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Head and Neck and Laryngeal Specimens
Head and neck specimens are often challenging due to the numerous complex structures and the variety of disease processes that involve them.
Sinus Contents
Functional endoscopic sinus surgery (FESS) is used as a treatment for patients with chronic sinusitis who have not responded to medical therapy. , The contents of the sinuses are examined and obstructing areas and polyps are removed. A subset of these patients may have allergic sinusitis. If allergic mucin consisting predominantly of eosinophils and Charcot-Leyden crystals is seen histologically, special stains for fungi can be performed to look for the hyphae of Aspergillus. Allergic sinusitis must be distinguished from obstructive aspergillosis (due to a “fungal ball” consisting of a mat of hyphae obstructing the sinus outlet) and invasive fungal disease.
Invasive fungal disease is a medical emergency that is classified as a critical value. Physicians should be contacted when this diagnosis is made. These patients are usually immunocompromised and the diagnosis suspected clinically. In many cases, biopsies from patients in which invasion is suspected are sent for frozen section. ,
PROCESSING THE SPECIMEN
- 1.
The specimen consists of multiple minute fragments of bone and soft tissue. Describe color and aggregate size. If polyps are present, see the following section.
- 2.
The specimen will generally need to be decalcified. However, do not decalcify soft tissue unnecessarily.
- 3.
Submit a representative section of the tissue in one cassette including mucin if present. If a portion of grossly normal nasal septum is submitted, it can be described but not examined histologically.
Nasal Polyps
The most common specimen consists of inflammatory nasal polyps. These polyps look like translucent, gelatinous, rounded masses ranging from 0.5 to 3 cm in diameter. The cut surface is homogeneous grey or pink. Small cystic areas may be present and areas of chronic inflammation appear as white patches. Calcification or bone may be found and, if present, these portions of the specimen must be decalcified before submission. If large, the polyps may be bisected and half of each one submitted.
Polyps consisting of firm, dense white tissue may be neoplastic. Benign (but locally aggressive) papillomas or squamous cell carcinomas can occur in the nasal passages. Attempt to identify the base of firm polyps and submit as a separate section if possible. Lesions suspicious for malignancy clinically or grossly should be completely examined microscopically.
Oral Cavity/Tongue Resections
These are often large resections that may include a portion of the maxilla or mandible and teeth. Such resections are almost always performed for invasive squamous cell carcinomas. These specimens are often accompanied by a radical neck dissection (see below). Lip resections are discussed in Chapter 15 .
Although separate margins may be taken by the surgeon for either frozen section or permanent section evaluation, it is also important to take additional margins from the main resection. The separately submitted additional margins may not be large enough to encompass the entire margin.
PROCESSING THE SPECIMEN
- 1.
Identify structures present including bone, teeth, mucosal surfaces, palate, tongue, and muscle. Anatomically complex specimens should be reviewed with the surgeon before processing. Record measurements for each component. Major nerves or vessels should be identified by the surgeon.
Correlation with clinical and radiographic information is necessary to determine the likelihood that there is bone invasion. If there is any clinical or gross suspicion of bone invasion, a specimen radiograph may be helpful to identify areas of abnormal bone that should be sampled.
- 2.
Describe the lesion including location, size, invasion into adjacent structures, and distance from margins.
Squamous cell carcinomas usually grow as raised irregular lesions with central ulceration. If the patient has received prior radiation, the carcinoma may be difficult to identify grossly. A radiated carcinoma may have the appearance of a firm ulcerated area of mucosa.
- 3.
Take sections of the lesion demonstrating relationship to mucosal and soft tissue margins and deepest extent of invasion. Margins (especially mucosal) must be submitted as perpendicular sections .
Sample all margins not included in other sections.
Note that all margins on the specimen should be evaluated, even if separately submitted intraoperative frozen sections were performed.
- 4.
After all mucosal and soft tissue sections have been removed, the bone is decalcified.
