Intraoperative Consultation for Renal Masses: Challenges and Implications for Treatment

Chapter

Abstract

Intraoperative pathologic consultation provides critical information that determines immediate diagnostic decision making for optimal patient care. Frequent indications for intraoperative consultation during kidney surgery include assessment of renal masses, surgical margin status during partial or radical nephrectomy, and extrarenal masses/lymph nodes. Only gross examination of renal masses during radical nephrectomy may suffice unless the macroscopic findings are equivocal. Nonetheless, it is particularly important to distinguish between benign versus malignant conditions and renal cell carcinoma versus urothelial carcinoma. The intraoperative diagnosis may result in changes in the surgical procedure, for instance, partial nephrectomy for benign conditions, radical nephrectomy for renal cell carcinomas, and nephroureterectomy for urothelial carcinoma. For the assessment of surgical margins of partial nephrectomy specimens, the pathologist should be aware that normal proximal renal tubules may mimic an oncocytoma with a tubular growth pattern and that distorted renal tubules at the periphery of the tumor can be mistaken as a low-grade renal cell carcinoma. Other common pitfalls in the frozen section diagnosis include various types of artifacts such as thermal injury, crush artifact, and freeze artifact. Recognizing these artifacts, reviewing clinical and imaging finding as well as previous biopsy material if available prior to the intraoperative consultation is always helpful for adequate interpretation of the specimens.

Keywords

Cystic renal mass Frozen section assessment Lymph node dissection Lymph node metastasis Nephroureterectomy Partial nephrectomy Radical nephrectomy Renal cell carcinoma Surgical margin Urothelial carcinoma 

References

  1. 1.
    Israel GM, Bosniak MA. How I do it: evaluating renal masses. Radiology. 2005;236(2):441–50.CrossRefPubMedGoogle Scholar
  2. 2.
    Joniau S, Vander Eeckt K, Van Poppel H. The indications for partial nephrectomy in the treatment of renal cell carcinoma. Nat Clin Pract Urol. 2006;3(4):198–205.CrossRefPubMedGoogle Scholar
  3. 3.
    Crépel M, Jeldres C, Perrotte P, Capitanio U, Isbarn H, Shariat SF, Liberman D, Sun M, Lughezzani G, Arjane P, Widmer H, Graefen M, Montorsi F, Patard JJ, Karakiewicz PI. Nephron-sparing surgery is equally effective to radical nephrectomy for T1BN0M0 renal cell carcinoma: a population-based assessment. Urology. 2010;75(2):271–5.CrossRefPubMedGoogle Scholar
  4. 4.
    Patard JJ, Shvarts O, Lam JS, Pantuck AJ, Kim HL, Ficarra V, Cindolo L, Han KR, De La Taille A, Tostain J, Artibani W, Abbou CC, Lobel B, Chopin DK, Figlin RA, Mulders PF, Belldegrun AS. Safety and efficacy of partial nephrectomy for all T1 tumors based on an international multicenter experience. J Urol. 2004;171(6):2181–5.CrossRefPubMedGoogle Scholar
  5. 5.
    Yossepowitch O, Thompson RH, Leibovich BC, Eggener SE, Pettus JA, Kwon ED, Herr HW, Blute ML, Russo P. Positive surgical margins at partial nephrectomy: predictors and oncological outcomes. J Urol. 2008;179(6):2158–63.CrossRefPubMedCentralPubMedGoogle Scholar
  6. 6.
    Bensalah K, Pantuck AJ, Rioux-Leclercq N, Thuret R, Montorsi F, Karakiewicz PI, Mottet N, Zini L, Bertini R, Salomon L, Villers A, Soulie M, Bellec L, Rischmann P, De la Taille A, Avakian R, Crepel M, Ferriere JM, Bernhard JC, Dujardin T, Pouliot F, Rigaud J, Pfister C, Albouy B, Guy L, Joniau S, vanPoppel H, Lebret T, Culty T, Saint F, Zisman A, Raz O, Lang H, Spie R, Wille A, Roigas J, Aguilera A, Rambeaud B, Martinez PL, Nativ O, Farfara R, Richard F, Roupret M, Doehn C, Bastian PJ, Muller SC, Tostain J, Belldegrun AS, Patard JJ. Positive surgical margin appears to have negligible impact on survival of renal cell carcinomas treated by nephron-sparing surgery. Eur Urol. 2010;57(3):466–71.CrossRefPubMedGoogle Scholar
  7. 7.
    Venigalla S, Wu G, Miyamoto H. The impact of frozen section analysis during partial nephrectomy on surgical margin status and tumor recurrence: a clinicopathologic study of 433 cases. Clin Genitourin Cancer. 2013;11(4):527–36.CrossRefPubMedGoogle Scholar
  8. 8.
    Perez-Montiel D, Wakely PE Jr., Hes O, Michal M, Suster S. High-grade urothelial carcinoma of the renal pelvis: clinicopathologic study of 108 cases with emphasis on unusual morphologic variants. Mod Pathol. 2006;19(4):494–503.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Departments of Pathology and UrologyThe Johns Hopkins Medical InstitutionsBaltimoreUSA
  2. 2.Department of Pathology and Genomic MedicineHouston Methodist HospitalHoustonUSA

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