Neck dissection

Background

Dissections of the neck are undertaken to excise cancer metastases to the cervical lymphatics and to evaluate the extent of spread. 1-3


Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

Fresh tissue received
  • No
    • Non-routine fixation (not formalin), describe.
  • Yes
    • Special studies required, describe.
    • Ensure samples are taken prior to fixation.
Intraoperative consultation
  • Not performed
  • Performed, describe type and result
    • Frozen section
    • Imprints
    • Other, describe

See general information for more detail on specimen handling procedures.

Inspect the specimen and dictate a macroscopic description.

External InspectionBack to top


Orientate and identify the anatomical features of the specimen.

Complex specimens should be examined and orientated together with the responsible surgeon, if possible. Alternatively the surgeon should orientate the specimen with the use of ties or pin the specimen out and label the cork board (as demonstrated in the photo provided).2,3

Record additional orientation or designation provided by operating clinician:

Orientation markers

Record additional orientation or designation provided by operating clinician:

  • Absent
  • Present
    • Method of designation (e.g. suture, incision)
    • Featured denoted

Photograph the intact specimen if required.

Describe the following features of the specimen:

Procedure 

Record as stated by the clinician.

Options2-4
  • Radical neck dissection
  • Modified radical neck dissection
    • Internal jugular vein
      • Absent
      • Present
    • Spinal accessory nerve
      • Absent
      • Present
    • Sternocleidomastoid muscle
      • Absent
      • Present
    • Selective neck dissection
  • Extended radical neck dissection
    • Specify additional structures/lymph nodes groups
More detail2-4

Radical neck dissection:

Removal of all ipsilateral cervical lymph nodes (I-V) within an area demarcated by the inferior border of the mandible superiorly to the clavicle inferiorly and the lateral border of the sternohyoid muscle and hyoid bone to the anterior aspect of the trapezius laterally.

The internal jugular vein (IJV), sternocleidomastoid (SCM) and spinal accessory nerve (SAN) should also be included unless otherwise stated.

Modified radical neck dissection:

Excision of all lymph nodes routinely removed by the radical neck dissection with preservation of one or more non-lymphoid structures which is/are clearly stated on the request form (e.g. internal jugular vein, sternocleidomastoid and spinal accessory nerve).

Selective neck dissection:

Cervical lymphadenectomy in which there is preservation of one or more lymph node groups. Again included groups must be stated by the clinician.

Extended radical neck dissection

Radical neck dissection with additional lymphoid or non-lymphoid structures which must be specifically identified by the clinician.

Specimen laterality

  • Left
  • Right

Specimen integrity

  • Intact
  • Disrupted

Anatomical components included (more than one may apply)2 and specimen size (mm)

Describe and measure the anatomical components present.

  • Total specimen size in three dimensions, length x width x thickness
  • Submandibular gland (superficial)
  • Internal jugular vein (deep aspect)
  • Spinal accessory nerve (superficial)
  • Sternocleidomastoid (superficial)
  • Omohyoid (superficial)
  • Parotid
  • Skin
  • Other, describe

Lymph nodes levels/groups

Record the levels included. 2,5,6

  • Submental (IA)
  • Submandibular (IB)
  • Upper jugular (IIA and IIB)
  • Middle jugular (III)
  • Lower jugular (IV)
  • Posterior triangle (VA and VB)
  • Other, specify

DissectionBack to top


Lymph node extraction is enhanced by prolonged fixation4,7 (24-48 hours) in a formaldehyde-based fixative (in a ratio of 10:1 fixative to tissue). See fixation for further detail.

A radical neck dissection will include between 10-30 lymph nodes (unless affected by chemotherapy or radiotherapy) but 50-100 nodes have been found in some specimens. Careful examination should reveal all palpable nodes >3mm in diameter. 7

One method is to section the specimen at 5mm sequential intervals but retain its integrity by conserving the most lateral sternocleidomastoid muscle (SCM). It is important to dissect the specimen in a methodical fashion. A suggested approach is to begin with level I, then level V as both these levels can be easily separated from the SCM. Levels II-IV can then be dissected from the deep to superficial aspect.4

More detail

While it is usually straight forward to locate large lymph nodes, smaller nodes can be less obvious. Knotted suture material can resemble a lymph node but is usually distinguished on closer inspection. Nodes in Level V may appear to be the same colour as adipose tissue so when in doubt sample the area for processing. Small nodes may be visible at microscopic examination.4

Levels I and V
  • Section vertically in parallel slices 3
Levels II-IV
  • Section medially to laterally in parallel slices. 3
  • Alternatively, identify lymph nodes by inspection and palpation (using gloved fingers) to sense nodules within the adipose tissue.3

Examine each level of the neck dissection for the presence of enlarged lymph nodes. Dissect out each lymph node with its pericapsular adipose tissue.

