Clinical outcomes and prognostic factors in patients undergoing radical nephrectomy with lymphadenectomy for pN1 renal cell carcinoma.

Objective: This study aims to evaluate the clinical effectiveness of radical nephrectomy combined with regional lymphadenectomy in patients with locally advanced renal cell carcinoma (RCC) at the pathological N1 stage.

Methods: We retrospectively analyzed clinical data from a cohort of 112 patients diagnosed with locally advanced RCC at the pathological N1 stage who underwent radical nephrectomy between June 2012 and June 2024. The indications for LND in this study were preoperative imaging suggesting lymph node enlargement (short diameter ≥1 cm) or intraoperative suspicion of metastasis; the scope of dissection followed the anterior template (including lymph nodes from the renal hilum to the level of the inferior mesenteric artery). The analysis included univariate and multivariate Cox proportional hazards regression models, as well as Kaplan-Meier survival curves.

Results: The cohort comprised 112 patients with pT1-4N1M0 RCC, with a mean age of 49 years (±14) and consisted of 74 males and 38 females. Among these patients, 32 had stage pT1-2 cancer, while 80 presented with more advanced stages (pT3 and above). The median follow-up time was 51 months (range: 12-110 months), with 101 (90.2%) patients completing follow-up and 11 (9.8%) lost to follow-up by the end of the study. The median number of lymph nodes dissected during surgery was 8.0 (range 4.0-13.0), and the median number of pathological lymph node metastases was 2.0 (range 1.0-6.0). The postoperative complication rate was 5.4% (6/112), with 5 (4.5%) Grade II and 1 (0.9%) Grade III complications according to the Clavien-Dindo classification. Throughout the follow-up period, tumor progression was observed in 58 patients, including 9 cases of local recurrence and 54 cases of distant metastasis. The median relapse-free survival (RFS) was approximately 0.90 years (range 0.35-2.60 years), while the median overall survival (OS) was about 2.25 years (range 1.15-4.10 years). The 1-, 3-, and 5-year RFS rates were 44.6%, 21.5%, and 12.1%, respectively, and the corresponding OS rates were 78.5%, 36.8%, and 17.2%. Multivariate analysis identified sarcomatoid differentiation (P=0.001) and postoperative tumor progression (P=0.001) as independent risk factors for poor overall survival. Preoperative lymph node enlargement was identified as an independent risk factor for distant metastasis (P=0.038), while multigroup regional lymph node metastasis was linked to an increased risk of local recurrence (P=0.031).

Conclusion: Patients with lymph node metastatic locally advanced RCC exhibit a high risk of postoperative recurrence and metastasis, leading to a poor prognosis. Consequently, these patients require close monitoring and follow-up. Key adverse factors associated with tumor recurrence or poor survival identified include preoperative regional lymph node enlargement, sarcomatoid differentiation, and postoperative tumor progression in stage N1 RCC.