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    Kidney renal parenchymal tumour

    Background

    Nephrectomies are most commonly required for treatment of malignancies such as renal cell carcinoma and urothelial cell carcinoma in adults but benign tumours such as oncocytomas do occur.

    The most common tumour seen in children is nephroblastoma. Lymphomas and sarcomas can also occur in the kidney.1

    Partial nephrectomy may be used to remove small tumours to preserve kidney function. Total nephrectomy (with or without adrenal gland) may be used to remove larger tumours.

    This protocol is relevant to nephrectomies for lesions of the renal parenchyma. Separate protocols are provided for non-tumour specimens and tumours of the renal pelvis and ureter.

    Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. Include the reason for nephrectomy and whether surgery was open or laparoscopic if known.

    Correlation of the specimen with previous radiological and pathological reports may be useful.

    See overview page for more detail on identification principles.

    • No
      • Non-routine fixation (not formalin), describe.
    • Yes
      • Special studies required, describe.
      • Ensure samples are taken prior to fixation.
    • Not performed
    • Performed, describe type and result
      • Frozen section
      • Imprints
      • Other, describe

    See general information for more detail on specimen handling procedures.

    Inspect the specimen and dictate a macroscopic description.


    External Inspection

    Orientate and identify anatomical features of the specimen:2

    Although laterality is usually indicated in the clinical notes, principal landmarks such as the adrenal gland, ureter, renal vein and artery will confirm whether the specimen is the right or left kidney. The ureter extends inferiorly from the renal sinus along the medial border of the kidney posterior to the renal artery and vein.2,3

    Specimen integrity

    • Intact
    • Opened
    • Fragmented (morcellated)
      • Number of pieces

    Laparoscopically removed kidneys may be received in fragments and require particular consideration during cut-up.4

    Procedure

    ​Record as stated by the clinician.

    • Radical nephrectomy
    • Partial nephrectomy
    • Other, describe

    Record additional orientation or designation provided by operating clinician:

    • Absent
    • Present
      • Method of designation (e.g. suture, incision)
      • Feature denoted

    If unable to orientate, contact the on-call pathologist or surgeon.

    Anatomical components included (more than one may apply) and dimensions (mm)

    Describe and measure the components present.

    • Entire specimen
      • Weight (g)
      • Size in three dimensions (mm)
    • Kidney, in three dimensions
    • Ureter (posterior), length
    • Renal artery (middle), length
    • Renal vein (anterior), length
    • Adrenal (if present), in three dimensions
    • Gerota’s fascia
      • Absent
      • Present
    • Other, specify

    Photograph the intact specimen if required.


    Dissection

    Paint the entire specimen or alternatively paint the hilar and nearest perinephric fat margins to tumour with ink.

    Strip uninvolved perirenal fat from the capsular/hilar surface carefully preserving perirenal fat around areas suspicious of capsular involvement, inking the adjacent surgical/perirenal margin.

    Carefully palpate the perirenal fat superiorly to locate the adrenal gland. If present, examine for direct infiltration by tumour, then section at 3-4mm intervals.

    Take shave margins of ureter and renal vessels submitting any clot identified within the renal vein.

    Open the renal vein and its tributary vessels and record if there is macroscopic evidence of tumour within the lumen.

    The initial section of kidney should be along its long axis at midpoint. This could be an incision along the midline through the hilum from lateral to medial or along probes placed in the largest branches of the renal vein.

    Take further sections parallel or perpendicular to the first incision. Parallel sections should include one just anterior to the renal pelvis to evaluate any venous involvement.

    To grossly examine for perinephric fat invasion, keep the overlying fat intact and make multiple perpendicular incisions from the kidney through the fat. Sample any suspicious areas.

    Photograph the specimen if required.

    Take sections from areas suspicious of renal vein/hilar fat invasion.

    Locate all lymph nodes.

    Ink the surgical ("cut") margin (or margins if so designated) and the perirenal fat margin, if tumour involves the capsule.

    Serially section at 3-5mm intervals perpendicularly to the cut margin.

    Photograph the specimen if required.

    After opening the specimen may require longer fixation in larger quantity of formalin.


    Internal Inspection

    Describe the internal appearance including the following items:

    Adrenal gland infiltration5

    • No
    • Yes
      • Direct infiltration by tumour
      • Separate metastatic deposit

    Macroscopic inspection of adrenal gland involvement is important for staging purposes to distinguish contiguous spread (pT4) from metastatic deposits (pM1).5

    Tumour/thrombus present in renal vein

    • No
    • Yes 6,7
      • In lumen

    Capsular penetration/abnormality (cortical surface abnormalities)

    • No tumour penetration
      • Distance to renal capsule (mm)
    • Yes 6
      • Tumour penetrates through renal capsule
      • Tumour extends beyond Gerota’s fascia
      • Tumour invades adjoining tissue, specify
      • Distance to closest surgical margin2 (mm), specify margin if orientated

    Capsular penetration may be indicated by adherence of the renal capsule to the visceral surface of the perirenal fat.

    Tumour

    • Absent
    • Present
    • Number; if more than one tumour, designate and describe each tumour separately

    For each tumour, describe:

    Tumour size (mm)

    • In three dimensions2,6,8

    The maximum size of the tumour is important for staging purposes. Length of renal vein should not be part of the tumour measurement.

