Lack of retroperitoneal lymphadenopathy predicts survival of patients withmetastatic renal cell carcinoma

Purpose: Patients with metastatic renal cell carcinoma have a reported 5-ye ar survival of 0% to 20%. The ability to predict which patients would benef it from nephrectomy and interleukin-2 (IL-2) therapy before any treatment i s initiated would be useful for maximizing the advantage of therapy and imp roving the quality of life. Materials and Methods: A retrospective analysis of the x-rays and charts of patients treated at the National Institutes of Health Surgery Branch betwe en 1985 and 1996, who presented with metastatic renal cancer beyond the loc oregional area and the primary tumor in place, was performed. Preoperative computerized tomography or magnetic resonance imaging, or radiological repo rts if no scans were available, were used to obtain an estimate of the volu me of retroperitoneal lymphadenopathy. Operative notes were used to evaluat e whether all lymphadenopathy was resected or disease left in situ, or if a ny extrarenal resection, including venacavotomy, was performed. Mean surviv al rate was calculated from the time of nephrectomy to the time of death or last clinical followup. If patients received IL-2 therapy, the response to treatment was recorded. Mean survival and response rate for IL-2 were comp ared among patients in 3 separate analyses. Patients without preoperatively detected lymphadenopathy were compared with those with at least 1 cm.(3) r etroperitoneal lymphadenopathy. Also, the patients who had detectable lymph adenopathy were divided into subgroups consisting of all resected, incomple tely resected, unresectable and unknown if all disease was resected. Each s ubgroup was compared with patients without detectable preoperative lymphade nopathy. Patients with less than were compared to those with greater than 5 0 cm. retroperitoneal lymphadenopathy. Patients undergoing extrarenal resec tion at nephrectomy (complex surgery) due to direct invasion of the tumor i nto another intra-abdominal organ were compared with those undergoing radic al nephrectomy alone, regardless of lymph node status. Statistical analysis was done with the Mantel-Cox test for comparison of survival on Kaplan-Mei er curves and with Fisher's exact test for response rates for IL-2. Results: A total of 154 patients with metastatic renal cell carcinoma under went cytoreductive nephrectomy as preparation for IL-2 based regimens. Ther e were 82 patients with metastatic renal cell carcinoma and no preoperative retroperitoneal lymphadenopathy who survived longer (median 14.1 months) t han the 72 with lymphadenopathy (median 8.5, p = 0.0004). Patients with inc ompletely resected, unresectable or an unknown volume resected had decrease d survival compared to those with no retroperitoneal lymphadenopathy. A mul tivariate analysis of survival was performed evaluating the known prognosti c indicators, performance status and tumor burden, as represented by the nu mber of organs involved with metastases, and the new prognostic factor, lym phadenopathy. Lymphadenopathy was more closely associated with survival tha n performance status, and appeared to be a new prognostic variable. Patient s with and without retroperitoneal lymphadenopathy at initial presentation had similar rates for treatment with IL-2 (54% for both groups). Of the 82 patients with no lymphadenopathy 11 (13%) had long-term survival greater th an 5 years. Of the 6 complete responses to IL-2, 5 occurred in this group. Only I other patient with incompletely resected retroperitoneal lymphadenop athy survived longer than 5 years. No significant difference in survival wa s seen between patients who did or did not undergo complex surgery. Conclusions: Patients who presented with metastatic renal cancer and retrop eritoneal lymphadenopathy had a shorter survival than those with no detecta ble retroperitoneal lymphadenopathy. It is warranted to continue to perform complex extrarenal resection during nephrectomy since no significant diffe rence in the response rate for IL-2 or mean survival compared with those of patients undergoing nephrectomy alone is currently detectable.