Protocol for the Examination of Specimens From Patients With

Carcinomas of the Nasal Cavity and Paranasal Sinuses

Protocol applies to all invasive carcinomas of the nasal cavity and paranasal
sinuses. Mucosal malignant melanoma is included. Lymphomas
neuroectodermal neoplasms and sarcomas are not included.
!ased on "#CC$%&CC 'NM (th edition
Protocol web posting date: June 2012
Procedures
Biopsy
Resection
"uthors
Diane L. Carlson !D "C#P$
Depart%ent o& Pat'ology !e%orial (loan)*ettering Cancer Center +ew ,or- +,
Leon Barnes !D
Depart%ent o& Pat'ology .ni/ersity o& Pittsburg' (c'ool o& !edicine Pittsburg' P#
Jo'n C'an !D "C#P
Depart%ent o& Pat'ology 0ueen 1li2abet' 3ospital 3ong *ong
4ary 1llis DD(
#R.P Laboratories (alt La-e City .5
Louis B. 3arrison !D
Depart%ent o& Radiation 6ncology Bet' 7srael !edical Center (t. Lu-e8s and Roose/elt 3ospitals +ew ,or-
+,
Jenni&er Leig' 3unt !D "C#P
Depart%ent o& Pat'ology !assac'usetts 4eneral 3ospital Boston !#
!ary (. Ric'ardson !D DD(
Depart%ent o& Pat'ology !edical .ni/ersity o& (out' Carolina C'arleston (C
Jatin ('a' !D "#C(
3ead and +ec- (er/ice Depart%ent o& (urgery !e%orial (loan *ettering Cancer Center +ew ,or- +,
Lester D. R. 5'o%pson !D "C#P
Depart%ent o& Pat'ology (out'ern Cali&ornia Per%anente !edical 4roup 9oodland 3ills C#
Ric'ard :arbo !D D!D "C#P
Depart%ent o& Pat'ology 3enry "ord 3ealt' (yste%s Detroit !7
Bruce !. 9enig !D "C#P;
Depart%ent o& Pat'ology and Laboratory !edicine Bet' 7srael !edical Center (t. Lu-e8s and Roose/elt
3ospitals +ew ,or- +,
"or t'e !e%bers o& t'e Cancer Co%%ittee College o& #%erican Pat'ologists
$ Denotes pri%ary aut'or. ; Denotes senior aut'or. #ll ot'er contributing aut'ors are listed alp'abetically.
Previous contri)utors* Ben :. Pilc' !D< 1li2abet' 4illies !D< Jo'n R. 3ouc- Jr !D< *yung)9'an !in !D<
Da/id +o/is !D< Jatin ('a' !D< Ric'ard J. :arbo !D D!D< Bruce ! 9enig !D
+ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
. /01/ College of "merican Pathologists 2C"P3. "ll rights reserved.
5'e College does not per%it reproduction o& any substantial portion o& t'ese protocols wit'out its written
aut'ori2ation. 5'e College 'ereby aut'ori2es use o& t'ese protocols by p'ysicians and ot'er 'ealt' care pro/iders
in reporting on surgical speci%ens in teac'ing and in carrying out %edical researc' &or nonpro&it purposes. 5'is
aut'ori2ation does not e>tend to reproduction or ot'er use o& any substantial portion o& t'ese protocols &or
co%%ercial purposes wit'out t'e written consent o& t'e College.
5'e C#P also aut'ori2es p'ysicians and ot'er 'ealt' care practitioners to %a-e %odi&ied /ersions o& t'e
Protocols solely &or t'eir indi/idual use in reporting on surgical speci%ens &or indi/idual patients teac'ing and
carrying out %edical researc' &or non)pro&it purposes.
5'e C#P &urt'er aut'ori2es t'e &ollowing uses by p'ysicians and ot'er 'ealt' care practitioners in reporting on
surgical speci%ens &or indi/idual patients in teac'ing and in carrying out %edical researc' &or non)pro&it
purposes: ?1@ 4ictation &ro% t'e original or %odi&ied protocols &or t'e purposes o& creating a te>t)based patient
record on paper or in a word processing docu%ent< ?2@ Copying &ro% t'e original or %odi&ied protocols into a
te>t)based patient record on paper or in a word processing docu%ent< ?=@ 5'e use o& a computeri5ed system &or
ite%s ?1@ and ?2@ pro/ided t'at t'e Protocol data is stored intact as a single te>t)based docu%ent and is not
stored as %ultiple discrete data &ields.