    Tumour location, if known

    • Upper pole
    • Mid zone
    • Lower pole

    Evidence of infiltration to:

    Renal sinus

    • No
    • Yes

    Renal vessels6,8

    • No
    • Yes

    Tumour appearance

    (more than one may apply)

    Colour

    • Describe

    Variegated tumours with yellow areas are often rich in fat and this appearance is most frequently seen in a clear cell renal cell carcinoma. Chromophobe renal cell carcinomas and sarcomatoid carcinomas are often pale.2

    Cut surface

    • Solid
    • Cystic
    • Other

    Consistency

    • Firm
    • Friable
    • Other, describe

    Sarcomatoid carcinomas are often firm while papillary renal cell carcinomas usually have a friable consistency.2

    Necrosis

    • Absent
    • Present

    The presence of necrosis within RCC has prognostic significance for clear cell renal cell carcinoma and chromophobe renal cell carcinoma but not for papillary renal cell carcinoma.2,9

    Other abnormalities on the cut surface

    • Describe any background renal changes e.g. calculi, obstructive appearances

    Retrieved from resection specimen

    • Describe site(s)
    • Number retrieved

    Separately submitted

    • For each specimen container, record specimen number and designation
    • Collective size of tissue in three dimensions (mm)
    • Number of grossly identified lymph nodes submitted
    • Maximum diameter of each (mm)

    Processing

    Dissect the specimen further and submit sections for processing as follows:

    Submit representative sections of tumour; including sampling from a minimum of the five largest tumours.2,10

    Submit at least three sections or one per 10mm of tumour, demonstrating the relationship with:

    • Capsule/perinephric fat
    • Hilar vessels and fat including the hilar resection margin
    • Adrenal
    Submit sections demonstrating presence or absence of renal sinus invasion.

     

    • If obviously not present (e.g. small peripheral tumour), submit one block to confirm
    • If grossly evident, submit representative section to confirm
    • If uncertain, submit at least three sections of tumour sinus interface

    Submit representative sections of:

    • Abnormal areas of lumen of renal vein or artery
    • Background renal cortex, noting site taken
    • Caval thrombus (if present), at least two sections to demonstrate possible adherent caval wall tissue
    • Adrenal tissue, if present

    Submit all lymph nodes


    Record details of each cassette.

    An illustrated block key similar to those provided below may be useful.

    Block allocation keys

    Cassette id
    Site
    No. of pieces
    A
    Shave sections of ureter/ renal artery/vein
     
    B
    Any thrombus of renal vein if present
     
    C
    Tumour closest to capsule/possible invasion
     
    D
    Tumour invading perirenal fat including surgical margin (if applicable)
     
    E-F
    Tumour close to renal sinus (or one representative section of renal sinus if tumour is distant)
     
    G
    Tumour and renal vein (if close)
     
    H-I
    Tumour, representative sections
     
    J
    Background kidney cortex lower pole
     
    K
    Adrenal gland
     
    L+
    Lymph nodes
     
    Cassette id
    Site
    No. of pieces
    A
    Tumour closest to parenchymal margin
     
    B
    Tumour closest to capsule
     
    C-E
    Tumour, representative sections
     

     

    Acknowledgements

    A/Prof Hemamali Samaratunga for her contribution in reviewing and editing this protocol.


    References

    1. Lester SC. Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010.
    2. Delahunt B, Charles A, Clouston D, Delprado W, O'Donnell A, Eade T, Kench J, Lau H and Samaratunga H. Renal malignancy (renal cell cancer) structured reporting protocol, The Royal College of Pathologists of Australasia, Surry Hills, NSW, 2011.
    3. Eble JN. Recommendations for examining and reporting tumor-bearing kidney specimens from adults. Semin Diagn Pathol 1998;15(1):77-82.
    4. Rabban JT, Meng MV, Yeh B, Koppie T, Ferrell L and Stoller ML. Kidney morcellation in laparoscopic nephrectomy for tumor: recommendations for specimen sampling and pathologic tumor staging. Am J Surg Pathol 2001;25(9):1158-1166.
    5. Trpkov K, Grignon DJ, Bonsib SM, Amin MB, Billis A, Lopez-Beltran A, et al. Handling and Staging of Renal Cell Carcinoma: The International Society of Urological Pathology Consensus (ISUP) Conference Recommendations. Am J Surg Pathol 2013;37(10): 1505-17.
    6. Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL and Trotti A (eds). AJCC Cancer Staging Manual, Springer, New York, NY, 2010.
    7. Bonsib SM. Renal veins and venous extension in clear cell renal cell carcinoma. Mod Pathol 2007;20(1):44-53.
    8. Delahunt B, Kittelson JM, McCredie MR, Reeve AE, Stewart JH and Bilous AM. Prognostic importance of tumor size for localized conventional (clear cell) renal cell carcinoma: assessment of TNM T1 and T2 tumor categories and comparison with other prognostic parameters. Cancer 2002;94(3):658-664.
    9. Eble JN, Sauter G, Epstein JI and Sesterhenn IA (eds). World Health Organization Classification of Tumours. Pathology and Genetics of Tumours of the Urinary System and Male Genital Organs, IARC Press, Lyon, 2004.
    10. Harnden P and Hancock B. Dataset Adult Renal Parenchymal Cancer Histopathology Reports, The Royal College of Pathologists, London, 2006.

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      Kidney parenchymal tumour 1

      Kidney with haemorrhagic yellow tumour typical of clear cell RCC

      Kidney parenchymal tumour 2

      Kidney parenchymal tumour close-up

      Kidney parenchymal tumour 3

      Left kidney, coronal section (posterior view of anterior half)

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      25-Mar-2019
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