If there is possible bone invasion, as indicated by clinical history, specimen radiographs, or gross evaluation, take sections demonstrating the relationship of carcinoma to the bone. The closest bone margins are sampled.
If there is no gross, radiologic, or clinical suspicion of bone invasion, only bone margins need be submitted.
SPECIAL STUDIES
Squamous cell carcinomas: Some head and neck squamous cell carcinomas are associated with human papilloma virus (HPV). These account for most oropharyngeal carcinomas with nonkeratinizing morphology (arising in the tonsil or base of tongue) and have a separate AJCC 8th edition staging system (see the section on Tonsil). HPV-associated squamous cell carcinomas are strongly positive for p16 by IHC (immunohistochemistry). HPV can be identified by HPV RNA ISH (in situ hybridization) or PCR (polymerase chain reaction) on formalin fixed tissue. Testing is generally recommended for oropharyngeal squamous cell carcinomas and for metastatic squamous cell carcinoma to neck lymph nodes in the absence of a known primary site.
MICROSCOPIC SECTIONS
| Lesion | One to five sections demonstrating relationship to margins. |
| Margins | Mucosal and soft tissue margins not included in the prior sections. |
| Bone | Margins and any areas with suspicion of invasion by tumor. Teeth are described grossly and not sampled unless abnormal or thought to be involved by tumor. |
SAMPLE DICTATION
Received fresh labeled with the patient’s name and unit number and “Composite resection” is a resection specimen (12.5 × 10. 5 × 6.2 cm) consisting of left mandibular ramus (7 × 6 × 0.6 cm) containing three molars, base of tongue (3.9 × 3.4 × 1.9 cm), floor of mouth (5.5 × 3.5 × 0.6 cm), soft tissue on the external portion of the ramus (6.5 × 2.6 × 1.2 cm), and soft tissue posterior and lateral to the base of the tongue (3.5 × 3.8 × 1.6 cm). A raised irregular white/tan tumor mass (4.8 × 3.5 × 1.9 cm in depth) is present involving the soft tissue at the base of the tongue, extends into and through the bone, and is present in the soft tissue external to the bone. The tumor invades into the muscle of the tongue. The margins of resection are grossly free of tumor. The tumor is 0.3 cm from the lateral mucosal margin, 0.8 cm from the posterior mucosal margin, 0.8 cm from the medial mucosal margin, and 0.5 cm from the anterior mucosal margin. The tumor is 0.5 from the inferior soft tissue margin at the base of the tongue and 0.4 cm from the soft tissue margin in the external soft tissue to the ramus. Representative sections are submitted for microscopic evaluation.
The specimen is radiographed and an irregular trabecular pattern is seen in the area of gross tumor involvement of the ramus. The bone is fixed and decalcified prior to histologic sectioning. The entire proximal and distal bone margins are submitted for microscopic evaluation.
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Micro A1: Anterior mucosa and tumor, perpendicular margin, 1 frag.
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Micro A2: Medial mucosa and tumor, perpendicular margin, 1 frag.
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Micro A3: Lateral mucosa and tumor, perpendicular margin, 1 frag.
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Micro A4: Posterior mucosa and tumor, perpendicular margin, 1 frag.
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Micro A5: Deepest extent of tumor at base of tongue, perpendicular margin, 1 frag.
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Micro A6: Tumor and bone, 1 frag.
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Micro A7: Tumor and soft tissue external to ramus, 1 frag.
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Micro A8: Bone, proximal margin, en face, 1 frag.
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Micro A9: Bone, distal margin, en face, 1 frag.
