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T KONDO ET AL.
Editorial Comment Editorial Comment to Template-based lymphadenectomy in urothelial carcinoma of the renal pelvis: A prospective study Kondo et al. defined lymph node mapping, the anatomical extent of regional lymph nodes, when carrying out radical nephroureterectomy (RNU) in patients with upper tract urothelial carcinoma (UTUC), and prospectively evaluated whether anatomical template-based lymph node dissection (LND) could have a therapeutic benefit in renal pelvic tumors and in ureteral tumors separately.1 They found that patients treated with template-based LND had significantly better survival than those treated without LND, especially for ≥ pT2N0M0 renal pelvic tumors. Their efforts to establish a real template for LND in UTUC patients treated with RNU should be supported, and needs to be validated in a larger surgical series. Unfortunately, just 43% of UTUC patients received the appropriate LND during RNU in a recent large RNU series.2 Why are surgeons reluctant to carry out LND in UTUC patients treated with RNU? The answer is because we urologists still doubt LND has a real therapeutic benefit. What is required to establish the clinical importance of LND in patients treated with RNU? First, the candidate for LND should be selected appropriately. Kondo et al. mainly carried out template-based LND in patients younger than 75 years-of-age and without significant comorbidities. Furthermore, they carried out template-based LND on all staged UTUC patients, even Ta or T1 cancers. Of course, preoperative clinical staging for UTUC is not perfect, and the degree of staging error is not small in the diagnosis of UTUC patients; however, current modalities such as CT urography and diffusion-weighted magnetic resonance imaging could have more accurate diagnostic properties for preoperative T categorization, especially in determining a locally infiltrative tumor.3,4 Furthermore, combined tools including the findings of CT urography, urinary cytology and ureteroscopy with biopsy grading might minimize the staging error, and could diagnose muscle invasive or non-organ confined UTUC more accurately.5 Good candidates for template-based LND in UTUC should be determined in future studies. Second, a standard process for pathological evaluation should be established. Reproducible and consistent processing methods for evaluating lymph nodes are essential for the accurate diagnosis of metastatic lymph nodes. Urologists need to stay in constant contact with pathologists, so pathologists can receive clinical findings and estimations, and provide precise information of the status of the lymph nodes. Finally, we must determine what surgical procedure for template-based LND is the most appropriate in terms of improving the efficiency, as well as minimizing the risk of related complications. We still do not know whether template-
460
based LND should be carried out transperitoneally or retroperitonally, or by an open procedure, laparoscopic surgery, or robotic procedure. Interestingly, the incidence of lymph node metastasis (local recurrence) of renal pelvic cancer in the template-based LND group was 5%, which was significantly smaller than that in the no LND group (20%). This was not observed in regard to distant metastasis in their series. In a large series of RNU in which LND was not carried out meticulously, the local recurrence rate was almost 18%,6 which is relatively high compared to that of bladder carcinoma treated with radical cystectomy with regional LND. Local recurrences, including regional lymph node metastasis, are major sites of disease recurrence in UTUC. If template-based LND could reduce the risk of local recurrence, marked survival improvement might be obtained in advanced UTUC patients. Further study in a larger series of patients would be warranted to confirm the therapeutic benefit of “template-based LND” in UTUC patients. Eiji Kikuchi M.D., Ph.D. Department of Urology, Keio University School of Medicine, Tokyo, Japan [email protected] DOI: 10.1111/iju.12354
Conflict of interest None declared.
References 1 Kondo T, Hara I, Takagi T et al. Template-based lymphadenectomy in urothelial carcinoma of the renal pelvis: a prospective study. Int. J. Urol. 2014; 21: 453–9. 2 Margulis V, Shariat SF, Matin SF et al. Outcomes of radical nephroureterectomy: a series from the Upper Tract Urothelial Carcinoma Collaboration. Cancer 2009; 115: 1224–33. 3 Akita H, Jinzaki M, Kikuchi E et al. Preoperative T categorization and prediction of histopathologic grading of urothelial carcinoma in renal pelvis using diffusion-weighted MRI. AJR Am. J. Roentgenol. 2011; 197: 1130–6. 4 Jinzaki M, Matsumoto K, Kikuchi E et al. Comparison of CT urography and excretory urography in the detection and localization of urothelial carcinoma of the upper urinary tract. AJR Am. J. Roentgenol. 2011; 196: 1102–9. 5 Favaretto RL, Shariat SF, Savage C et al. Combining imaging and ureteroscopy variables in a preoperative multivariable model for prediction of muscle-invasive and non-organ confined disease in patients with upper tract urothelial carcinoma. BJU Int. 2012; 109: 77–82. 6 Tanaka N, Kikuchi E, Kanao K et al. Patient characteristics and outcomes in metastatic upper tract urothelial carcinoma after radical nephroureterectomy: the experience of Japanese multi-institutions. BJU Int. 2013; 112: E28–34.
© 2013 The Japanese Urological Association
T KONDO ET AL.
