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    Retroperitoneal lymph node resection for germ cell tumours

    Background

    Retroperitoneal lymph node lymph node dissection (RPLND) is usually performed in the setting of non seminomatous germ cell tumour. In the United states, approximately 70% of these patients will present at a low clinical stage (I, IIA or IIB) and may benefit or even be cured with RPLND or chemotherapy and RPLND is preferred over chemotherapy in some centres for patients with a NSGCT because of the long term morbidity of RPLND and infield retroperitoneal relapse is less than induction chemotherapy1,2,3.


    Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

    • No
      • Non-routine fixation (not formalin), describe.
    • Yes
      • Special studies required, describe.
      • Ensure samples are taken prior to fixation.2
    • Not performed
    • Performed, describe type and result
      • Frozen section
      • Imprints

    Inspect the specimen and dictate a macroscopic description.


    External Inspection

    Describe the following features of the specimen:

    Pre operative therapy

    • None
    • Chemo/radiotherapy
    • Not known

    Procedure

    Record as described by the clinician.

    • Retroperitoneal lymphadenectomy
      • Bilateral (radical)
      • Unilateral
    • Other, describe

    Specimen side/site and lymph node groups included

    • Left
      • Lymph node groups included
        • Not stated
        • List as stated (Sites may include preaortic, paraaortic, retroaortic, or other lymph nodes)
    • Right
      • Lymph node groups included
        • Not stated
        • List as stated (Sites may include precaval, paracaval, retrocaval, interaortocaval regions and iliac region)
    • Other, describe

    Specimen description

    • Orientation marker
      • No
      • Yes, describe
    • Entire specimen size in three dimensions (mm)1

    Dissection

    Fix overnight in 10% neutral buffered formalin, after this Carnoy’s fixative can be used to clear the fat and make lymph nodes easier to see.


    Paint the specimen with ink according to your departmental protocol

    This specimen may be received separated into clearly designated lymph node groups by the surgeon or it may be received as one specimen. If it is received as one specimen it will usually be orientated by the surgeon who will identify the upper and lower borders and the periaortic and pericaval regions and consultation with the relevant departmental pathologist is recommended before sectioning the specimen.

    Specimens should be examined methodically to maximise lymph node yield and ensure lymph nodes in each anatomical group are recorded correctly.

    Each lymph node must be blocked, examined and recorded in such a way so as to enable accurate measurement of lymph node numbers and involvement at microscopic examination. This is usually achieved by slicing of the entire specimen into 5mm intervals and carefully examining for lymph nodes by inspection and palpation.

    Small lymph nodes, <3mm in maximum dimension, usually will not require dissection and can be submitted whole.

    Lymph nodes >3 mm, serially section at 3mm intervals, looking for grossly identifiable deposits

    In most cases the specimen will be received after chemotherapy and therefore comprehensive sampling is essential for any residual mass because even a small amount of tumour or a different tumour subtype can affect patient management. Correlation with post treatment serological tumour markers may be helpful in determining whether the specimen has been adequately sampled.

    As a guide one section per centimetre of maximum tumour diameter is recommended4. Any sampling must include macroscopically different looking areas e.g. solid,cystic, haemorrhagic or frankly teratomatous areas. If the mass is largely necrotic, sampling from the edge of lymph node capsule may harbour residual viable tumour cells.

    Macroscopically involved lymph nodes/tumour masses may be bisected along the median plane to demonstrate the relationship of tumour to the capsule and surgical margin. Where extracapsular extension is apparent or suspected, lines of dissection should extend through adjacent tissues to allow microscopic evaluation of extracapsular invasion and involvement of the surgical margin if applicable.

    The lymph node or tumour closest to the surgical margin should be so identified and sampled. If extranodal tumour is close to the surgical soft tissue margin, the margin may be painted with ink. If oriented specify the margin.

    The description of any macroscopically involved lymph nodes should include the location of the lymph node/mass if the specimen is orientated. If there is doubt about which group of lymph nodes an involved lymph node belongs to consultation with the surgeon through the pathologist in charge should be considered.

    Left and right RPLND may include the following lymph node groups.