6t'er t'an uses ?1@ ?2@ and ?=@ abo/e t'e C#P does not aut'ori2e any use o& t'e Protocols in electronic %edical
records syste%s pat'ology in&or%atics syste%s cancer registry co%puter syste%s co%puteri2ed databases
%appings between coding wor-s or any co%puteri2ed syste% wit'out a written license &ro% C#P. #pplications
&or suc' a license s'ould be addressed to t'e (+6!1D 5er%inology (olutions di/ision o& t'e C#P.
#ny public disse%ination o& t'e original or %odi&ied Protocols is pro'ibited wit'out a written license &ro% t'e C#P.
5'e College o& #%erican Pat'ologists o&&ers t'ese protocols to assist pat'ologists in pro/iding clinically use&ul and
rele/ant in&or%ation w'en reporting results o& surgical speci%en e>a%inations o& surgical speci%ens. 5'e College
regards t'e reporting ele%ents in t'e A(urgical Pat'ology Cancer Case (u%%aryB portion o& t'e protocols as
essential ele%ents o& t'e pat'ology report. 3owe/er t'e %anner in w'ic' t'ese ele%ents are reported is at t'e
discretion o& eac' speci&ic pat'ologist ta-ing into account clinician pre&erences institutional policies and
indi/idual practice.
5'e College de/eloped t'ese protocols as an educational tool to assist pat'ologists in t'e use&ul reporting o&
rele/ant in&or%ation. 7t did not issue t'e protocols &or use in litigation rei%burse%ent or ot'er conte>ts.
+e/ert'eless t'e College recogni2es t'at t'e protocols %ig't be used by 'ospitals attorneys payers and ot'ers.
7ndeed e&&ecti/e January 1 200C t'e Co%%ission on Cancer o& t'e #%erican College o& (urgeons %andated
t'e use o& t'e reDuired data ele%ents o& t'e protocols as part o& its Cancer Progra% (tandards &or #ppro/ed
Cancer Progra%s. 5'ere&ore it beco%es e/en %ore i%portant &or pat'ologists to &a%iliari2e t'e%sel/es wit'
t'ese docu%ents. #t t'e sa%e ti%e t'e College cautions t'at use o& t'e protocols ot'er t'an &or t'eir intended
educational purpose %ay in/ol/e additional considerations t'at are beyond t'e scope o& t'is docu%ent.
5'e inclusion o& a product na%e or ser/ice in a C#P publication s'ould not be construed as an endorse%ent o&
suc' product or ser/ice nor is &ailure to include t'e na%e o& a product or ser/ice to be construed as disappro/al.
2
+ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
C"P Nasal Cavity Paranasal Sinuses Protocol 6evision +istory
7ersion Code
5'e de&inition o& t'e /ersion code can be &ound at www.cap.orgEcancerprotocols.
7ersion* +asalCa/ityParanasal(inus =.1.0.1
Summary of Changes
5'e &ollowing c'anges 'a/e been %ade since t'e "ebruary 2011 release.
Explanatory Notes
Scope of 8uidelines
5'e word Ac'ec-list?s@B was c'anged to Acase su%%ary?ies@B or AprotocolB as appropriate.
=
C"P "pproved +ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
Surgical Pathology Cancer Case Summary
Protocol web posting date: June 2012
N"S"L C"7&'9 "N4 P"6"N"S"L S&N%SES* &ncisional !iopsy Excisional !iopsy 6esection
Select a single response unless other:ise indicated.
Specimen 2select all that apply3 2Note "3
FFF +asal ca/ity
FFF (eptu%
FFF "loor
FFF Lateral wall
FFF Gestibule
FFF Paranasal sinus?es@ %a>illary
FFF Paranasal sinus?es@ et'%oid
FFF Paranasal sinus?es@ &rontal
FFF Paranasal sinus?es@ sp'enoid
FFF 6t'er ?speci&y@: FFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFF +ot speci&ied
Recei/ed:
FFF "res'
FFF 7n &or%alin
FFF 6t'er ?speci&y@: FFFFFFFFFFFFFFFFFFFFFFFFFFFF
Procedure 2select all that apply3
FFF 7ncisional Biopsy
FFF 1>cisional Biopsy
FFF Resection ?speci&y type@
FFF Partial %a>illecto%y
FFF Radical %a>illecto%y
FFF +ec- ?ly%p' node@ Dissection ?speci&y@: FFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFF 6t'er ?speci&y@: FFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFF +ot (peci&ied
; Specimen &ntegrity
H FFF 7ntact
H FFF "rag%ented
Specimen Si5e
4reatest di%ensions: FFF > FFF > FFF c%
H #dditional di%ensions ?i& %ore t'an one part@: FFF > FFF > FFF c%
Specimen Laterality 2select all that apply3
FFF Rig't
FFF Le&t
FFF Bilateral
FFF !idline
FFF +ot speci&ied
'umor Site 2select all that apply3 2Note "3
FFF +asal ca/ity
FFF (eptu%
H Data ele%ents preceded by t'is sy%bol are not reDuired. 3owe/er t'ese ele%ents %ay be
clinically i%portant but are not yet /alidated or regularly used in patient %anage%ent.
