Upper Aerodigestive Tract

 

Protocol applies to all carcinomas of the upper aerodigestive tract: carcinomas of the oral cavity (including lip and tongue), pharynx, oropharynx, hypopharynx, nasopharynx, larynx, paranasal sinuses, and salivary glands.

 

 

Procedures

·        Cytology

·        Biopsy

·        Resection

 

 

This protocol is intended to assist pathologists in providing clinically useful and relevant information as a result of the examination of surgical specimens. Use of this protocol is intended to be entirely voluntary. If equally valid protocols or similar documents are applicable, the pathologist is, of course, free to follow those authorities. Indeed, the ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of the individual circumstances presented by a specific patient or specimen.

 

It should be understood that adherence to this protocol will not guarantee a successful result. Nevertheless, pathologists are urged to familiarize themselves with the document. Where a physician chooses to deviate from the protocol based on the circumstances of a particular patient or specimen, the physician is advised to make a contemporaneous written notation of the reason for the procedure followed.

 

The College recognizes that this document may be used by hospitals, attorneys, managed care organizations, insurance carriers, and other payers. However, the document was developed solely as a tool to assist pathologists in the diagnostic process by providing information that reflects the state of relevant medical knowledge at the time the protocol was first published. It was not developed for credentialing, litigation, or reimbursement purposes. The College cautions that any uses of the protocol for these purposes involve considerations that are beyond the scope of this document.

 

 

I. Cytologic material                  back     Top     Main Page

            A.        Clinical Information

                        1.         Patient identification

                                    a.         Name

                                    b.         Identification number

                                    c.         Age (birth date)

                                    d.         Gender

                        2.         Responsible physician(s)/clinic(s)

                        3.         Date of procedure

                        4.         Other clinical information

                                    a.         Relevant history

                                    b.         Clinical findings, as indicated

                                    c.         Clinical diagnoses

                                    d.         Procedure (e.g. FNA)

                                    e.         Anatomic site(s) of specimen(s)

 

            B.         Macroscopic Examination

                        1.         Specimen

                                    a.         Unfixed/fixed (specify fixative)

                                    b.         Number of slides received

c.         Quantity and appearance of fluid specimen (if appropriate)

                                    d.         Other (e.g. tissue received for cytologic preparation)

                                    e.         Results of intraprocedural consultation

2.         Material submitted for microscopic evaluation (e.g. smear, cytocentrifuge, touch or filter preparation, cell block)

                        3.         Special studies (specify)

            C.        Microscopic evaluation

1.         Adequacy of specimen (if unsatisfactory for evaluation, specify reason)

                        2.         Tumor, if present

                                    a.         Histologic type, if possible (Note A)

                                    b.         Other characteristics (e.g. nuclear grade/necrosis)

                                    c.         Indeterminate

                        3.         Additional pathologic findings, if present

                        4.         Results/status of special studies (specify)

                        5.         Comments

a.         Correlation with intraprocedural consultation, as appropriate

                                    b.         Correlation with other specimens, as appropriate

                                    c.         Correlation with clinical information as appropriate

           

 

II.  Biopsy                    back     Top     Main Page

A.        Clinical information

                        1.         Patient identification

                                    a.         Name

                                    b.         Identification number

                                    c.         Age (birth date)

                                    d.         Gender

                        2.         Responsible physician(s)/clinic(s)

                        3.         Date of procedure

                        4.         Other clinical information

                                    a.         Relevant history

                                                (1)        surgery and date(s)

                                                (2)        radiation and date(s)

                                                (3)        chemotherapy and date(s)

                                                (4)        others (e.g. hyperthermia, photodynamic therapy)

                                    b.         Clinical findings (e.g. imaging studies)

                                    c.         Clinical diagnosis

                                    d.         Procedure

                                    e.         Operative findings

f.          Anatomic site(s) of specimen(s) (e.g. tongue, tonsil, pharynx, epiglottis, false cord, true cord.Specify right, left, midline, etc.)

