Intraoperative Consultation for Renal Masses: Challenges and Implications for Treatment
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.
KeywordsCystic renal mass Frozen section assessment Lymph node dissection Lymph node metastasis Nephroureterectomy Partial nephrectomy Radical nephrectomy Renal cell carcinoma Surgical margin Urothelial carcinoma
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