=
C"P "pproved +ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
FFF "loor
FFF Lateral wall
FFF Gestibule
FFF Paranasal sinus?es@ %a>illary
FFF Paranasal sinus?es@ et'%oid
FFF Paranasal sinus?es@ &rontal
FFF Paranasal sinus?es@ sp'enoid
FFF 6t'er ?speci&y@: FFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFF +ot speci&ied
'umor Focality 2select all that apply3
FFF (ingle &ocus
FFF Bilateral
FFF !ulti&ocal ?speci&y@: FFFFFFFFFFFFFFFFFFFF
'umor Si5e
4reatest di%ension: FFF c%
H #dditional di%ensions: FFF > FFF c%
FFF Cannot be deter%ined ?see Co%%ent@
; 'umor 4escription 2select all that apply3
H 4ross subtype:
H FFF Polypoid
H FFF 1>op'ytic
H FFF 1ndop'ytic
H FFF .lcerated
H FFF (essile
H FFF 6t'er ?speci&y@: FFFFFFFFFFFFFFFFFFFFFFFFFFF
H Macroscopic Extent of 'umor
H (peci&y: FFFFFFFFFFFFFFFFFFFFFFFFFF
+istologic 'ype 2select all that apply3 2Note !3
Carcino%as o& t'e +asal Ca/ity and Paranasal (inuses
FFF (Dua%ous cell carcino%a con/entional
FFF *eratini2ing
FFF +on-eratini2ing ?&or%erly cylindrical cell transitional cell@
Gariants o& (Dua%ous Cell Carcino%a
FFF #cant'olytic sDua%ous cell carcino%a
FFF #denosDua%ous carcino%a
FFF Basaloid sDua%ous cell carcino%a
FFF Papillary sDua%ous cell carcino%a
FFF (pindle cell sDua%ous cell carcino%a
FFF Gerrucous carcino%a
FFF 4iant cell carcino%a
FFF Ly%p'oepit'elial carcino%a ?non)nasop'aryngeal@
FFF (inonasal undi&&erentiated carcino%a ?(+.C@
#denocarcino%a +on)(ali/ary 4land 5ype
FFF 7ntestinal type
FFF Papillary)type
FFF Colonic)type
FFF (olid type
H Data ele%ents preceded by t'is sy%bol are not reDuired. 3owe/er t'ese ele%ents %ay be
clinically i%portant but are not yet /alidated or regularly used in patient %anage%ent.