 

            B.         Macroscopic Examination

                        1.         Specimen

                                    a.         Unfixed/fixed (specify fixative)

                                    b.         Size (three dimensions)

                                    c.         Results of intraoperative consultation

2.         Tissue(s) submitted for microscopic evaluation (all or selected samples).

3.         Special studies (specify)

            C.        Microscopic evaluation

                        1.         Tumor if present

                                    a.         Histologic type (Note A)

                                    b.         Histologic grade (Note B)

                                    c.         Extent of invasion

                                                (1)        Noninvasive (in situ)

(2)        Subepithelial connective tissue (microinvasion, ____mm from the basement membrane)

                                                (3)        Muscle, when applicable

                                                (4)        Bone or cartilage, when applicable

                                                (5)        Indeterminate (state reasons)

                                    d.         Vascular invasion (if identified)

                                                (1)        Lymphatic (specify location)

                                                (2)        Blood vessel (specify location)

                                                (3)        Indeterminate

                                    e.         Perineural invasion (if identified)

                        2.         Tissue changes adjacent to the tumor, if present

                                    a.         Dysplasia or atypia

                                    b.         Flat carcinoma in situ (CIS)

                                    c.         Others (e.g. hyperkeratosis, radiation change, scar)

                        3.         Results/status of special studies (specify)

                        4.         Comments

a.         Correlation with intraoperative consultation, as appropriate

                                    b.         Correlation with other specimens, as appropriate

                                    c.         Correlation with clinical information, as appropriate

 

 

III.  Resection               back     Top     Main Page

            A.        Clinical Information

                        1.         Patient identification

                                    a.         Name

                                    b.         Identification number

                                    c.         Age (birth date)

                                    d.         Gender

                        2.         Responsible physician(s)/clinic(s)

                        3.         Date of procedure

                        4.         Other clinical information

                                    a.         Relevant history

                                                (1)        previous diagnoses

                                                (2)        previous cervical lymph node biopsy, if applicable

                                                (3)        surgery and date(s)

                                                (4)        radiation and date(s)

                                                (5)        chemotherapy and date(s)

                                                (6)        others (e.g. hyperthermia, photodynamic therapy)

                                    b.         Relevant findings

                                    c.         Clinical diagnosis

                                    d.         Procedure (specify anatomic site(s))

                                                (1)        excision (e.g. right hemiglossectomy)

                                                (2)        list all anatomical structures removed (Note C)

                                                (3)        lymph node dissection (Note D)

e.         Operative findings (documentation of areas of concern marked by surgeon)

                                    f.          Anatomic site(s) of specimen(s)

 

            B.         Macroscopic Examination

                        1.         Specimen

                                    a.         Unfixed/fixed (specify fixative)

                                    b.         Size (three dimensions)

                                    c.         Constituent organs/tissues

d.         Margins (tumor present/absent, distance from free margin)

                                                (1)        note areas designated by surgeon

                                                (2)        ink margin(s) of clinical relevance

e.         Neck contents accompanying  specimen in continuity or separately (specify)

                                    f.          Results of intraoperative consultation

                        2.         Neoplasm

                                    a.         Anatomical site(s) involved by tumor

                                    b.         Size (three dimensions) (Note E)

                                    c.         Pattern of growth

                                                (1)        exphytic

                                                (2)        endophytic

                                                (3)        others

d.         Anatomic extent (structures involved by tumor and depth of invasion) (Note E)

                                    e.         Relation to margins

                                    f.          Additional tumors (describe each primary tumor as above)

                                                (1)        size

                                                (2)        number

                                                (3)        location

                        3.         Additional pathologic findings, if present

                                    a.         Abnormal mucosa (e.g. leukoplakia)

                                    b.         Other lesions (e.g. scar)

                        4.         Lymph nodes submitted as part of specimen

                                    a.         Location by levels (Note F)

                                    b.         Number, each level (Note G)

                                    c.         Description

                                                (1)        matted

                                                (2)        gross metastasis

                                                (3)        size (largest) (Note H)

                                                (4)        extra nodal extension

5.         Separately submitted lymph nodes(designate according to the regional lymph node groups or levels)(Note F)

                        6.         Other separately submitted organ(s)/tissue(s)

                                    a.         Location (as specified by surgeon)

                                    b.         Description

                                                (1)        salivary gland

                                                (2)        thyroid

                                                (3)        parathyroid

                                                (4)        others

                        7.         Tissue submitted for microscopic evaluation

                                    a.         Tumor, representative

                                    b.         Tumor at point of deepest penetration

                                    c.         Interface of tumor with adjacent non-tumorous mucosa

                                    d.         Mucosa remote from cancer

                                    e.         Margin(s) of resection

                                    f.          Areas designated by surgeon

                                    g.         Areas with additional pathologic findings

                                    h.         Other organ(s)/tissue(s)

