ESTADIFICACIÓN Y MANEJO DE LA NEFRECTOMÍA EN CARCINOMA RENAL XXX Congreso de la Sociedad Latinoamericana de Patología Santa Cruz de La Sierra, Bolivia, 2015 DR. ROBERTO OROZCO DEPARTAMENTO DE PATOLOGÍA, HOSPITAL GENERAL SAN JUAN DE DIOS, GUATEMALA Agradezco la oportunidad que nos han brindado de participar en este congreso, especialmente al Dr. Martín Sangueza, presidente del comité organizador, y a la Dra. Laura Jufe, coordinadora del programa de uropatología. Esta charla sobre el qué hacer del residente de patología o del patólogo luego de recibir una pieza quirúrgica de nepfrectomía por carcinoma renal. Nos recuerda que la estadificación patológica del carcinoma de células renales y el manejo de la pieza quirúrgica están intimamente relacionados y son de primordial importancia para el diagnóstico histológico, pronóstico y manejo del paciente.

Handling and Staging of Renal Cell Carcinoma The International Society of Urological Pathology Consensus (ISUP) Conference Recommendations Kiril Trpkov, MD, FRCPC, David J. Grignon, MD, FRCPC, Stephen M. Bonsib, MD, Mahul B. Amin, MD, Athanase Billis, MD, Antonio Lopez-Beltran, MD, Hemamali Samaratunga, MD, FRCPA, Pheroze Tamboli, MD, Brett Delahunt, MD, FRCPA, Lars Egevad, MD, PhD, Rodolfo Montironi, MD, FRCPath, John R. Srigley, MD, FRCPC, and the members of the ISUP Renal Tumor Panel Am J Surg Pathol 2013;37:1505–1517 La charla está basada en las recomendaciones expresadas en este artículo, producto de la conferencia de consenso sobre cáncer renal de la Sociedad Internacional de patología urológica celebrada en Vancouver en el 2012. Estos autores fueron los integrantes del grupo de trabajo 3, encargado de este tema, algunos de ellos nos honran con su presencia en este salón. Las recomendaciones para la estadificación del carcinoma renal y el manejo de la nefrectomía por carcinoma renal, pueden ser implementadas en cualquier laboratorio de anatomopatología, pues no requieren de tecnología alguna.

The International Society of Urologic Pathology 2012 Consensus Conference on Renal Cancer El año anterior a la conferencia, se envía una encuesta via internet. Consenso se obtuvo cuando la misma respuesta fue escogida por el 65% de los participantes. La ISUP ha venido consensuando la práctica de la uropatología por mas de 20 años.

The Seventh Edition of the TNM Staging System of the American Joint Commission on Cancer/International Union Against Cancer (AJCC/UICC) introduced several changes T2: Tumor >7cm in greatest dimension, limited to the kidney T2a Tumor >7cm but < -10 cm, limited to the kidney T2b Tumor >10cm, limited to the kidney T3: Tumor extends into major veins or perinephric tissues but not into the ipsilateral adrenal gland and not beyond the Gerota fascia T3a Tumor grossly extends into the renal vein or its segmental (muscle-containing) branches, or tumor invades perirenal and/or renal sinus fat but not beyond the Gerota fascia T3b Tumor grossly extends into the vena cava below the diaphragm T3c Tumor grossly extends into the vena cava above the diaphragm or invades the wall of the vena cava T4 Tumor invades beyond the Gerota fascia Contiguous extension into the ipsilateral adrenal gland Y ha venido proponiendo cambios a organizaciones con mayor influencia. Por ejemplo, estos cambios resaltados, han sido incorporados gracias a la participación de la sociedad.

Pathology and Why It is So Damn Important! How Does the Pathology Report Help Direct my Treatment Options? Lecture by Dr. Daniel Luthringer of Cedars Sinai Medical Center of Los Angeles at Kidney Cancer Association meeting December 2013.