C
C"P "pproved +ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
FFF !ucinous type
FFF !i>ed type
FFF +on)intestinal type
FFF Low grade
FFF 7nter%ediate grade
FFF 3ig' grade
Carcino%as o& !inor (ali/ary 4lands
FFF #cinic cell carcino%a
FFF #denoid cystic carcino%a
FFF #denocarcino%a not ot'erwise speci&ied ?+6(@
FFF Low grade
FFF 7nter%ediate grade
FFF 3ig' grade
FFF Carcino%a e> pleo%orp'ic adeno%a ?%alignant %i>ed tu%or@
FFF Clear cell adenocarcino%a
FFF 1pit'elial)%yoepit'elial carcino%a
FFF !ucoepider%oid carcino%a:
FFF Low grade
FFF 7nter%ediate grade
FFF 3ig' grade
FFF !yoepit'elial carcino%a ?%alignant %yoepit'elio%a@
FFF 6ncocytic carcino%a
FFF Poly%orp'ous low)grade adenocarcino%a
FFF (ali/ary duct carcino%a
FFF 6t'er ?speci&y@: FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
+euroendocrine Carcino%a
FFF 5ypical carcinoid tu%or ?well di&&erentiated neuroendocrine carcino%a@
FFF #typical carcinoid tu%or ?%oderately di&&erentiated neuroendocrine carcino%a@
FFF (%all cell carcino%a ?poorly di&&erentiated neuroendocrine carcino%a@
FFF Co%bined ?or co%posite@ s%all cell carcino%a neuroendocrine type
FFF !ucosal %alignant %elano%a
FFF 6t'er ?speci&y@: FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
FFF Carcino%a type cannot be deter%ined
+istologic 8rade 2Note C3
FFF +ot applicable
FFF 4I: Cannot be assessed
FFF 41: 9ell di&&erentiated
FFF 42: !oderately di&&erentiated
FFF 4=: Poorly di&&erentiated
FFF 6t'er ?speci&y@: FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF
; Microscopic 'umor Extension
H (peci&y: FFFFFFFFFFFFFFFFFFFFFFFFFFFF
Margins 2select all that apply3 2Notes 4 and E3
FFF Cannot be assessed
FFF !argins unin/ol/ed by in/asi/e carcino%a
Distance &ro% closest %argin: FFF %% or FFF c%
(peci&y %argin?s@ per orientation i& possible: FFFFFFFFFFFFFFF
FFF !argins in/ol/ed by in/asi/e carcino%a
(peci&y %argin?s@ per orientation i& possible: FFFFFFFFFFFFFFF
H Data ele%ents preceded by t'is sy%bol are not reDuired. 3owe/er t'ese ele%ents %ay be
clinically i%portant but are not yet /alidated or regularly used in patient %anage%ent.
J
C"P "pproved +ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
FFF !argins unin/ol/ed by carcino%a in situ ?includes %oderate and se/ere dysplasia
K
@ ?+ote D@
Distance &ro% closest %argin: FFF %% or FFF c%
(peci&y %argin?s@ per orientation i& possible: FFFFFFFFFFFFFFF
FFF !argins in/ol/ed by carcino%a in situ ?includes %oderate and se/ere dysplasia
K
@ ?+ote D@
(peci&y %argin?s@ per orientation i& possible: FFFFFFFFFFFFFFF
FFF +ot applicable
#
Applicable only to squamous cell carcinoma and histologic variants.
; 'reatment Effect 2applica)le to carcinomas treated :ith neoad<uvant therapy3
H FFF +ot identi&ied
H FFF Present ?speci&y@: FFFFFFFFFFFFFFFFFFFF
H FFF 7ndeter%inate
Lymph=7ascular &nvasion
FFF +ot 7denti&ied
FFF Present
FFF 7ndeter%inate

Perineural &nvasion 2Note F3
FFF +ot identi&ied
FFF Present
FFF 7ndeter%inate
Lymph Nodes Extranodal Extension 2Note 83
FFF +ot identi&ied
FFF Present
FFF 7ndeter%inate
Pathologic Staging 2p'NM3 2Note +3
5+! Descriptors ?reDuired only i& applicable@ ?select all t'at apply@
FFF % ?%ultiple pri%ary tu%ors@
FFF r ?recurrent@
FFF y ? posttreat%ent@
Pri%ary 5u%or ?p5@
FFF p5I: Cannot be assessed
FFF p50: +o e/idence o& pri%ary tu%or
FFF p5is: Carcino%a in situ
For "ll Carcinomas Excluding Mucosal Malignant Melanoma
Pri%ary 5u%or ?p5@: !a>illary (inus
FFF p51: 5u%or li%ited to %a>illary sinus %ucosa wit' no erosion or destruction o& bone
FFF p52: 5u%or causing bone erosion or destruction including e>tension into t'e 'ard palate andEor %iddle
nasal %eatus e>cept e>tension to posterior wall o& %a>illary sinus and pterygoid plates
FFF p5=: 5u%or in/ades any o& t'e &ollowing: bone o& t'e posterior wall o& %a>illary sinus subcutaneous
tissues &loor or %edial wall o& orbit pterygoid &ossa et'%oid sinuses
FFF p5Ca: !oderately ad/anced local disease. 5u%or in/ades anterior orbital contents s-in o& c'ee-
pterygoid plates in&rate%poral &ossa cribri&or% plate sp'enoid or &rontal sinuses
FFF p5Cb: Gery ad/anced local disease. 5u%or in/ades any o& t'e &ollowing: orbital ape> dura brain %iddle
cranial &ossa cranial ner/es ot'er t'an %a>illary di/ision o& trige%inal ner/e ?G2@ nasop'aryn> or
cli/us
H Data ele%ents preceded by t'is sy%bol are not reDuired. 3owe/er t'ese ele%ents %ay be
clinically i%portant but are not yet /alidated or regularly used in patient %anage%ent.
