Lymph node dissection for renal cell carcinoma: what are we missing?

PURPOSE OF REVIEW: The role of lymph node dissection (LND) is uncertain for patients diagnosed with renal cell carcinoma (RCC). The aim of the current review is to discuss the available literature considering the role and the impact of LND in RCC patients elected for surgical treatment. Controversies, uncertainties as well as outstanding research questions were assessed. RECENT FINDINGS: Anatomical and biological peculiarities of RCC make difficult to localize a sentinel lymph node. Cross-sectional imaging as well as preoperative risk score showed limited applicability in determining which patients may benefit from LND. In patients with larger tumors, locally advanced disease or in the presence of unfavorable characteristics (e.g., lymphadenopathy, high grade, tumor necrosis, and sarcomatoid features), LND has a role mainly for staging purposes. In this specific scenario, a potential effect on the natural history of the disease has been suggested, as well. Salvage LND has been increasingly considered, although no definitive recommendation can be nowadays provided. SUMMARY: The assessment of the role and the effect of LND in RCC is still affected by the presence of limited and flawed data available. Further efforts in terms of basic, translational, and imaging research are urgently needed.