El estadio es el factor pronóstico mas importante en carcinoma renal Información clínica indispensable Realizar un examen macroscópico cuidadoso Muestreo adecuado Informe de parámetros importantes

503-A2 If the specimen is a radical nephrectomy specimen, inspect the external aspect of the specimen (Gerota fascia) for evidence of tumor. Locate the ureteral and vascular margins in the renal hilus. El espécimen debe ser midado y pesado en su conjunto. Cada componente del especimen debe ser evaluado y descrito, empezando por la superficie. Cytogenetic data have clarified the morphologic features of some of these tumors

FIGURE 1. The preferred method to make the initial section in radical nephrectomy specimens is along the long axis. Kidney opened through the collecting system is illustrated.

EXAMEN MACROSCÓPICO The renal capsule and the perinephric fat should not be stripped from the kidney until after their relationships to the tumor are established Anatomically orient the specimen

Invasión al tejido adipose peri-renal 1587-3 The International Society of Urologic Pathology 2012 Consensus Conference on renal cancer, through working group 3, focused on the issues of staging and specimen handling of renal tumors. The conference was preceded by an online surveyof the International Society of Urologic Pathology members, and the results of this were used to inform the focus of conference discussion. On formal voting a Z65% majority was considered a consensus agreement. In radical nephrectomy specimens the initial cut is made along the long axis (93.2%)

The International Society of Urologic Pathology 2012 Consensus Conference on renal cancer, through working group 3, focused on the issues of staging and specimen handling of renal tumors. The conference was preceded by an online surveyof the International Society of Urologic Pathology members, and the results of this were used to inform the focus of conference discussion. On formal voting a Z65% majority was considered a consensus agreement. In radical nephrectomy specimens the initial cut is made along the long axis (93.2%)

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NEFRECTOMÍA RADICAL El corte inicial debe hacerse a lo largo del eje renal (93.2%) The International Society of Urologic Pathology 2012 Consensus Conference on renal cancer, through working group 3, focused on the issues of staging and specimen handling of renal tumors. The conference was preceded by an online surveyof the International Society of Urologic Pathology members, and the results of this were used to inform the focus of conference discussion. On formal voting a Z65% majority was considered a consensus agreement. In radical nephrectomy specimens the initial cut is made along the long axis (93.2%)

Una muestra por cm – mínimo de 3 bloques (96.5%) The International Society of Urologic Pathology 2012 Consensus Conference on renal cancer, through working group 3, focused on the issues of staging and specimen handling of renal tumors. The conference was preceded by an online surveyof the International Society of Urologic Pathology members, and the results of this were used to inform the focus of conference discussion. On formal voting a Z65% majority was considered a consensus agreement. In radical nephrectomy specimens the initial cut is made along the long axis (93.2%)

Nefrectomía radical En casos de múltiples tumors: - tomar muestras de los 5 mas grandes (89.9%) There have been significant changes in the staging, classification and grading of renal cell neoplasia in recent times. Major changes have occurred in our understanding of extra-renal extension by renal cell cancer and how gross specimens must be handled to optimally display extra-renal spread. 90% of clear cell renal cell carcinoma (RCC)   ≥ 7cm in diameter to have invaded the renal sinus Appropriate handling is clearly the first step toward accurate diagnosis and staging of RCC that margin involvement should be assessed by inking suspicious areas, the perinephric fat margin and hilum of radical nephrectomy specimens or the renal parenchymal resection margin and perinephric margin of partial nephrectomy specimens. The International Society of Urologic Pathology 2012 Consensus Conference on renal cancer, through working group 3, focused on the issues of staging and specimen handling of renal tumors. The conference was preceded by an online surveyof the International Society of Urologic Pathology members, and the results of this were used to inform the focus of conference discussion. On formal voting a Z65% majority was considered a consensus agreement. In radical nephrectomy specimens the initial cut is made along the long axis (93.2%)