L
C"P "pproved +ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
Pri%ary 5u%or ?p5@: +asal Ca/ity and 1t'%oid (inus
FFF p51: 5u%or restricted to any one subsite wit' our wit'out bone in/asion
FFF p52: 5u%or in/ading two subsites in a single region or e>tending to in/ol/e an adMacent region wit'in t'e
nasoet'%oidal co%ple> wit' our wit'out bone in/asion
FFF p5=: 5u%or e>tends to in/ade t'e %edial wall or &loor o& t'e orbit %a>illary sinus palate or cribri&or%
plate
FFF p5Ca: !oderately ad/anced local disease 5u%or in/ades any o& t'e &ollowing: anterior orbital contents
s-in o& nose or c'ee- %ini%al e>tension to anterior cranial &ossa pterygoid plates sp'enoid or
&rontal sinuses
FFF p5Cb: Gery ad/anced local disease. 5u%or in/ades any o& t'e &ollowing: orbital ape> dura brain %iddle
cranial &ossa cranial ner/es ot'er t'an %a>illary di/ision o& trige%inal ner/e ?G2@ nasop'aryn> or
cli/us
Regional Ly%p' +odes ? p+@
K
?+otes 7 t'roug' L@
FFF p+I: Cannot be assessed
FFF p+0: +o regional ly%p' node %etastasis
FFF p+1: !etastasis in a single ipsilateral ly%p' node = c% or less in greatest di%ension
FFF p+2: !etastasis in a single ipsilateral ly%p' node %ore t'an =c% but not %ore t'an L c% in greatest
di%ension or in %ultiple ipsilateral ly%p' nodes none %ore t'an L c% in greatest di%ension or in
bilateral or contralateral nodes none %ore t'an L c% in greatest di%ension
FFF p+2a: !etastasis in a single ipsilateral ly%p' node %ore t'an = c% but not %ore t'an L c% in greatest
di%ension
FFF p+2b: !etastasis in %ultiple ipsilateral ly%p' nodes none %ore t'an L c% in greatest di%ension
FFF p+2c: !etastasis in bilateral or contralateral ly%p' nodes none %ore t'an L c% in greatest di%ension
FFF p+=: !etastasis in a ly%p' node %ore t'an L c% in greatest di%ension
FFF +o nodes sub%itted or &ound
Number of Lymph Nodes Examined
(peci&y: FFFF
FFF +u%ber cannot be deter%ined ?e>plain@: FFFFFFFFFFFFFFFFFFFFFF
Number of Positive Lymph Nodes
(peci&y: FFFF
FFF +u%ber cannot be deter%ined ?e>plain@: FFFFFFFFFFFFFFFFFFFFFF
H (i2e o& t'e largest positi/e ly%p' node: FFFFFFFFF ?+ote *@
H (i2e o& t'e associated %etastatic &ocus: FFFFFFFFFF ?+ote *@
H Position o& t'e in/ol/ed node ?le/el@: FFFFFFFFFF ?+ote *@
#
Metastases at level !! are considered regional lymph node metastases. Midline nodes are considered ipsilateral nodes.
Distant !etastasis ?p!@
FFF +ot applicable
FFF p!1: Distant %etastasis
H (peci&y site?s@ i& -nown: FFFFFFFFFFFFFFFFFFFFFFFF
H (ource o& pat'ologic %etastatic speci%en ?speci&y@: FFFFFFFFFFFFFFF
For Mucosal Malignant Melanoma
Pri%ary 5u%or ?p5@
FFF p5=: !ucosal disease
FFF p5Ca: !oderately ad/anced disease. 5u%or in/ol/ing deep so&t tissue cartilage bone or o/erlying s-in
FFF p5Cb: Gery ad/anced disease. 5u%or in/ol/ing brain dura s-ull base lower cranial ner/es ?7I I I7 I77@
%asticator space carotid artery pre/ertebral space or %ediastinal structures
H Data ele%ents preceded by t'is sy%bol are not reDuired. 3owe/er t'ese ele%ents %ay be
clinically i%portant but are not yet /alidated or regularly used in patient %anage%ent.
