors.lastname: Di Trapani
authors.forename: Andrea
authors.initials: A
authors.lastname: Russo
authors.forename: Alberto
authors.initials: A
authors.lastname: Briganti
authors.forename: Cristina
authors.initials: C
authors.lastname: Carenzi
authors.forename: Andrea
authors.initials: A
authors.lastname: Salonia
authors.forename: Francesco
authors.initials: F
authors.lastname: Montorsi
authors.forename: Patrizio
authors.initials: P
authors.lastname: Rigatti
authors.forename: Roberto
authors.initials: R
authors.lastname: Bertini
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002292:Carcinoma, Renal Cell / Q000401:mortality / Q000473:pathology / Q000556:secondary / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D007680:Kidney Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D008197:Lymph Node Excision / Q000379:methods*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009336:Necrosis; D060787:Neoplasm Grading; D009367:Neoplasm Staging; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012187:Retroperitoneal Space; D012720:Severity of Illness Index; D047368:Tumor Burden