Pattern and implication of lymphatic drainage in renal tumors Axel - - PowerPoint PPT Presentation

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

Contralateral paraaortic SN location

Supraclavicular lymph node metastases

4/22 patients with SPECT- SN identification (18.2 %)

Brouwer et al., Lymph Res Biol 11:233-38, 2013

65% inside LND templates 35%

• utside

from which 20% in thoracic area

Kuusk et al., J Urol 2018

Parker was the first to describe connections to the thoracic duct

Parker 1935

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

Paraaortic TD subclavian vein lung mediastinal nodes Brouwer et al, Assoud et al

Implications

• The pattern of lymphatic spread in RCC

is very unpredictable

• The true rate of single early occult LN

metastasis is unknown but seems low

• The sentinel node concept should be

studied in clinically high-risk cN0 patients or used for translational research purposes