PATHOLOGIC PROGNOSTIC/DIAGNOSTIC FEATURES SIGN-OUT CHECKLIST FOR ORAL CAVITY AND TONGUE TUMORS
| Specimen | Lip (vermilion border, mucosa, commissure, upper or lower), tongue (lateral, ventral, dorsal, anterior two-thirds), gingiva (upper, lower), anterior floor of mouth, floor of mouth, hard palate, buccal mucosa, vestibule of mouth (upper, lower), alveolar process (upper, lower), mandible, maxilla |
| Procedure | Excision, glossectomy, buccal mucosal resection, mandibulectomy, maxillectomy, palatectomy, lymph node dissection |
| Specimen Laterality | Right, left, bilateral, midline |
| Tumor Site | Lip (vermilion border, mucosa, commissure, upper or lower), tongue (lateral, ventral, dorsal, anterior two-thirds), gingiva (upper, lower), anterior floor of mouth, floor of mouth, hard palate, buccal mucosa, vestibule of mouth (maxillary, mandibular), alveolar process (maxillary, mandibular), mandible, maxilla, retromolar area |
| Right, left, midlne | |
| Tumor Focality | Single focus, multifocal (specify number) |
| Tumor Size | Greatest dimension (other dimensions optional) |
| Tumor Thickness | Give depth of invasion in mm. This is important for small (T1 or T2) oral squamous cell carcinomas. |
| Surface ulcerated or not ulcerated | |
| Tumor Description | Polypoid, exophytic, endophytic, ulcerated, sessile |
| Histologic Type | Squamous cell carcinoma, minor salivary gland carcinoma, other rare types |
| Histologic Grade | Well, moderate, poor – only required for squamous cell carcinomas |
| Tumor Extension | Invasion into adjacent structures (bone, skin, muscle) |
| Margins | Uninvolved or involved by invasive carcinoma or carcinoma in situ, as well as dysplasia (which should be graded). Give distance from closest margin. These are margins obtained from the main specimen, and should be reported even if margins were separately submitted as intraoperative frozen sections. |
| Explanation: Separately submitted margins are typically biopsies from the tumor bed. These specimens may sample but not completely encompass the entire margin. They may also not identify how close a tumor is to the margin. Therefore, margins taken from the main specimen are also of value. | |
| Mucosal, soft tissue, bone | |
| Tumor Bed Margins | Orientation, uninvolved or involved by invasive carcinoma, carcinoma in situ, or high-grade dysplasia; distaince to margin. These are separate margins taken by the surgeon. Only required for squamous cell carcinoma and mucosal melanoma. |
| Treatment Effect | If there has been prior treatment: Not identified, present |
| Lymphovascular Invasion | Not identified, present |
| Perineural Invasion | Not identified, present (extent) |
| Worst Pattern of Invasion (WPOI) | Five categories for oral cavity squamous carcinomas have been identified based on microscopic findings ranging from WPOI-1 to WPOI-5. |
| Bone Invasion | Not identified, present |
| Lymph Nodes | Number and location (ipsilateral or midline, contralateral, bilateral) of involved lymph nodes, size of metastatic deposits |
| Extranodal Extension (ENE) | Not identified, present, distance from capsule, size (major > 0.2 cm; microscopic ≤ 0.2 cm) |
| Tumor Necrosis | Present or absent, extent |
| Additional Pathologic Findings | Keratinizing or nonkeratinizing dysplasia (mild, moderate, severe (carcinoma in situ), inflammation (type), epithelial hyperplasia, colonization (fungal, bacterial) |
| Ancillary Studies | EBV or HPV may be requested by clinicians. HPV-associated oropharyngeal carcinomas have a better prognosis. |
| Distant Metastasis | If distant metastasis is not present on pathologic examination, the M category is a clinical classification. pM0 and pMX should not be used. |
| AJCC Classification | T, N, and M classifications should be provided, when possible ( Tables 20.1 , 20.2 and 20.3 ). cM0 is conferred after clinical assessment. There is no pM0 category. pMX should not be used. |
Table 20.1
Epithelial and minor salivary gland cancers of the lip and oral cavity
| information needed for AJCC (8th edition) classification | ||
|---|---|---|
| Group | Features | Comments |
| T | In situ or invasive carcinoma | Determined by microscopic evaluation but often evident on gross examination. |
