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

ORAL CAVITY/TONGUESpecimen 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].

Cassette Submission: 8-10 cassettes

- Sample all margins - One cassette per 1 cm of lesion

o Show maximum depth of invasiono Show relationship to peripheral/deep margins

- One cassette of unremarkable tissue

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

Standard – includes cervical lymph nodes, sternomastoid muscle, internal jugular vein, spinal accessory nerve, submaxillary gland.

Modified – does not include the sternomastoid muscle, the spinal accessory nerve, or the internal jugular vein.

Extended – includes retropharyngeal, paratracheal, parotid, suboccipital, and/or upper mediastinal lymph nodes.

Regional (partial or selective) – includes only the lymph nodes of the first metastatic station.

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)

- One cassette of submandibular gland (submit more if involved by tumor)

- 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 GLANDSpecimen Type: RESECTION (partial/total)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

Cassette Submission: Non-neoplastic conditions:

- Small specimens - submit entirely.- Large specimens - representative sections are submitted. One

section is adequate for glands removed incidentally to surgical treatment of disease. Parotid salivary gland often contains lymph nodes. They should be submitted for histologic examination for unsuspected lymphoma, leukemia or other pathology.

Neoplasitc conditions:

- Small tumors can be submitted entirely.

- Large tumors should be sampled to demonstrate tumor type, margins, involvement of contiguous structures.

- Section of uninvolved gland.- Lymph nodes, if present.- Indicate margins with ink; margins are generally important in

salivary gland lesions.

TONSILS and ADENOIDSSpecimen Type: TONSILLECTOMY/ ADENOIDECTOMYGross 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)

THYMUSSpecimen Type: RESECTION (partial/total thymectomy)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] [partial/total] thymectomy. [Describe orientation if provided]. Sectioning reveals [describe any lesions present including size, color, external appearance, relationship to capsule, calcification, necrosis, relationship to uninvolved thymus]. The remaining cut surfaces are [yellow, smooth, lobulated, fatty, unremarkable]. The adherent adipose tissue is dissected through for lymph nodes. [Describe number/size of lymph nodes identified]. Representative sections are submitted [describe cassette submission].

Ink Key:Black- external surface (if unoriented and for tumor)[Additional ink may be required if oriented for margin assement]

Cassette Submission: 10-12 cassettes

- One cassette if incidentally removed - One cassette per 1 cm of lesion/tumor

o Show relationship to capsuleo Show relationship to unremarkable parenchyma

- One cassette of unremarkable parenchyma- Submit all lymph nodes identified

- Submit representative sections of other structures present (pleura, pericardium, etc.)

THYROIDSpecimen Type: THYROIDECTOMY (hemi/total)Procedure:

1. Weigh and measure2. Orient3. Examine capsule and document any defects4. Ink:

a. Blue- anterior lobe and isthmusb. Black- posterior lobe and isthmusc. Orange- isthmus resection surface/margin

5. Serially section from superior to inferior6. Describe lesions and presence of capsule, hemorrhage/necrosis,

fibrosis/calcification 7. Describe remaining cut surface

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].

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

Cassette Submission: 4-8 cassettes- Single nodule: 1 section per 1 cm of tumor, can submit entirely if small- Diffuse lesions: 3 sections per lobe and 1 section of isthmus- Multinoduler goiter: 1 cassette per 1 cm of the greatest dimension of the thyroid (i.e. thyroid measures 10 cm in maximum dimension, submit 10 representative cassettes)

- Focus on hemorrhagic, calcified, or fibrous areas- Follicular lesion: 1-2 sections of tumor and entire tumor capsule

- Unremarkable lobe and isthmus- Papillary carcinoma: 1 section per 1 cm of lesion including relationship to unremarkable tissue- Other carcinoma: 3 sections of tumor and 2 sections of uninvolved lobe/isthmus

PARATHYROIDSpecimen 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

LARYNXSpecimen Type: BIOPSYGross 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 LARYNGECTOMYProcedure:

1. Orient specimen and determine structures presenta. If radical neck dissection present, remove from larynx and process as

described in the manualb. Preserve soft tissue relationships if tumor is grossly involving the organ

i. May remove thyroid if present and uninvolved2. Ink the external soft tissue, avoid inking over mucosa

c. Black- rightd. Blue- left

3. Remove inferior tracheal ring (marin)4. Open along the posterior midline (may need to crack cartilage) and prop open and fix overnight5. Photograph6. Describe mucosa and presences of lesion(s)/ulcerations

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, hyoid bone, thyroid, cartilage (thyroid and/or cricoid), strap muscles, and involvement of any additional tissue/organs present

7. Shave the mucosal margins8. Section along anterior midline and photograph cut surface9. Document maximum thickness of lesion and distance to all margins

- superior epiglottis- inferior tracheal ring- right and left lateral inked soft tissue- anterior and posterior inked soft tissue- superior inked soft tissue (base of tongue)

10. Describe remaining unremarkable tissue and additional pathology

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 measures [***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 [describe extent-piriform sinus, aryepiglottic folds, cartilage, bone, thyroid, strap muscles, anterior and posterior commissure, tracheal rings, etc.].

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- Shave of mucosal margins- Anterior and posterior commissure- Epiglottis- Right and left piriform sinuses and aryepiglottic folds- If lesion grossly identified

- 1 section per 1 cm of lesion- 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 cross section of each lobe if uninvolved- Anterior skin to include tracheostomy, if present

Specimen Type: HEMILARYNGECTOMYProcedure:

1. Fix the specimen for at least 2-4 hoursa. Specimen will consist of true and false cord and underlying cartilage

2. Separate the soft tissue of the entire vocal cord from the underlying cartilage3. Section vertically at 2-3 mm internal to include true and false cord4. Submit each level in separate cassette, 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 tumor