Head and Neck Pathology Grossing Guidelines

Head and Neck Pathology Grossing Guidelines

Do not cut any HN specimens unless you are fully oriented anatomically

Orient by anatomic structures (oral tongue, junction of buccal/gingival mucosa, alveolar ridge, angle of jaw, hard palate, etc)
For mandibulectomies/maxillectomies, please ask for help if unsure
Ink resection margins
Describe all abnormalities: size (staging cutoffs: 2 cm, 4 cm), location, extent, depth (staging cutoffs: 0.5 cm, 1 cm), distance to margins
Sample all margins (if grossly close, e.g. 1 cm, submit perpendicular section; otherwise submit a shave of the margin closest to tumor)
Sample tumor:
Show relationship to peripheral/deep margins
Show maximum depth of invasion
Specimens containing mandible or maxilla:
Bone margins
Sections of bone adjacent to tumor or gross involvement of bone
Diagrams and gross photos are appreciated

TONGUE

Specimen Type: GLOSSECTOMY (total/partial)

Gross Template:

Labeled with the patient’s name (last name, first name), medical record number (#), designated “***”, and received [fresh/in formalin] is a [partial/total] glossectomy measuring ***x***x*** cm. [Describe orientation provided]. The mucosais remarkable for [describe lesion – location, size, distance from margins]. Sectioning reveals the lesion has a [describe cut surface of lesion] and***cm maximum thickness. The lesion measures ***cm from the deep resection margin [indicate extent of lesion].

The remaining mucosal surface is [smooth, pink, glistening, unremarkable]. Representative sections are submitted [describe cassette submission].

Cassette Submission: 8-10 cassettes

-Sample all margins

-One cassette per 1 cm of lesion

Show maximum depth of invasion
Show relationship to peripheral/deep margins

-One cassette of unremarkable tissue

LYMPH NODES

Specimen Type:RADICAL NECK DISSECTION (standard, modified, extended, regional)

If specimen is received oriented please consult with PA/attending
Submit all lymph nodes
If the remainder of the specimen can be submitted in less than 5 cassettes, submit entirely. If not, submit 5 cassettes of fat.
For grossly positive nodes:
Describe size of metastatic focus (staging cutoffs: 3 cm, 6 cm) and if extranodal extension is present grossly

Gross Template:

Labeled with the patient’s name (last name, first name), medical record number (#), designated “***”, and received [fresh/in formalin] is a [standard, modified, extended, regional] neck dissection measuring ***x***x*** cm. The dissection consists of [describe tissue/glands/vasculature present]. [Describe orientation provided]. Sectioning reveals [describe number/size of lymph nodes identified]. The salivary gland is sectioned to reveal [describe cut surfaces]. The muscle is sectioned to reveal [describe cut surface]. The internal jugular vein is opened to reveal [describe contents – noting thrombosis and relation to tumor]. Representative sections are submitted [describe cassette submission].

Cassette Submission: 12-15 cassettes

-Submit all lymph nodes identified (separated into levels if applicable)

If the remainder of the specimen can be submitted in less than 5 cassettes, submit entirely. If not, submit 5 cassettes of fat.

-Large nodes (including matted nodes), 1/cm including one full cross section, to include largest focus of tumor and suspicious areas for extranodal extension

-One representative section of submandibular gland (submit more if involved by tumor; make sure to section)

-One cassette of muscle and vein (submit more if involved by tumor)

-Note: If patient has malignant tumor of the head region, for example malignant melanoma, squamous cell carcinoma or angiosarcoma of the scalp, the tail or superficial lobe of the parotid gland may be removed. The specimen should be sectioned for peri- and intraparotid lymph node. Submit appropriate sections.

SALIVARY GLAND

Specimen Type: SALIVARY GLAND RESECTION (partial/total)

Neoplastic:

Ink surface and bread loaf

-If un-oriented ink one color

-If oriented, ink to maintain orientation

Document size (see salivary gland CAP protocol for staging size cutoffs) describe lesion, location

Small tumors (3 cm or less): submit entirely
Large tumors should be sampled to demonstrate tumor type, margins, involvement of contiguous structures
Look for areas of necrosis, hemorrhage, invasive, and sclerotic areas and submit if present
Look for and submit lymph nodes
Section of uninvolved gland

Non-neoplastic:

Small specimens (less than 10 cassettes): submit entirely
Large specimens: representativesections

-One section is adequate for incidental removal of gland (and no gross lesions)

Look for lymph nodes and submit

Gross Template:

Labeled with the patient’s name (last name, first name), medical record number (#), designated “***”, and received [fresh/in formalin] is an [intact/disrupted] *** gram, *** x *** x *** cm salivary gland. Sectioning reveals [describe lesions including size, number color, consistency, involvement of nerve trunks, relationship to remainder of gland and capsule, relationship to resection margin]. The remaining parenchyma is [tan, lobulated, fibrotic]. [Describe size/number of lymph nodes identified]. Representative sections are submitted [describe cassette submission].