Editorial Comment Editorial Comment to Template-based lymphadenectomy in urothelial carcinoma of the renal pelvis: A prospective study Kondo et al. defined lymph node mapping, the anatomical extent of regional lymph nodes, when carrying out radical nephroureterectomy (RNU) in patients with upper tract urothelial carcinoma (UTUC), and prospectively evaluated whether anatomical template-based lymph node dissection (LND) could have a therapeutic benefit in renal pelvic tumors and in ureteral tumors separately.1 They found that patients treated with template-based LND had significantly better survival than those treated without LND, especially for ≥ pT2N0M0 renal pelvic tumors. Their efforts to establish a real template for LND in UTUC patients treated with RNU should be supported, and needs to be validated in a larger surgical series. Unfortunately, just 43% of UTUC patients received the appropriate LND during RNU in a recent large RNU series.2 Why are surgeons reluctant to carry out LND in UTUC patients treated with RNU? The answer is because we urologists still doubt LND has a real therapeutic benefit. What is required to establish the clinical importance of LND in patients treated with RNU? First, the candidate for LND should be selected appropriately. Kondo et al. mainly carried out template-based LND in patients younger than 75 years-of-age and without significant comorbidities. Furthermore, they carried out template-based LND on all staged UTUC patients, even Ta or T1 cancers. Of course, preoperative clinical staging for UTUC is not perfect, and the degree of staging error is not small in the diagnosis of UTUC patients; however, current modalities such as CT urography and diffusion-weighted magnetic resonance imaging could have more accurate diagnostic properties for preoperative T categorization, especially in determining a locally infiltrative tumor.3,4 Furthermore, combined tools including the findings of CT urography, urinary cytology and ureteroscopy with biopsy grading might minimize the staging error, and could diagnose muscle invasive or non-organ confined UTUC more accurately.5 Good candidates for template-based LND in UTUC should be determined in future studies. Second, a standard process for pathological evaluation should be established. Reproducible and consistent processing methods for evaluating lymph nodes are essential for the accurate diagnosis of metastatic lymph nodes. Urologists need to stay in constant contact with pathologists, so pathologists can receive clinical findings and estimations, and provide precise information of the status of the lymph nodes. Finally, we must determine what surgical procedure for template-based LND is the most appropriate in terms of improving the efficiency, as well as minimizing the risk of related complications. We still do not know whether template-
460
based LND should be carried out transperitoneally or retroperitonally, or by an open procedure, laparoscopic surgery, or robotic procedure. Interestingly, the incidence of lymph node metastasis (local recurrence) of renal pelvic cancer in the template-based LND group was 5%, which was significantly smaller than that in the no LND group (20%). This was not observed in regard to distant metastasis in their series. In a large series of RNU in which LND was not carried out meticulously, the local recurrence rate was almost 18%,6 which is relatively high compared to that of bladder carcinoma treated with radical cystectomy with regional LND. Local recurrences, including regional lymph node metastasis, are major sites of disease recurrence in UTUC. If template-based LND could reduce the risk of local recurrence, marked survival improvement might be obtained in advanced UTUC patients. Further study in a larger series of patients would be warranted to confirm the therapeutic benefit of “template-based LND” in UTUC patients. Eiji Kikuchi M.D., Ph.D. Department of Urology, Keio University School of Medicine, Tokyo, Japan [email protected] DOI: 10.1111/iju.12354
Conflict of interest None declared.
References 1 Kondo T, Hara I, Takagi T et al. Template-based lymphadenectomy in urothelial carcinoma of the renal pelvis: a prospective study. Int. J. Urol. 2014; 21: 453–9. 2 Margulis V, Shariat SF, Matin SF et al. Outcomes of radical nephroureterectomy: a series from the Upper Tract Urothelial Carcinoma Collaboration. Cancer 2009; 115: 1224–33. 3 Akita H, Jinzaki M, Kikuchi E et al. Preoperative T categorization and prediction of histopathologic grading of urothelial carcinoma in renal pelvis using diffusion-weighted MRI. AJR Am. J. Roentgenol. 2011; 197: 1130–6. 4 Jinzaki M, Matsumoto K, Kikuchi E et al. Comparison of CT urography and excretory urography in the detection and localization of urothelial carcinoma of the upper urinary tract. AJR Am. J. Roentgenol. 2011; 196: 1102–9. 5 Favaretto RL, Shariat SF, Savage C et al. Combining imaging and ureteroscopy variables in a preoperative multivariable model for prediction of muscle-invasive and non-organ confined disease in patients with upper tract urothelial carcinoma. BJU Int. 2012; 109: 77–82. 6 Tanaka N, Kikuchi E, Kanao K et al. Patient characteristics and outcomes in metastatic upper tract urothelial carcinoma after radical nephroureterectomy: the experience of Japanese multi-institutions. BJU Int. 2013; 112: E28–34.
© 2013 The Japanese Urological Association