N
C"P "pproved +ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
Regional Ly%p' +odes ?p+@
FFF p+I: Regional ly%p' nodes cannot be assessed
FFF p+0: +o regional ly%p' node %etastases
FFF p+1: Regional ly%p' node %etastases present
Distant !etastasis ?p!@
FFF +ot applicable
FFF p!1: Distant %etastasis present
H (peci&y site?s@ i& -nown: FFFFFFFFFFFFFFFFFFFFFFFFF
H (ource o& pat'ologic %etastatic speci%en ?speci&y@: FFFFFFFFFFFFFFF
; "dditional Pathologic Findings 2select all that apply3
H FFF +one identi&ied
H FFF Carcino%a in situ ?+ote !@
H FFF 1pit'elial dysplasia ?+ote !@
H (peci&y: FFFFFFFFFFFFFFFFFFFFFFFFFFFF
H FFF 7n&la%%ation ?speci&y type@: FFFFFFFFFFFFFFFFFFFFFFFFFFFF
H FFF (Dua%ous %etaplasia
H FFF 1pit'elial 'yperplasia
H FFF Coloni2ation
H FFF "ungal
H FFF Bacterial
H FFF 6t'er ?speci&y@: FFFFFFFFFFFFFFFFFFFFFFFFFFFF
; "ncillary Studies 2Note N3
H (peci&y type?s@: FFFFFFFFFFFFFFFFFFFFFFFFFFF
H (peci&y result?s@: FFFFFFFFFFFFFFFFFFFFFFFFFF
; Clinical +istory 2select all that apply3
H FFF +eoadMu/ant t'erapy
H FFF ,es ?speci&y type@: FFFFFFFFFFFFFFFFFFFFFFFFFFFF
H FFF +o
H FFF7ndeter%inate
H FFF 6t'er ?speci&y@: FFFFFFFFFFFFFFFFFFFFFFFFFFFF
; Comment2s3
H Data ele%ents preceded by t'is sy%bol are not reDuired. 3owe/er t'ese ele%ents %ay be
clinically i%portant but are not yet /alidated or regularly used in patient %anage%ent.
O
!ac,ground 4ocumentation +ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
Explanatory Notes
Scope of 8uidelines
5'e reporting o& oral cancer including t'e lip is &acilitated by t'e pro/ision o& a case su%%ary illustrating t'e
&eatures reDuired &or co%pre'ensi/e patient care. 3owe/er t'ere are %any cases in w'ic' t'e indi/idual
practicalities o& applying suc' a case su%%ary %ay not be straig't&orward. Co%%on e>a%ples include &inding t'e
prescribed nu%ber o& ly%p' nodes trying to deter%ine t'e le/els o& t'e radical nec- dissection and deter%ining i&
isolated tu%or cells in a ly%p' node represent %etastatic disease. Case su%%aries 'a/e e/ol/ed to include
clinical radiograp'ic %orp'ologic i%%uno'istoc'e%ical and %olecular results in an e&&ort to guide clinical
%anage%ent. #dMu/ant and neoadMu/ant t'erapy can signi&icantly alter 'istologic &indings %a-ing accurate
classi&ication an increasingly co%ple> and de%anding tas-. 5'is protocol tries to re%ain si%ple w'ile still
incorporating i%portant pat'ologic &eatures as proposed by t'e #%erican Joint Co%%ittee on Cancer ?#JCC@
cancer staging %anual t'e 9orld 3ealt' 6rgani2ation classi&ication o& tu%ours t'e 5+! classi&ication t'e
#%erican College o& (urgeons Co%%ission on Cancer and t'e 7nternational .nion on Cancer ?.7CC@. 5'is
protocol is to be used as a guide and resource an adMunct to diagnosing and %anaging cancers o& t'e oral ca/ity
in a standardi2ed %anner. 7t s'ould not be used as a substitute &or dissection or grossing tec'niDues and does not
gi/e 'istologic para%eters to reac' t'e diagnosis. (ubMecti/ity is always a &actor and ele%ents listed are not
%eant to be arbitrary but are %eant to pro/ide uni&or%ity o& reporting across all t'e disciplines t'at use t'e
in&or%ation. 7t is a &oundation o& practical in&or%ation t'at will 'elp to %eet t'e reDuire%ents o& daily practice to
bene&it bot' clinicians and patients ali-e.