Ink key:Black-external surface

TONSILS and ADENOIDS

Specimen Type: TONSILLECTOMY/ ADENOIDECTOMY

Gross Template:

Labeled with the patient’s name (last name, first name), medical record number (#), designated “***”, and received [fresh/in formalin] is a ***gram, *** x *** x *** cm [tonsillectomy/adenoidectomy]. Sectioning reveals[tan, smooth, homogenous cut surfaces with cryptic architecture]. Representative sections are submitted [describe cassette submission].

Cassette Submission: 1 cassette with representative cross section(s)

THYROID

Specimen Type: THYROIDECTOMY (hemi/total)

Procedure:

Weigh (fresh), orient, and measure
Examine for defects on surface
Comment on presence/absence of skeletal muscle
Ink: anterior blue, posterior black, orange isthmic margin
Check clinical record for location of suspected lesions (imaging/FNA)
Draw diagram with locations and sizes
Serially section from superior to inferior (keeping order in case you need to return to case and nodule/region)
Identify other structures (lymph nodes, pyramidal lobe etc)
Describe cut surfaces
Size (staging size cutoffs: 1 cm, 2 cm, 4 cm)
Number, location, characteristics (color, consistency, hemorrhage, necrosis, fibrosis, calcs) of nodules
Encapsulation of nodules
Distance to margins
Remaining parenchyma
Indicate in which cassettes the nodules are located

Gross Template:

Labeled with the patient’s name (last name, first name), medical record number (#), designated “***”, and received [fresh/in formalin] is *** gram [intact/disrupted] [hemi/total] thyroidectomy. [Describe orientation if provided] . The thyroid measures *** x *** x *** cm. The capsule is [intact, ruptured, smooth]. The specimen is serially sectioned into [#] of levels to reveal [describe any lesions present including size, color, external appearance, relationship to capsule, calcification, necrosis, relationship to uninvolved thyroid, and isthmus resection margin]. Nodule #1 is *** x *** x *** cm (encapsulated/well-circumscribed/ill defined) and measures *** cm to the anterior resection surface, *** cm to the posterior resection surface, *** cm to the isthmus resection surface, and *** to Nodule #2…

The remaining cut surface is [red-brown, smooth, unremarkable]. Representative sections are submitted [describe cassette submission].

Cassette Submission: 4-7 cassettes

Single/dominant encapsulated nodule:
Submit entire capsule of nodule and include nearest inked margins
If nodule is very large, can refrain from submitting center of lesion
Submit representative uninvolved thyroid tissue
Single/dominant unencapsulated nodule(often papillary ca):
If small, submit entire lesion
If >2 cm, can submit representative 1/cm; lesion to margin
Submit representative uninvolved thyroid tissue
For medullary carcinoma, in addition to lesion, submit middle 1/3 of both lobes
Multinodular goiter:
1 cassette per 1 cm of the greatest dimension of the thyroid
Focus on suspicious areas (solid, sclerotic, hemorrhagic)
Multiple small unencapsulated nodules:
Submit representative sections of each nodule and note distances to one another and to margins
Focus on larger and grossly suspicious nodules
Unremarkable gland/homogenous, diffusely enlarged: (including Graves and Hashimoto)
3 blocks per lobe (upper, mid, lower) and isthmus (7 for total thyroid)

PARATHYROID

Specimen Type: PARATHYROIDECTOMY

Gross Template:

Labeled with the patient’s name (last name, first name), medical record number (#), designated “***”, and received [fresh/in formalin] is *** gram, *** x *** x *** cm red-brown, semi-firm portion of tissue. The specimen is entirely submitted [describe cassette submission].

Cassette Submission: 1-2 cassettes, entirely submit

*Important to weigh parathyroid to the nearest milligram (i.e. 0.156g)

* Use appropriate scale in gross room

LARYNX

Specimen Type: BIOPSY

Gross Template:Labeled with the patient’s name (last name, first name), medical record number (#), designated “[ ]”, and received [fresh/in formalin] are multiple [color, consistency] pieces of tissue measuring [___ x ___ x ___] cm in aggregate and ranging from [___] cm to [___] cm in greatest dimension. The specimen is entirely submitted [describe cassette summary].

