Locally advanced T4 disease is very rare. Patients usually present symptomatically with pain, due to invasion of posterior abdominal wall / nerves / muscles.
Large tumours are still more likely to metastasises, cf. invade.
Imaging can be misleading – i.e. suspicious for liver or bowel invasion on CT, but preserved intra-operative planes.
Be suspicious of large invasive masses for alternate pathology:
- Adrenocortical carcinoma
- TCC
- Sarcoma
- Lymphoma
Take a multi-disciplinary approach if considering very large en bloc resections.
Disease free and overall survival is poor for T4 disease even if non metastatic at time of resection.
There may be an emerging evidence base for “neo-adjuvant” immunotherapy to attempt to reduce tumour burden and also act as a ‘litmus test’ for surgical candidates.
What is the role of lymphadenectomy for radical nephrectomy?
LND provides accurate staging, and LN involvement is a poor prognostic indicator – but – there has been failure to show a therapeutic benefit for lymph node dissection.
Other criticisms of LND:
- Enlarged lymph nodes on imaging often are not pathologically involved
- Often patients with positive nodes are outside the traditional peri-hilar dissection.
EORTC 30881 was an RCT comparing RN +/- LND for clinically N0 disease:
- No difference in overall survival, disease specific survival, or progression at 12 years
- Positive nodes found in 1 % of palpably normal nodes, and 17 % palpably enlarged nodes.
- 4 % overall lymph node involvement
EORTC 30881 involved many organ confined cases with low chance of nodal mets. Several retrospective analyses and reviews of higher risk patients have shown conflicting results.
EAU guidelines:
- If clinically negative nodes on imaging – remove LNs only if abnormal during surgery
- If clinically enlarged nodes on imaging – removal of LNs is justified.
AUA – perform a lymph node dissection for staging purposes, if clinically concerning regional lymphadenopathy.
The extent of any proposed lymphadenectomy is also controversial
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