© 2008 THE AUTHORS JOURNAL COMPILATION © 2 0 0 8 B J U I N T E R N A T I O N A L | 1 0 3 , 3 3 – 3 7 | doi:10.1111/j.1464-410X.2008.08014.x 33 2008 THE AUTHORS. JOURNAL COMPILATION 2008 BJU INTERNATIONAL Urological Oncology EFFECT OF EXCLUSIVE NODAL METASTASES ON CSS OF PATIENTS WITH RCC DIFFERS WITH T STAGE CAPITANIO et al. Stage-specific effect of nodal metastases on survival in patients with non-metastatic renal cell carcinoma Umberto Capitanio 1 , Claudio Jeldres 1 , Jean-Jacques Patard 2 , Paul Perrotte 3 , Laurent Zini 1 , Alexandre de La Taille 4 , Vincenzo Ficarra 5 , Luca Cindolo 6 , Karim Bensalah 2 , Walter Artibani 7 , Jacques Tostain 8 , Antoine Valeri 9 , Richard Zigeuner 10 , Arnaud Méjean 10 , Jean Luc Descotes 11 , Eric Lechevallier 12 , Peter F. Mulders 13 , Herve Lang 13 , Didier Jacqmin 14 and Pierre I. Karakiewicz 1,3 1 Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada, 2 Department of Urology, Rennes University Hospital, Rennes, France, 3 University of Montreal, Montreal, Quebec, Canada, 4 CHU Henri Mondor, Creteil, France, 5 University of Padua, Padua, 6 G. Rummo Hospital, Benevento, Italy, 7 St-Etienne University Hospital, St-Etienne, 8 Brest University Hospital, Brest, France, 9 Graz Medical University, Graz, Austria, 10 Necker Medical School, Paris, 11 Grenoble University Hospital, Grenoble, 12 Marseille University Hospital, Marseille, France, 13 Nijmegen University Hospital, the Netherlands, and 14 Strasbourg University Hospital, Strasbourg, France Accepted for publication 18 June 2008 analyses relied on T stage, Fuhrman grade and presence of eNM. Data were analysed using univariable, multivariable and stratified analyses. RESULTS Overall 165 (4.7%) patients had eNM; of 2023 patients of stage T1, 23 (1.1%) had eNM, vs 20 of 448 (4.5%) for T2 and 122 of 993 (12.3%) for T3. In univariable analyses the presence of eNM increased the rate of cancer specific mortality (CSM) by 7.1 times. After adjusting for T stage and Fuhrman grade, in all patients eNM increased the rate of CSM by 3.2 times. In stratified analyses adjusted for Fuhrman grade, the increase in CSM related to the presence of eNM was 28.9, 4.3 and 2.5 times (all P < 0.001) for stages T1, T2 and T3, respectively. CONCLUSIONS From the prognostic perspective, staging lymphadenectomy appears of most value in patients with T1-2 RCC, but the low prevalence of eNM questions the practical applicability of nodal staging in those patients. Conversely, in patients with T3 RCC, the prevalence and the prognostic impact of eNM might make a staging lymphadenectomy worthwhile. KEYWORDS renal cell carcinoma, radical nephrectomy, lymph node invasion, cause-specific survival Study Type – Prognosis (retrospective cohort study) Level of Evidence 2b OBJECTIVE To quantify the survival disadvantage related to the presence of exclusive nodal metastases (eNM) in patients with otherwise non-metastatic (M0) renal cell carcinoma (RCC). PATIENTS AND METHODS Data were retrieved from 12 institutional databases and yielded 3507 patients with T1-3N1-2M0 RCC treated with partial or radical nephrectomy. Cox regression INTRODUCTION The presence of nodal metastases is associated with a poor prognosis in patients with RCC but no distant metastases [1–8]. However, to date it is not known to what extent nodal metastases worsen cancer- specific survival (CSS) in such patients. Some of the difficulties relate to the clinical staging of lymph node metastases [9,10]. In many instances grossly enlarged lymph nodes will be benign. Conversely, in other instances, unenlarged lymph nodes might contain neoplastic cells. Therefore, nodal staging has so far been limited to surgical staging [11–13] in patients with suspected but unconfirmed lymph node metastases [12]. Our objective was to quantify the prevalence and the detriment to CSS associated with the presence of nodal metastases in all non- metastatic patients with RCC, and in a stage- specific fashion for various T substages (T1 vs T2 vs T3). PATIENTS AND METHODS Data were retrieved from institutional databases for 3507 consecutive patients with RCC, who were treated with partial or radical BJUI BJU INTERNATIONAL