                        8.         Special studies (specify)

 

            C.        Microscopic evaluation

                        1.         Tumor, if present

                                    a.         Histologic type (Note A)

                                    b.         Histologic grade  (Note B)

                                    c.         Location

                                    d.         Extent of invasion (Note E)

                                                (1)        noninvasive (carcinoma in situ)

                                                (2)        subepithelial connective tissue

                                                (3)        muscle (if applicable)

                                                (4)        bone or cartilage (if applicable)

                                                (5)        adjacent structures

                                    e.         Vascular invasion

f.          Perineural invasion (designate the name of nerve, if applicable)

                        2.         Margins

                        3.         Status of area(s) marked by surgeon

                        4.         Additional pathologic findings, if present

                                    a.         Dysplasia or atypia

                                    b.         Flat carcinoma in situ (CIS)

                                    c.         Others (e.g. radiation changes or scars)

                        5.         Lymph nodes

                                    a.         Site(s) (according to levels) (Note F)

                                                (1)        included in specimen (report according to  level)

                                                (2)        Separately submitted (report as specified)

                                    b.         Number

                                                (1)        Total number, according to level

                                                (2)        Number involved by tumor according to level

                                    c.         Extracapsular extension

                        6.         Results/status of special studies (specify)

                        7.         Comments

a.         Correlation with intraoperative consultation, as appropriate

                                    b.         Correlation with other specimens, as appropriate

                                    c.         Correlation with clinical information, as appropriate

 

 

EXPLANATORY NOTES

 

A.        Histological Type                      back     Top     Main Page

A modification of the World Health Organization (WHO) classification of carcinomas of the head and neck is shown below. This protocol applies only to carcinomas and does not apply to melanomas, lymphomas or sarcomas.

 

Carcinomas of upper aerodigestive tract

·        Carcinoma in situ* (specify the histologic type, e.g. squamous)

·        Squamous cell carcinoma

·        Verrucous squamous cell carcinoma

·        Spindle cell carcinoma

·        Adenoid squamous cell carcinoma

·        Basaloid squamous cell carcinoma

·        Adenocarcinoma

·        Acinic cell carcinoma

·        Mucoepidermoid carcinoma

·        Adenoid cystic carcinoma

·        Carcinoma in pleomorphic adenoma

·        Epithelial-myoepithelial carcinoma

·        Clear cell carcinoma

·        Adenosquamous carcinoma

·        Giant cell carcinoma

·        Salivary duct carcinoma

·        Carcinoid tumor

·        Atypical carcinoid tumor

·        Small cell carcinoma

·        Lymphoepithelial carcinoma

·        Undifferentiated carcinoma*

·        Other*

 

*Diagnoses not included in WHO classification.

 

Carcinomas of salivary gland. The histologic classification recommended is a modification of the WHO classification of salivary gland tumors. The major malignant varieties include the following:

·        Acinic cell carcinoma

·        Adenoid cystic carcinoma (cylindroma)

·        Adenocarcinoma

·        Squamous cell carcinoma

·        Carcinoma in pleomorphic adenoma(malignant mixed tumor)

·        Mucoepidermoid carcinoma

                        Well differentiated (low grade)

                        Poorly differentiated (high grade)

·        Undifferentiated carcinoma*

·        Other

 

*Diagnosis not included in WHO classification.

 

B.         Histologic Grade                       back     Top     Main Page

For histologic types of carcinomas that are amenable to grading, four histologic grades are suggested as shown below.

Grade X           Cannot be assessed

Grade 1            Well differentiated

Grade 2            Moderately differentiated

Grade 3            Poorly differentiated

Grade 4            Undifferentiated

 

 

C. Orientation of Specimen       back     Top     Main Page                

Complex specimens should be examined and oriented with the attending surgeon.  Optimally, the attending surgeon should submit a diagram in which the extent of the tumor and line of resection are graphically illustrated as shown in the exhibit samples (Figure 1).

