Should hilar lymph nodes be expected in radical nephrectomy specimens?

Area of Science:

• Urologic Oncology
• Pathology
• Surgical Staging

Background:

• Lymph node (LN) status is critical for staging renal cell carcinoma (RCC) and pelvic urothelial carcinoma (PUC).
• Accurate assessment of regional LN involvement in radical nephrectomies (RNs) is influenced by surgical extent and gross examination.
• The hilar fat region (HFR) is a key area for potential LN metastasis in RNs.

Purpose of the Study:

• To evaluate the presence and diagnostic yield of hilar lymph nodes (LNs) in radical nephrectomies (RNs).
• To compare the efficacy of standard gross examination protocol (SGEP) versus total submission protocol (TSP) of the hilar fat region (HFR) for LN identification.
• To determine if SGEP is sufficient for accurate staging of RCC and PUC regarding hilar LNs.

Main Methods:

• Fifty consecutive RNs were prospectively analyzed.
• Hilar fat regions (HFRs) were initially examined using a standard gross examination protocol (SGEP).
• Subsequently, the entire HFR was submitted for microscopic evaluation (ME) under the total submission protocol (TSP) for comparison.

Main Results:

• Lymph nodes (LNs) were identified in only 20% of RNs, irrespective of the examination protocol.
• Nodal metastases were detected in 8% of cases, all identified by the standard gross examination protocol (SGEP).
• The total submission protocol (TSP) identified additional minute negative LNs in 6% of cases, not impacting staging accuracy.

Conclusions:

• Hilar lymph nodes (LNs) are infrequently present in radical nephrectomies (RNs).
• The standard gross examination protocol (SGEP) is adequate for identifying clinically significant hilar LNs in RNs for staging purposes.
• Complete microscopic evaluation of the hilar fat region (HFR) does not significantly alter staging outcomes for renal cell carcinoma (RCC) and pelvic urothelial carcinoma (PUC).