Should hilar lymph nodes be expected in radical nephrectomy specimens?

Lymph node (LN) status is essential in staging both renal cell carcinoma (RCC) and pelvic urothelial carcinoma (PUC). The rate of regional LN involvement is influenced by pathologic tumor stage, extent of the surgical resection, and accuracy of pathologic gross examination. In this study, we assess the presence of hilar LNs in radical nephrectomies (RN) by entirely submitting the hilar fat region (HFR) for microscopic evaluation (ME). Fifty consecutive RNs from 2006 to 2008 were evaluated by a standard gross examination protocol (SGEP) which consisted of palpation and sectioning of the HFR with submission of grossly identified LNs. Subsequently, the entire HFR was re-evaluated and submitted as study's total submission protocol (TSP). The number and disease status of hilar LNs identified by the SGEP and TSP were compared. Fifty RNs (37 clear cell RCC, 6 papillary RCC, 7 PUC) were studied prospectively. Ten of the 50 RNs had LNs identified (20%) with both protocols. Four of the 50 RNs had nodal metastases (8%) with the LN sizes ranging between 1.3 and 2.5 cm (mean 1.8 cm). All nodal metastases were identified by the SGEP. In three RNs (6%), additional minute (mean 0.12 cm) negative LNs not seen by the SGEP were identified by the TSP. LNs are present in only 20% of RNs, even after complete ME of the HFR. The SGEP for identifying hilar LNs in RNs is sufficient for staging and did not lead to underreporting of LN metastases.