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CONSULT an attending before grossing and take photographs (BOTH intact and after sectioning). Gross orientation, planning your sections appropriately, and gross staging are critical.
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- Measure in 3 dimensions.
- Orient and identify anatomic landmarks on the external surface.
- Identify hyoid bone (if present).
- Identify thyroid gland (if present) on anterior surface and measure.
- Identify skin +/- tracheostomy (if present) on anterior surface and measure.
- Ink peripheral soft tissue margins (anterior, posterior, right, left, superior).
- For Laryngectomy: If the tumor is centered on the anterior larynx, open longitudinally through posterior midline (designated 6:00).
- For Laryngopharyngectomy: If the tumor is located in the posterior pharyngeal wall, please consult an attending prior to sectioning. This will require opening the pharynx laterally to create a pharyngeal “flap.”
- For Thyroid Cancer invasive into trachea: You may consider sectioning the specimen axially. Consult an attending prior to opening.
- Prop open with wooden stick and photograph fresh prior to sectioning.
- Measure mucosal-based mass lesions (in 3D) or ulcerated lesions (in 2D) in the fresh state, noting their location and distance to nearest mucosal margins.
- If directed by the attending, you may make additional fresh sections.
- Otherwise, fix in formalin overnight.
- Identify the anatomic subsite where the tumor is located – this will be important for sectioning and staging:
- Supraglottis: extends from the tip of the epiglottis to a horizontal line passing through the apex of the ventricle. Structures included in this compartment are the epiglottis (lingual and laryngeal aspects), aryepiglottic folds, arytenoids, false vocal cords, and the ventricle.
- Glottis: extends from the ventricle to approximately 1.0 cm below the free level of the true vocal cord and includes the anterior and posterior commissures and the true vocal cord.
- Subglottis: extends from approximately 1.0 cm below the level of the true vocal cord to the inferior rim of the cricoid cartilage.
- Take mucosal margins. You can take them radially or en face, as discussed with the attending. A general rule of thumb is to take radial margins if less than or equal to 5 mm from tumor and take en face margins if more than 5 mm from tumor. Mucosal margins include:
- Right and left “arytenoid” area (at posterior cricoid cartilage)
- Right and left aryepiglottic fold or pyriform sinus (at lateral edges)
- Right and left anterior epiglottis (at vallecula)
- Take the circumferential distal tracheal margin en face.
- Take soft tissue margins radially, including anterior/lateral (strap muscles), superior (pre-epiglottic space), and posterior if applicable. You can do this after the larynx has been sectioned (see below).
- Most tumors require longitudinal sectioning through the larynx: Start by bisecting the specimen longitudinally (sagittally) through the anterior midline, i.e. anterior commissure (you can designate the anterior commissure as 12:00 and the posterior midline as 6:00). Note whether lesion crosses the MIDLINE anteriorly or posteriorly, and note extent of involvement of laryngeal subsites (glottis, supraglottis, subglottis, epiglottis, pyriform sinus, base of tongue, etc). Make additional parasagittal sections perpendicular to the mucosa to determine the gross extent of invasion and document involvement of extralaryngeal subsites (paraglottic space, preepiglottic space, strap muscles).
- The paraglottic space is a potential space deep to the vocal cords and filled with adipose and connective tissue. It is bounded by the conus elasticus inferiorly, the thyroid cartilage laterally, the quadrangular membrane medially, and the piriform sinus posteriorly.
- The pre-epiglottic space is also filled with adipose and connective tissue. It is triangular in shape and is bounded by the thyroid cartilage and thyrohyoid membrane anteriorly, the epiglottis and thyroepiglottic ligament posteriorly, and the hyoepiglottic ligament at its base.
- The post-cricoid space is the tissue posterior to the cricoid cartilage (at the area of the obliquely-oriented posterior crico-arytenoid muscles).
- Take photographs of the cut section, to include tumor and (if applicable) deepest invasion into tracheal cartilage or soft tissue.
- If the mass is large and exophytic, submit representative sections (~1 per cm), including:
- Involvement of laryngeal subsites (if applicable).
- Deepest invasion into tracheal cartilage or soft tissues.
- Closest approximation to peripheral soft tissue margins (usually anterior and superior are closest, occasionally right, left, or posterior).
- Don’t forget that you can use your clock-face for orientation (i.e. anterior midline 12:00, posterior midline 6:00, left side 9:00, right side 3:00, etc)
- If the only lesion is ulcer and no definitive mass is identified, submit the entire ulcer.
- If tracheal cartilage is calcified, you may need to decalcify individual blocks, AFTER adequate fixation.
- Submit representative sections of other normal structures, including thyroid and skin.