 

D.        Classification of Neck Dissection(1)      back     Top     Main Page

1.         Radical neck dissection

2.         Modified radical neck dissection

            Type 1.            11th nerve saved

            Type 2.            Nerve, internal jugular and vein spared

            Type 3.            Nerve, internal jugular vein, sternocleidomastoid muscle saved

3.         Selective neck dissection

            a.         Supra myahyoid neck dissection

            b.         Posterolateral neck dissection

            c.         Lateral neck dissection

            d.         Anterior compartment neck dissection

            e.         Others

4.         Extended radical neck dissection

 

E.         TNM and Stage Groupings                   back     Top     Main Page

The protocol recommends the TNM Staging System of the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer (UICC) for head and neck cancer.(2)  Separate categories and stage grouping classifications for the various specific sites of the aerodigestive tract (including salivary glands) are enumerated individually below.

 

By AJCC/UICC convention, the designation “T” refers to a primary tumor that has not been previously treated. The symbol “p” refers to the pathologic classification of the TNM, as opposed to the clinical classification and is based on gross and microscopic examination.  pT entails a resection of the primary tumor or biopsy adequate to evaluate the highest pT category; pN entails removal of nodes adequate to validate lymph node metastasis; and pM implies microscopic examination of distant lesions.  Clinical classification (cTNM) is usually carried out by the referring physician before treatment during initial evaluation of the patient or when pathologic classification is not possible.

 

Tumor Remaining in the Patient

Tumor remaining in a patient after therapy with curative intent (e.g., surgical resection for cure) is categorized by a system known as R classification, shown below.  

 

RX                   Presence of residual tumor cannot be assessed

R0                    No residual tumor

R1                    Microscopic residual tumor

R2                    Macroscopic residual tumor.

 

For the surgeon, the R classification may be useful to indicate the known or assumed status of the completeness of a surgical excision.  For the pathologist, the R classification is relevant to the status of the margins of a surgical resection specimen.  That is, tumor involving the resection margin on pathologic examination may be assumed to correspond to residual tumor in the patient and may be classified as macroscopic or microscopic according to the findings at the specimen margin(s).

 

Tumor Remaining in a Specimen

In contrast, tumor remaining in a resection specimen from a patient who has undergone previous (neoadjuvant) treatment of any type (radiation therapy alone, chemotherapy therapy alone, or any combined modality treatment) is codified by the TNM using a prescript “y” (e.g., ypT1).  Thus, yTNM indicates the post-treatment status of the tumor.  For many neoadjuvant therapies, the classification of residual disease may be a strong predictor of postoperative outcome.  In addition, the ypTNM classification provides a standardized framework for the collection of data needed to accurately evaluate new neoadjuvant therapies.

 

Locally Recurrent Tumor

In contrast to “residual” tumor, classification of a tumor as “recurrent” requires a documented disease-free interval after definitive therapy.  Recurrent tumor may also be classified according to the TNM categories, but the prefix “r” (e.g., rpT1) is used to indicate the recurrent status of the tumor. 

 

Lip and Oral Cavity

Primary Tumor (T)

TX                   Primary tumor cannot be assessed

T0                    No evidence of primary tumor

Tis                    Carcinoma in situ

T1                    Tumor 2 cm or less in greatest dimension

T2                    Tumor more than 2 cm but not more than 4 cm in greatest dimension

T3                    Tumor more than 4 cm in greatest dimension

T4                    Lip:  Tumor invades adjacent structures, e.g. through cortical bone, inferior alveolar nerve, floor of mouth, skin of face.

                        Oral Cavity:  Tumor invades adjacent structures e.g. through cortical bone, into

                        deep (extrinsic) muscle of tongue, maxillary sinus, skin.  (Superficial crosion alone of

                        bone/tooth socket by gingival primary is not sufficient to classify a tumor as T4.)

 

Pharynx

Primary Tumor (T)

TX                   Primary tumor cannot be assessed

T0                    No evidence of primary tumor

Tis                    Carcinoma in situ

 

Oropharynx

Primary Tumor (T)

T1                    Tumor 2 cm or less in greatest dimension

T2                    Tumor more than 2 cm but not more than 4 cm in greatest dimension

T3                    Tumor more than 4 cm in greatest dimension

T4                    Tumor invades adjacent structures, e.g. pterygoid muscles, mandible, hard palate, deep muscle of tongue, larynx

 

Hypopharynx

Primary Tumor (T)

T1                    Tumor limited to one subsite of hypo-pharynx and 2 cm or less in greatest dimension