EXAMEN MACROSCÓPICO CUIDADOSO DE LA PIEZA RENAL CON CARCINOMA (Nefrectomía parcial)

Nefrectomía Parcial El corte inicial debe hacerse a lo largo del eje renal (93.2%) The International Society of Urologic Pathology 2012 Consensus Conference on renal cancer, through working group 3, focused on the issues of staging and specimen handling of renal tumors. The conference was preceded by an online surveyof the International Society of Urologic Pathology members, and the results of this were used to inform the focus of conference discussion. On formal voting a Z65% majority was considered a consensus agreement. In radical nephrectomy specimens the initial cut is made along the long axis (93.2%) ink the renal parenchymal resection margin and “bread loaf” the tumor perpendicular to the inked surface.

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Margen positivo de la vena renal Únicamente cuando hay invasión (adherencia) microscopicamente del tumor al verdadero margen

Muestras del tejido renal sin neoplasia normal parenchyma with tumor normal parenchyma distant from the tumor

Búsqueda de ganglios linfáticos dissection/palpation of the fat in the hilar area only

Invasión al tejido adipose peri-renal Tumor invade o por lo menos hace contacto con el tejido adiposo peri-renal

Invasión al seno renal The tumor is in direct contact with the sinus fat The tumor is in contacta wint the loose connective tissue of the sinus, clearly beyond the renal parenchyma Involvement of any endothelium-lined spaces within the renal sinus, regardless of the size. at least 3 blocks of the tumor-renal sinus interface should be submitted

Initial sectioning and inking of renal specimens In radical nephrectomy specimens the initial cut is made along the long axis (93.2%) Ink should be used in radical nephrectomies (87.2%) Ink should be used in partial nephrectomies (94.6%)

Renal tumor measurement When measuring a renal tumor, the length of a renal vein/caval thrombus should not be part of the main tumor mass measurement (90.9%)

Number of blocks for tumor sampling Sampling of renal tumors should follow a general guideline of sampling 1 block/cm with a minimum of 3 blocks (subject to modification as needed in individual cases) (96.5%)

Assessment of perinephric fat invasion Perinephric fat invasion is determined by examining multiple perpendicular sections of the tumor/perinephric fat interface and, if present, by sampling the areas suspicious for invasion (79.2%) Perinephric fat invasion requires either tumor touching fat or extending as irregular tongues into the perinephric tissue (with or without desmoplasia) (70.9%)

Assessment of renal sinus fat invasion Our prosectors (or I, if I do the dissection) are very familiar with the renal sinus anatomy (77.5%) When invasion of the renal sinus is uncertain at least 3 blocks of the tumor-renal sinus interface should be submitted. If invasion is grossly evident, or obviously not present (small peripheral tumor) only 1 block is needed to confirm the gross impression (97.5%) Renal sinus invasion is present when the tumor is in direct contact with the sinus fat (100%) Renal sinus invasion is present when the tumor is in direct contact with the loose connective tissue clearly beyond the renal parenchyma (74.7%) For staging purposes, renal sinus invasion (pT3a) is present when the sections show involvement of any endothelium-lined spaces within the renal sinus regardless of the size (90.3%)

INITIAL SECTIONING AND INKING OF RENAL SPECIMENS The goal of specimen dissection is to achieve proper fixation before or after sampling and to allow gross evaluation extrarenal invasion into the perinephric fat, renal sinus, renal vein, and adrenal gland. initial section into radical nephrectomy specimens along the long axis (93%) (Fig. 1).

The International Society of Urologic Pathology 2012 Consensus Conference on renal cancer, through working group 3, focused on the issues of staging and specimen handling of renal tumors. The conference was preceded by an online surveyof the International Society of Urologic Pathology members, and the results of this were used to inform the focus of conference discussion. On formal voting a Z65% majority was considered a consensus agreement. In radical nephrectomy specimens the initial cut is made along the long axis (93.2%)