Internal jugular vein (IJV) if present
  • Open the IJV and remove any blood clot.3
  • Examine the luminal surface for tumour spread across the vessel wall and sample where applicable, 3 including areas of suspected ulceration of the intima and thrombosis.
  • Sample any areas of tumour fixation to the IJV.3
Matted and/or cystic nodes
  • Where the specimen consists of matted nodes, measure the mass and slice as described above. Make an estimate of the number of component nodes and process sections demonstrating the peripheral extent.4
  • Cystic nodes should be treated with caution; ensure measurement of the maximum tumour dimension including the cystic lumen. Sample the cyst wall and peripheral extent of the tumour.4

After opening the specimen may require longer fixation in larger quantity of formalin.

Internal InspectionBack to top


For each anatomical level, describe: 2

Lymph nodes

Retrieved from resection specimen (this may incorporate a block key)

  • Describe anatomical level
  • Number of lymph nodes retrieved per level and per cassette
  • Maximum dimension of largest metastatic deposit

Note the presence of obvious tumour and any extracapsular spread recording the distance to the closest margin and involvement of other structures. 7-10

Separately submitted specimens

  • For each pot, record specimen number and designation
  • Collective size of tissue in three dimensions (mm)
  • Number of lymph nodes submitted
  • Maximum diameter of each (mm)

ProcessingBack to top


Lymph nodes <6mm
  • Submit whole for processing.
Lymph nodes 6-15mm
  • Bisect longitudinally through the hilum and submit both sections for processing together in a single cassette.4
Lymph nodes >15mm
  • Bisect longitudinally through the hilum the bisect one half  again at 90° to the original plane of sectioning (to demonstrate the subcapsular sinuses).
  • Where the node appears to be negative, process all tissue.4
  • Where obvious tumour is present, process one section; the half with more extensive tumour.2,4
  • If extracapsular spread is suspected, it is worthwhile painting the margin with ink to assist microscopic examination.3
  • Measure enlarged nodal masses and the largest lymph node.
  • Sample the surrounding surgical margin of enlarged nodes and macroscopically-involved nodes with or without apparent fixation to the surrounding tissue. 2

Enlarged lymph nodes (>10mm) without fixation to the surrounding tissue (i.e. without direct spread) may contain metastases. Examine carefully for extracapsular spread and the relationship to adjacent muscles, blood vessels, nerves and submandibular gland. Sample where applicable.2


Record details of each cassette.

Cassette labelling

It is advisable to establish a standard cassette labelling protocol for neck dissection specimens. One method may to use specific character for each level (A for level I, B for level II etc.) followed by a number for each cassette containing a node or several small nodes (A1, A2 etc.).4 Record whether a node has been bisected or sliced, particularly where a single node is processed in multiple cassettes.

An illustrated block key similar to the one provided may be useful.

Block allocation key

Cassette id
Site
No. of pieces
A+
Lymph nodes, identified by level
 

Acknowledgements

Prof Richard Logan for his contribution in reviewing and editing this protocol.


ReferencesBack to top


  1. Helliwell T and Woolgar J. Dataset for histopathology reporting of mucosal malignancies of the oral cavity, The Royal College of Pathologists, London, 2013.
  2. Dahlstrom J, Coleman H, Johnson N, Salisbury E, Veness M and Morgan G. Oral structured reporting protocol, The Royal College of Pathologists of Australasia, Surry Hills, NSW, 2012.
  3. Slootweg PJ. Complex head and neck specimens and neck dissections. How to handle them. J Clin Pathol.2005;58(3):243-8.
  4. Woolgar J, Triantafyllou A. Neck dissections: A practical guide for the reporting histopathologist. Current Diagnostic Pathology.  2007;13(6):499-511.
  5. Robbins KT, Shaha AR, Medina JE, Califano JA, Wolf GT, Ferlito A, Som PM and Day TA. Consensus statement on the classification and terminology of neck dissection. Arch Otolaryngol Head Neck Surg 2008;134(5):536-538.
  6. Robbins KT, Clayman G, Levine PA, Medina J, Sessions R, Shaha A, et al. Neck dissection classification update: revisions proposed by the American Head and Neck Society and the American Academy of Otolaryngology-Head and Neck Surgery. Arch Otolaryngol Head Neck Surg 2002;128(7):751-758.
  7. Genden EM, Ferlito A, Bradley PJ, Rinaldo A and Scully C. Neck disease and distant metastases. Oral Oncol 2003;39(3):207-212.
  8. Greenberg JS, Fowler R, Gomez J, Mo V, Roberts D, El Naggar AK and Myers JN. Extent of extracapsular spread: a critical prognosticator in oral tongue cancer. Cancer 2003;97(6):1464-1470.
  9. Ferlito A, Rinaldo A, Devaney KO, MacLennan K, Myers JN, Petruzzelli GJ, Shaha AR, et al. Prognostic significance of microscopic and macroscopic extracapsular spread from metastatic tumor in the cervical lymph nodes. Oral Oncol 2002;38(8):747-751.