Nephrectomy for Malignant Neoplasm
NEPHRECTOMY FOR MALIGNANT NEOPLASM
Nephrectomies are generally resected for tumors over 7.0 cm in size (i.e. renal cell, urothelial, etc.). The specimen may include: ureter, renal vein, renal artery, hilar lymph node(s) and adrenal gland (radical nephrectomy). It is important to open the ureter as most urothelial carcinomas arise here or within the pelvis/calyces. It is equally as important to open the renal vein as some renal cell carcinomas tend to invade into the lumen or vascular wall.
Here are a few simple methods for determining orientation:
- the ureter always points towards the inferior pole
- hilar structures in order of superior to inferior ~ renal artery, renal vein, ureter
- the adrenal gland is always at the superior pole
- Weigh and measure
- Dissect and submit any perirenal lymph nodes
- Ink any palpable areas. If no discrete lesions are identified, ink entire capsule/perirenal adipose
- Measure and describe hilar structures: ureter, renal vein, renal artery.
- Shave and submit ureter/vascular margins
- Open renal vein and ureter
- Describe and submit adrenal gland (if present)
- Describe capsule/perirenal adipose
- Bivalve the kidney coronally, opening the pelvis and calyces
Measure and describe lesion(s), give location (pelvis, upper pole, calyces, etc.), identify tumor extension into the following structures: capsule, perirenal adipose, calyces, pelvis, renal vein, ureter, renal sinus and adrenal gland.
If stones are present, submit for chemical analysis
- Describe and submit uninvolved kidney (external surface, cortex, and medulla)
- Describe pelvis (dilated, blunting of calyces, stones present)
Sections for Histology
- All hilar lymph nodes
- Vascular and ureter margins, submit true margin en face
- 1 cassette of normal adrenal or adrenal to tumor
- 1 section per cm of tumor (try to include the following if present: tumor to capsule/pericapsular adipose, tumor to sinus/renal vein and tumor to renal pelvis
- 1 section per cm of tumor (try to include the following if present: tumor to capsule/pericapsular adipose, tumor to sinus/renal vein and tumor to renal pelvis). If the tumor approaches the renal pelvis, submit extra sections of the tumor/fat interface as many tumors invade the fat at this location.
Sample Dictation of Radical Nephrectomy for Renal Cell Carcinoma
Received in formalin in a large container is a radical nephrectomy specimen, 15.0 x 10.0 x 8.0 cm and weighing 345 grams. An intact, unremarkable adrenal gland is identified, 4.0 x 3.0 x 2.0 cm. A single hilar lymph node is identified, 1.0 cm. The hilum contains the following: ureter (5.0 x 0.5cm), renal vein (2.0 x 0.3 cm) and renal artery (1.0 x 0.8cm). The capsule is intact and unremarkable. The specimen is bivalved to reveal a yellow, well circumscribed, cystic tumor (7.0 x 6.0 x 5.0 cm) remarkable for focal areas of hemorrhage and necrosis. The tumor is located within the calyces of the upper pole, and invades into the pelvis, renal sinus and renal vein, 1.0 cm from the margin. The tumor abuts the capsule, however does not invade through it. The uninvolved pelvis is dilated. The remaining parenchyma is unremarkable. Pictures have been taken for reference.
1A- 1 bisected lymph node (ns)
1B- vascular and ureter margins (ns)
1C- adrenal gland (ss)
1D- tumor to calyces (ss)
1E- tumor to pelvis (ss)
1F- tumor to renal sinus (ss)
1G- tumor to renal vein (ss)
1H- tumor to capsule (ss)
1I- tumor containing areas of hemorrhage/necrosis (2ss)
1J- uninvolved renal parenchyma (ss)
The Southwest Oncology group has established a protocol for the handling of renal cell carcinomas which have been therapeutically infarcted. For the grossing procedure and sections for histology, follow the steps in “Nephrectomy for Malignant Neoplasm”. When describing the tumor, give an estimate amount (%) of tumor which appears grossly infarcted. Make sure to take a photograph!
Tumors of this nature proliferate within the ureter, pelvis and calyces. It is not uncommon for the tumor to invade into the parenchyma. For these specific tumors, use the grossing protocol “Nephrectomy for Malignant Neoplasm”. The first step should always be to shave the surgical margin and submit en face. If the tumor has ureter extension, ink the entire adventitial surface and open longitudinally. Submit one section per cm of tumor, including greatest depth of invasion (i.e. limited to urothelium, invades through adventitia, etc.). Systematically submit sections of uninvolved/involved ureter, including distal, mid, proximal and ureter/pelvic junction. This is done to determine if any in-situ disease is present. Remember to keep the sectioned ureter in order, wrapped in a labeled paper towel if more sections from a specific area are required at a later time. Urothelial tumors of the renal pelvis and ureter are often very soft and friable. Please take care to ensure that when grossing it in you rinse your knife blade frequently to avoid carry-over of tumor into underlying tissue.
Modified February 2009