| Size of invasive carcinoma: ≤ 2 cm (depth of invasion ≤ 5 mm or > 5 mm but ≤ 10 mm), > 2 cm to ≤ 4 cm (depth of invasion ≤ 10 mm), > 4 cm | Gross evaluation of the size of the tumor is important. A perpendicular section is necessary to determine the depth of invasion. | |
| Lip: Invasion into cortical bone or involves the inferior alveolar nerve, floor of mouth, or skin of face (chin or nose) | Radiography of the specimen can be helpful to determine the extent of bone involvement. | |
| Oral cavity: Invasion into adjacent structures through the cortical bone of the mandible or maxilla or the maxillary sinus, or the skin of the face. | Radiography of the specimen can be helpful to determine the extent of bone involvement. | |
| Invasion of masticator space, pterygoid plates, or skull base, or surrounds the internal carotid artery. | Radiography of the specimen can be helpful to determine the extent of bone involvement. | |
| N | Metastasis: present or absent | |
| Number of lymph nodes: single or multiple | Counting the number of lymph nodes is essential and can only be accomplished by careful gross evaluation. | |
| Location of lymph nodes – ipsilateral or contralateral | ||
| Size of lymph nodes - ≤ 3 cm, > 3 cm to ≤ 6 cm, > 6 cm | Gross evaluation of the size of the lymph nodes is important. | |
| Extranodal extension | Careful gross evaluation is needed to identify the most likely area of invasion beyond the capsule of a lymph node and to take a perpendicular section of this area. | |
| M | Distant metastases | Usually determined clinically or with a separate biopsy of a metastatic site. |
Data from Amin MB, Edge SB, Green F, et al., eds. American Joint Commission on Cancer: Cancer Staging Manual, 8th ed. New York, NY: Springer; 2017.
Table 20.2
Mucosal melanoma of the head and neck
| Information needed for AJCC (8th edition) classification | ||
| Group | Features | Comments |
| T | Location: limited to mucosa, involving deep soft tissue, cartilage, bone, or overlying skin, brain, dura, skull base, lower cranial nerves, masticator space, carotid artery, prevertebral space, mediastinal structures | If bone is present, radiography of the specimen can be helpful to determine the presence and extent of involvement. |
| N | Metastases present or absent | |
| M | Distant metastases | Usually determined clinically or with a separate biopsy of a metastatic site. |
Data from Amin MB, Edge SB, Green F, et al., eds. American Joint Commission on Cancer: Cancer Staging Manual, 8th ed. New York, NY: Springer; 2017.
Table 20.3
Unknown primary tumor of the head and neck – cervical lymph nodes
| Information needed for AJCC (8th edition) classification | ||
| Group | Features | Comments |
| N | Metastasis: present or absent | |
| Number: single or multiple | Careful evaluation of the number of nodes is important. | |
| Size: ≤ 3 cm, ≥ 3 cm to ≤ 6 cm, > 6 cm | Gross evaluation of the size of the lymph nodes is important. | |
| Location: single side or bilateral | ||
| Extranodal extension | Careful gross evaluation is necessary to determine the most likely location of invasion beyond the lymph node capsule. | |
Data from Amin MB, Edge SB, Green F, et al., eds. American Joint Commission on Cancer: Cancer Staging Manual, 8th ed. New York, NY: Springer; 2017.
This checklist incorporates information from the CAP Cancer Committee protocols for reporting on cancer specimens (see www.cap.org/ ), as well as other sources.
Neck Dissections (Removal of Lymph Nodes)
Lymph nodes of the neck are removed to provide prognostic information, as well as to control local disease for some patients. The extent of the surgery and the number of nodes and structures removed varies:
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Radical neck dissection : Radical procedures are currently uncommon and are usually performed for squamous cell carcinoma of the head and neck. Poor prognosis is associated with multiple affected nodes, bilateral vs. unilateral involvement, extranodal extension, and positive nodes distal from the primary site. The standard radical neck dissection includes cervical lymph nodes, sternomastoid muscle, internal jugular vein, spinal accessory nerve, and submaxillary gland. The tail of the parotid gland may be included.