    Left sided resection includes the preaortic artery up to the inferior mesenteric artery, with the para-aortic and retroaortic areas with the ureteral crossing of the iliac artery representing the caudal and the lateral boundaries of dissection, respectively.

    Right sided resection includes the precaval, paracaval, retrocaval, interaortocaval regions and the area lateral to the common iliac vessels with the crossing of the ureter as caudal boundary and the ureter serving as lateral boundary of dissection. The renal vein represents the cranial boundary of dissection except in those patients demonstrating retrocrural or suprahilar lymph-node involvement. In these patients the crura of the diaphragm represents the cranial border of dissection5.


    Internal Inspection

    • Number of lymph nodes
    • Largest macroscopically-involved lymph node and/or matted tumour mass
      • Maximum dimension
      • Nodal location
        • Not known
        • Para-aortic, paracaval etc
      • Tumour description
        • Viable tumour macroscopically present
          • Present estimate %
          • absent
        • Necrosis
          • Absent
          • Present estimate % occupying cut surface
        • Cystic
        • Haemorrhagic
        • Bone/fat/skin other teratomatous elements
          • Absent
          • Present, describe
    • Macroscopic extranodal tumour
      • Absent
      • Present, describe
      • Distance from closest resection margin (mm)
      • Infiltration of vessels, nerves, skeletal muscle or other adjacent structures

    Processing

    Dissect the specimen further and submit sections for processing as follows:


    • Sample all lymph nodes present
    • >3 mm in max. dimension should be serially sectioned and submitted in their entirety, preferably one node in each cassette. Lymph nodes <3mm in max. dimension can be submitted whole and more than one can be included in each cassette.
    • Submit representative sections from tumour/nodal masses focussing on viable tumour and macroscopically heterogenous areas. At least one section per centimetre of the maximum tumour diameter is recommended
    • Submit sections demonstrating areas of extranodal spread
    • Submit sections of tumour to the closest surgical margin

    Record details of each cassette.

    Block allocation key

    Cassette id
    Site
    No. of pieces
    A-C
    Left suprahilar lymph nodes, 6 in each cassette
     
    D-E
    Pre-aortic lymph nodes , 3 in each cassette
     
    F-H
    Retro-aortic lymph nodes, 1 bisected in each cassette
     
    Cassette id Site No. of pieces
    I-M Right suprahilar lymph nodes 1 bisected in each  
    N-S Precaval lymph node mass, 2 rep in each cassette S, section with extranodal spread and closest distance to margin  
    T Paracaval lymph nodes, 6  
    U Retrocaval lymph nodes, 5  
    V Interaortocaval lymph nodes, 4  
    W Right common iliac lymph nodes, 3  

     


    References

    1. Jemal A, Tiwari R, Murray T, et al. Cancer Statistics , 2004. CA Cancer J Clin. 2004. doi:10.3322/canjclin.54.1.8
    2. Donohue JP, Thornhill JA, Foster RS, Rowland RG, Bihrle R. Clinical stage B non-seminomatous germ cell testis cancer: the Indiana University experience (1965-1989) using routine primary retroperitoneal lymph node dissection. Eur J Cancer. 1995.
    3. Horwich A, Norman A, Fisher C, Hendry WF, Nicholls J, Dearnaley DP. Primary chemotherapy for stage II nonseminomatous germ cell tumors of the testis. J Urol. 1994.
    4. Satish K. Tickoo MD*, Ming Zhou MD PhD*, Mahul B. Amin MD, Sam S. Chang MD PAHMP, James McKiernan MD, Victor E. Reuter MD, John R. Srigley MD TMUM. Protocol for the Examination of Specimens from Patients with Malignant Germ Cell and Sex Cord-Stromal Tumors of the Testis, College of American Pathologists. Published 2017. Accessed March 14, 2018.
    5. Heidenreich A, Pfister D, Witthuhn R, Thüer D, Albers P. Postchemotherapy Retroperitoneal Lymph Node Dissection in Advanced Testicular Cancer: Radical or Modified Template Resection. Eur Urol. 2009. doi:10.1016/j.eururo.2008.09.027

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      26-Apr-2019
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