T2                    Tumor invades more than one subsite of hypopharynx or an adjacent site, or measures more than 2 cm

but not more than 4 cm in greatest dimension, without fixation of hemilarynx

T3                    Tumor measures more than 4 cm in greatest dimension, or with fixation of hemilarynx

T4                    Tumor invades adjacent structures, e.g. thyroid/cricoid cartilage, carotid artery, soft

                        tissues of neck, prevertebral fascia/muscles, thyroid and/or esophagus

 

Regional Lymph Nodes (N)

(applicable to Lip and Oral Cavity, Pharynx, Oropharynx, and Hypopharynx)

NX                  Regional lymph nodes cannot be assessed

N0                   No regional lymph node metastasis

N1                   Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension

N2                   Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension;

or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension; or in bilateral

                        or contralateral lymph nodes, none more than 6 cm in greatest dimension

            N2a                 Metastasis in a single ipsilateral lymph node, more than 3 cm but not morethan 6 cm in greatest dimension

            N2b                 Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension

            N2c                 Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension

N3                   Metastasis in a lymph node more than 6 cm in greatest dimension

 

 

 

Distant Metastasis (M)

MX                  Distant metastasis cannot be assessed

M0                   No distant metastasis

M1                   Distant metastasis

 

Stage Groupings

(applicable to Lip and Oral Cavity, Pharynx, Oropharynx, and Hypopharynx)

Stage 0 Tis        N0       M0

Stage I T1        N0       M0

Stage II            T2        N0       M0

Stage III           T1        N1       M0

            T2        N1       M0

            T3        N0,N1 M0

Stage IVA        T4        N0,N1 M0

                        Any T   N2       M0

Stage IVB        Any T   N3       M0

Stage IVC        Any T   Any N  M1

 

Nasopharynx

Primary Tumor (T)

T1                    Tumor confined to nasopharynx

T2                    Tumor extends to soft tissue of oropharynx and/or nasal fossa

            T2a                  T2 without parapharyngeal extension*

            T2b                  T2 with parapharyngeal extension*

T3                    Tumor invades bony structures and/or paranasal sinuses

T4                    Tumor with intracranial extension and/or involvement of cranial nerves, infratemporal fossa, hypopharynx or orbit

 

*Parapharyngeal extension denotes postero-lateral infiltration of tumor beyond the pharyngo-basilar fascia.

 

Regional Lymph Nodes (N)

NX                  Regional lymph nodes cannot be assessed

N0                   No regional lymph node metastasis

N1                   Unilateral metastasis in lymph node(s),* 6 cm or less in greatest dimension, above supraclavicular fossa

N2                   Bilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above supraclavicular fossa

N3                   Metastasis in lymph node(s)

                        (a) greater than 6 cm in dimension

                        (b) extension to supraclavicular fossa

 

* Midline nodes are considered ipsilateral nodes

 

Distant Metastasis (M)

MX                  Distant metastasis cannot be assessed

M0                   No distant metastasis

M1                   Distant metastasis

 

Stage Groupings

Stage 0 Tis                    N0                   M0

Stage I T1                    N0                   M0

Stage IIA         T2a                  N0                   M0

Stage IIB          T1                    N1                   M0

                        T2a                  N1                   M0

                        T2b                  N0,N1             M0

Stage III           T1                    N2                   M0

                        T2a, T2b          N2                   M0

                        T3                    N0,N1,N2       M0

Stage IVA        T4                    N0,N1,N2       M0

Stage IVB        Any T               N3                   M0

Stage IVC        Any T               Any N              M1

 

Larynx

Rules for Classification

The classification applies only to carcinomas.  There should be histological confirmation of the disease.  The following are the procedures for assessing T, N, and M categories:

 

T categories      Physical examination, laryngoscopy and imaging

N categories     Physical examination and imaging

M categories    Physical examination and imaging

 

Anatomical Sites and Subsites for Larynx:

-Supraglottis

            -           Epilarynx, including marginal zone

                        -           Suprahyoid epiglottis, including tip,

                                    lingual (anterior) and laryngeal surfaces

                        -           Aryepiglottic fold, laryngeal aspect

                        -           Arytenoid

            -           Supraglottis, excluding epilarynx

                        -           Infrathyroid

                        -           Ventricular bands (false cords)

-Glottis

            -           Vocal cords