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Modified radical neck dissection (functional or Bocca neck dissection): This procedure spares the sternomastoid muscle and/or the internal jugular vein.
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Extended radical neck dissection: A more extensive radical procedure that can also include retropharyngeal, paratracheal, parotid, suboccipital, and/or upper mediastinal nodes.
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Selective (regional or partial) neck dissection : Defined as a procedure that removes fewer than the five levels removed in radical and modified radical dissections. Includes supraomohyoid neck dissection, posterolateral neck dissection, lateral neck dissection, and central compartment neck dissection.
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Superselective neck dissection (SSND): Removes two or fewer lymph node levels.
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The specific lymph node groups can only be identified without orientation by the surgeon when muscle, vein, and/or nerves are removed. The more common limited dissections lack the necessary anatomic landmarks. It is the recommendation of American Head and Neck Society that specimens be divided into levels and sublevels by the surgeon and submitted as separate designated specimens. The location, number, and size of metastases are all important prognostic factors, as well as the presence and extent of extranodal invasion.
PROCESSING THE SPECIMEN
- 1.
Identify the type of dissection and record the overall dimensions. If muscle is present, orient the specimen and divide the lymph nodes into groups ( Fig. 20.1 ). Contact the surgeon if the specimen cannot be oriented and there are features present that might allow orientation with additional information (e.g., sutures, salivary gland, fragments of muscle).
If not oriented by the surgeon, the specimen can be thought of as a letter Z. The upper horizontal line contains level I and can be identified by the presence of the submandicular gland, the lower horizontal line level V, and levels II, III, and IV comprise the upper, mid, and lower thirds of the oblique line defined by the sternocleidomastoid muscle.
- 2.
Record the dimensions and appearance of the sternocleidomastoid muscle including color and any irregular firm areas (possibly representing involvement by tumor). The jugular vein lies deep to this muscle. Record the length, diameter and appearance (color, patency). Open the vein along its length and examine for thrombus or tumor involvement. Tumor invasion into the vein is usually found only with extensive nodal disease. The soft tissue deep to the muscle is divided into three groups, high (level II), mid (level III), and low (level IV) jugular nodes, and placed in three separate labeled containers.
- 3.
The submandibular region is the area superior to the muscle and contains the submandibular gland. Record its size, consistency, color, and the presence of any lesions. Separate the nonmuscle tissue and save in a separate container (level I).
- 4.
The posterior triangle (level V) is the soft tissue inferior to the muscle. Record its dimensions and place all soft tissue in a separate container.
- 5.
If gross tumor is present, evaluate the surgical margins around the tumor.
- 6.
Record the number of lymph nodes and the size range of lymph nodes present. Record the size of all grossly positive lymph nodes.
Nodes with intact capsules have the appearance of ovoid firm masses with smooth contours. If there is extranodal extension (ENE) of the tumor into the surrounding tissue, the involved node will have an irregular shape. ENE is an important prognostic factor and is used in staging. The presence of ENE should be documented. “Matted” nodes occur when ENE connects two or more nodes. In such a case, it can be difficult to determine the number and size of involved nodes. If the exact number of nodes cannot be determined, an estimate is helpful. Prior needle biopsy or excision sites can also result in irregular tissue masses associated with nodes.
SPECIAL STUDIES
Metastatic squamous cell carcinoma of unknown origin: If a nonkeratizing metastasis is diagnosed in a young patient, these cancers are often due to a squamous cell carcinoma of the oropharynx associated with HPV. The primary carcinoma may be difficult to detect. HPV-associated metastastic carcinomas to a lymph node with an unknown primary are staged with HPV-cancers with known primaries, whereas non-HPV-related metastatic carcinomas have a different staging system. HPV testing should be performed for: 1) all squamous cell carcinomas of unknown primary in Level II or III cervical lymph nodes; 2) any cervical lymph node metastasis with a clinically apparent oropharyngeal primary (see Tonsil section). These studies can be performed on formalin fixed, paraffin embedded tissue.
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