Head and Neck Pathology Grossing GuidelinesDo not cut any HN specimens unless you are fully oriented anatomically

LIP AND ORAL CAVITY

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:

o Show relationship to peripheral/deep marginso Show maximum depth of invasion

Specimens containing mandible or maxilla:o Bone marginso Sections of bone adjacent to tumor or gross involvement of bone

Diagrams and gross photos are appreciated

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 mucosa is 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].

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

If specimen is received oriented please consult with PA/attending Submit all lymph nodes

o 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:o Describe size of metastatic focus (staging cutoffs: 3 cm, 6 cm) and if

extranodal extension is present grossly

o Sections to submit: Small nodes, submit entirely 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 rep of submandibular gland (more if involved by tumor; make sure to breadloaf)

One rep of muscle and vein (more if involved)

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

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 GLANDSpecimen Type: SALIVARY GLAND RESECTION (partial/total)

Neoplastic:

Ink surface and bread loaf (If unoriented, one color; if oriented, ink to maintain orientation)

Document size (please 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: rep sections; 1 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

THYROIDSpecimen Type: THYROIDECTOMY (hemi/total)

General:

Weigh (fresh), orient, and measure Examine for defects on surface

Ink: anterior blue, posterior black, orange isthmic margin Check clinical record for location of suspected lesions (imaging/FNA)

o 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

o Size (staging size cutoffs: 1 cm, 2 cm, 4 cm)o Number, location, characteristics (color, consistency, hemorrhage, necrosis,

fibrosis, calcs) of noduleso Encapsulation of noduleso Distance to marginso Remaining parenchymao Designate specific nodules into specific blocks

Sampling depends on the case:

Single/dominant encapsulated nodule : o Submit entire capsule of nodule and include nearest inked marginso If nodule is very large, can refrain from submitting center of lesiono Submit representative uninvolved thyroid tissue

Single/dominant unencapsulated nodule (often papillary ca) : o If small, submit entire lesiono If >2 cm, can submit representative 1/cm; lesion to margino Submit representative uninvolved thyroid tissueo For medullary ca, in addition to lesion, submit middle 1/3 of both lobes

Multinodular goiter: o 1 cassette per 1 cm of the greatest dimension of the thyroido Focus on suspicious areas (solid, sclerotic, hemorrhagic)

Multiple small unencapsulated nodules :o Submit representative sections of each nodule and note distances to one

another and marginso Focus on largest and suspicious nodules

Unremarkable gland/homogenous, diffusely enlarged : (including Graves and Hashimoto)

o 3 blocks per lobe (upper, mid, lower) and isthmus (7 for total thyroid)

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].

LARNYXSpecimen 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 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(s)/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)-gl ottic : (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

Sections of larynx include: Inferior tracheal ring (margin) Closest mucosal and soft tissue margins

Lesions (to include deepest invasion); if no gross lesion, block out ulcerated area and entirely submit

Base of tongue Epiglottis R/L aryepiglottic folds and piriform sinuses R/L true/false cords to include ventricle and anterior commissure R/L arytenoids Hyoid, closest to tumor If thyroid or cricoid cartilages are involved in tumor, this should be submitted Thyroid (1 block is fine if uninvolved); be sure to serially section; and

tracheostomy site if present

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

Specimen Type: HEMILARYNGECTOMYProcedure:

Fix the specimen for at least 2-4 hourso 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: 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 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 tumorPARATHYROIDSpecimen Type: PARATHYROIDECTOMY

Weigh and submit entirely

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