Larynx
Background
Most malignancies of the larynx are squamous cell carcinomas. However malignant salivary gland type tumours, malignant melanoma, neuroendocrine tumours and sarcomas may also occur.1,2
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.
- No
- Non-routine fixation (not formalin), describe.
- Yes
- Special studies required, describe.
- Ensure samples are taken prior to fixation.
See general information for more detail on specimen handling procedures.
Inspect the specimen and dictate a macroscopic description.
External Inspection
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.3
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.
- Incisional biopsy
- Excisional biopsy
- Partial resection, specify site
- Total resection
- Trans-oral laser resection
- Laryngectomy
- Pharyngolaryngectomy
Neoadjuvant therapy
Anatomical components included (more than one may apply) and specimen dimensions (mm)
Describe and measure the anatomical components present.
- Larynx, in three dimensions
- Epiglottic resection margin
- Hyoid bone
- Hypopharynx
- Tracheal resection margin
- Tracheostomy site, if present
- Cervical oesophagus
- Thyroid see thyroid protocol for more detail
- Extralaryngeal soft tissues and muscle
- Other, describe and measure according to the relevant tissue protocol.
Specimen integrity
Dissection
Small fragmented specimens may not require dissection and may be transferred whole to cassettes for processing.4 See protocol for small biopsies.
See Slootweg5 reference for excellent diagrams to assist with complex head and neck specimens.
Paint the anterior and posterior surgical margins with ink.4 If present, remove the hyoid bone from the ventrocranial surface (retain for later decalcification and sectioning if microscopic examination indicates possible tumour spread to the bone).5
Section the remainder of the specimen at 3-4mm intervals horizontally.1,5
Note that it may be better to leave laryngectomy specimens for hypopharyngeal tumours intact as opening posteriorly may disrupt the post-cricoid area and hamper evaluation of the caudal mucosal margin.
Examine the slices to evaluate the extent of tumour spread.4
- Sample any areas of possible extralaryngeal spread.5
- If the specimen contains a tracheostoma, sample to demonstrate the relationship of the tumour to the stoma and sample the stomal skin margins.5
- Examine the slices to evaluate the extent of tumour spread. Sample the tracheal margin for possible caudal endolaryngeal spread.5
- Sample the caudal surgical margin for possible submucosal spread. Note that thin mucosal margins may not be sufficient and ensure adequate submucosal tissue is included.5
Examine the slices to evaluate the extent of tumour spread. Tumours located dorsally may extend into the postcricoid area. Sample the submucosal soft tissues for possible spread.5
Supraglottic carcinomas should be examined to evaluate the relationship of the tumour with anterior resection margin at the base of the tongue. Sample the margin using sagittal sections.1
After opening the specimen may require longer fixation in larger quantity of formalin.
Internal Inspection
Describe the internal or cut surface appearance including the following items:
Tumour
- Absent
- Present
- Number; if more than one tumour, designate and describe each tumour separately
Laryngeal resections for benign disease are dissected and processed in a similar manner to those with malignant conditions.4
Tumour size (mm)
Tumour site of involvement
Record the site of tumour involvement (more than one may apply).
Hypopharynx
- Pyriform sinus -right/left/midline
- Post-cricoid area -right/left/midline
- Extends into supraglottic area (crosses aryepiglottic fold)
Larynx
- Supraglottis
- Side –Right/Left/Midline
- False cord
- Sinus of Morgagni (laryngeal ventricle)
- Epiglottis
- Lingual aspect
- Laryngeal aspect
- Glottis
- True vocal cords –left/right
- Anterior commissure
- Posterior commissure
- Subglottis -i.e. involves the true vocal cords with subglottic extension of >10mm or tumours entirely confined to the subglottic area
- Other, describe
Transglottic
Macroscopic involvement of other tissues
- Laryngeal cartilage, specify numbers involved
- Extralaryngeal tissues
- Other (e.g. thyroid gland etc), describe
Tumour appearance
- Polypoid/exophytic
- Endophytic
- Ulcer
- Fibrous thickening
Distance to margins
- Distance of tumour to closest surgical margin (mm) and specify margin(s)
- Distance of edge of tumour to tracheostomy site (mm)
Retrieved from resection specimen
- Describe site(s)
- Number retrieved
Separately submitted
- For each specimen container, record specimen number and designation
- Collective size of tissue in three dimensions (mm)
- Number of grossly identified lymph nodes submitted
- Maximum diameter of each (mm)
Neck dissection
See neck dissection protocol.
Non-tumour lesion
Photograph the dissected specimen, if required.
Note photographs taken, diagrams recorded and markings used for identification.
Processing
Dissect the specimen further and submit sections for processing according to the illustrations provided.
Submit all sections of tumour for processing. See small biopsy protocol for more detail.
Submit representative sections of:
- Tumour, at least one block per 10 mm of maximum dimension, demonstrating:1
- Relationship with anterior and posterior surgical margins
- Deepest point of invasion
- Relationship with surrounding soft tissue
- Relationship with laryngeal cartilages1,5
- For hypopharyngeal tumours; relationship with tracheal and caudal margins
- For glottic tumours; relationship with submucosal soft tissues
- For supraglottic carcinomas; relationship with cranial and ventral margins at the base of the tongue (using sagittal sections)1
- Tracheostomy site, if present
- Non-lesional tissue, one block
- Thyroid, if present
- Normal, one block
- Abnormal, one or more representative sections. See thyroid protocol and Structured Reporting Protocol6 for more detail.
- If present and suspicious for involvement
Submit all lymph nodes and identify the site of each.
Record details of each cassette.
An illustrated block key similar to the one provided may be useful.
Block allocation key
|
Cassette id
|
Site
|
No. of pieces
|
|
A-B
|
Tumour, all sections |
|
As demonstrated in laryngectomy photographs provided
| Cassette id |
Site |
No. of pieces |
| A |
Superior aspect of tumour |
|
| B-O |
Representative sections of tumour including full slice of tumour and sections demonstrating relationship with surgical margins |
|
| P |
Inferior margin |
|
| Q+ |
Lymph nodes if present |
|
Acknowledgements
Prof Alfred Lam for his contribution in reviewing and editing this protocol.
References
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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.
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