Cassette Submission: All tissue submitted

-Proper embedding for vertical sectioning through the mucosal surface is critical for the determination of early stromal invasion. To achieve this, instruction should be given to the histotechnologist for proper embedding. If the mucosal surface can be identified, instruct the histotechnologist to cut on edge. If the specimen is greater than 4 mm, bisect the specimen perpendicular to mucosal surface.

-Any head and neck biopsy smaller than 4 mm, request three separate slides with serial cuts up front. Subsequent recuts may lose diagnostic tissue.

Specimen Type:TOTAL LARYNGECTOMY

Procedure:

Orient specimen and determine structures present
If radical neck dissection present, remove from larynx and process as described in the manual
Note presence or absence of thyroid and hyoid bone
Identify tracheostomy site if present
Ink entire soft tissue margin
Black- right and Blue- left
Remove inferior tracheal ring, unless lesion is close and a perpendicular section would be more appropriate
Open along the posterior midline (splitting cricoid cartilage) and prop open and pin on corkboard to fix overnight
Take gross photographs and draw diagrams
Describe size/presences of lesion/ulcerations and structures they involve:

a. Indicate location of lesion

-supraglottic: (extends from the tip of epiglottis to the apex of ventricle and includes the epiglottis, aryepiglottic folds, arytenoids, false vocal cords, and the ventricle)

-glottic: (extends from the ventricle to 0.5-1.0 cm below the true vocal cord and includes the anterior and posterior commissures)

-subglottic:(extends from 1.0 cm below the true vocal cord to inferior rim of the cricoid cartilage)

-transglottic

* note if lesion crosses the midline

b. Indicate extent of lesion: document if lesion involves base of tongue, epiglottis, piriform sinus, aryepiglottic folds, arytenoid mucosa, anterior and posterior midlines, hydoid bone, thyroid, cartilage (thyroid and/or cricoid), strap muscles, and involvement of any additional tissue/organs present

Describe remainder of specimen and additional structures
Section along anterior midline and photograph cut surface
Describe maximum thickness and distance to all margins

Gross Template:

Labeled with the patient’s name (last name, first name), medical record number (#), designated “***”, and received [fresh/in formalin] is a total laryngectomy measuring ***cm (superior-inferior) x *** cm (right-left) x *** cm (anterior-posterior). The hyoid bone measures*** x *** x *** cm.The thyroid is *** x *** x *** cm. [Describe skin on anterior surface and presence of tracheostomy site].

The specimen is opened along the posterior midline to reveal a [supra-, sub-, trans- glottic] lesion [describe nature of lesion-exophytic, ulcerated, etc] located on the[indicate laterality-right, left, both, midline] measuring ***x*** cm. The lesion [crosses/does not cross] the midline. The lesion involves/does not involve the vocal cords. The lesion involves [describe extent-piriform sinus, aryepiglottic folds, cartilage, bone, thyroid, strap muscles, anterior and posterior commissure, tracheal rings, etc.]. The lesion involves/does not involve the outer cortex thyroid cartilage or tissue beyond larynx.

The remaining mucosa is [tan, smooth, unremarkable]. [Describe number/size of lymph nodes identified]. Representative sections are submitted [describe cassette submission].

Ink Key:

Black- right

Blue- left

Cassette Submission: 20-25 cassettes

- Shave inferior tracheal ring (margin)

- Closest mucosal and soft tissue margins

- Anterior and posterior commissure

- Epiglottis

- Right and left piriform sinuses and aryepiglottic folds

- Right and left true/false cords to include ventricle and anterior

commissure

- Right and left arytenoids

- Hyoid, closest to tumor

- Base of tongue

- If lesion grossly identified:

- include deepest invasion into cartilage and/or soft tissue

*submit some of the lesion without bone/cartilage to better appreciate histology without decalcification

- relationship to inked soft tissue margins

- lesion in relation to piriform sinus (if applicable)

- If no lesion grossly identified (patient may have had radiotherapy)

- block out ulcerated area and entirely submit

- Thyroid- one representative cassette, if uninvolved (serially section to

check for incidental lesions)

- Anterior skin to include tracheostomy, if present

Specimen Type:HEMILARYNGECTOMY

Procedure:

Fix the specimen for at least 2-4 hours
Specimen will consist of true and false cord and underlying cartilage
Separate the soft tissue of the entire vocal cord from the underlying cartilage
Section vertically at 2-3 mm internal to include true and false cord
Submit each level in separate cassettes, entirely and sequentially

Gross Template:

The laryngeal mucosa is remarkable for [describe any lesions including color, size, location, and extent of anatomical landmarks]. The remaining mucosa is [tan, smooth, unremarkable]. Representative sections are submitted [describe cassette submission].

Cassette Submission: 10-15 cassettes

-Submit each slice in separate cassette sequentially, to allow for proper localization of the tumor