". "natomical Sites and Su)sites for the Nasal Cavity and Paranasal Sinuses ?"igure 1@
5'e nasal ca/ity is di/ided in t'e %idline to rig't and le&t 'al/es by t'e septu%< eac' 'al& opens on t'e &ace /ia
t'e nares or nostrils and co%%unicates be'ind wit' t'e nasop'aryn> t'roug' t'e posterior nasal apertures or t'e
c'oanae. 5'e nasal ca/ity is di/ided into C subsites including t'e septu% &loor lateral wall and /estibule. 5'e
paranasal sinuses represent a grouping o& C paired sinuses including t'e %a>illary sinuses et'%oid sinuses
&rontal sinuses and sp'enoid sinuses. 5'e nasoet'%oidal co%ple> is di/ided into 2 sites including t'e nasal
ca/ity and t'e et'%oid sinuses.
Cancers o& t'e %a>illary sinuses are t'e %ost co%%on sinonasal %alignancies &ollowed by cancers o& t'e
et'%oid sinuses w'ic' are %uc' less co%%on.
1
Cancers o& t'e &rontal and sp'enoid sinuses are rare. 9'en
considering t'e nasal ca/ity and paranasal sinuses L0P o& %alignant neoplas%s originate &ro% t'e %a>illary
sinus 20P to =0P &ro% t'e nasal ca/ity 10P to 1JP &ro% t'e et'%oid sinus and 1P &ro% t'e sp'enoid and
&rontal sinuses.
2
9'en only considering t'e paranasal sinuses NNP o& %alignant neoplas%s originate &ro% t'e
%a>illary sinus 22P &ro% t'e et'%oid sinus and 1P &ro% t'e sp'enoid and &rontal sinuses.
2
5'e location as well as t'e e>tent o& t'e %ucosal lesion in t'e %a>illary sinus 'as prognostic i%portance.
6'ngrenQs line connecting t'e %edial cant'us o& t'e eye to t'e angle o& t'e %andible di/ides t'e %a>illary sinus
into an anterioin&erior portion ?in&rastructure@ and superioposterior portion ?suprastructure@ structures. Carcino%as
o& t'e in&rastructure are associated wit' a good prognosis< carcino%as o& t'e suprastructure are associated wit' a
poor prognosis. 5'e poorer prognosis wit' carcino%as o& t'e suprastructure re&lects early access o& t'ese tu%ors
to critical structures including t'e eye s-ull base pterygoids and in&rate%poral &ossa.
1
R
!ac,ground 4ocumentation +ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
Figure 1. #nato%ical sites and subsites &or t'e nasal ca/ity and paranasal sinuses. "ro% A"## #ancer $taging Manual. Lt'
ed. +ew ,or-: (pringer< 2002. S #%erican Joint Co%%ittee on Cancer. Reproduced wit' per%ission.
!. +istological 'ype
# %odi&ication o& t'e 9orld 3ealt' 6rgani2ation ?936@ classi&ication o& carcino%as o& t'e nasal ca/ity and
paranasal sinuses is s'own below.
=
5'is list %ay not be co%plete. 5'is protocol applies only to carcino%as and
%elano%as and does not apply to ly%p'o%as sarco%as or neuroectoder%al tu%ors ?eg ol&actory
neuroblasto%a pri%iti/e neuroectoder%al tu%or TP+15U ot'ers@.
Nasal Cavity and Paranasal Sinuses
(Dua%ous Cell Carcino%a Con/entional
*eratini2ing
+on-eratini2ing ?&or%erly cylindrical cell transitional cell@
Gariants o& (Dua%ous Cell Carcino%a %in alphabetical order&
#cant'olytic sDua%ous cell carcino%a
#denosDua%ous carcino%a
Basaloid sDua%ous cell carcino%a
Papillary sDua%ous cell carcino%a
(pindle cell sDua%ous cell carcino%a
Gerrucous carcino%a
4iant cell carcino%a
K
Ly%p'oepit'elial carcino%a ?non)nasop'aryngeal@
(inonasal undi&&erentiated carcino%a ?(+.C@
"denocarcinoma Non=Salivary 8land 'ype
7ntestinal)type
10
!ac,ground 4ocumentation +ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
+on)intestinal type
Carcinomas of Minor Salivary 8lands
#cinic cell carcino%a
#denoid cystic carcino%a
#denocarcino%a not ot'erwise speci&ied ?+6(@
Carcino%a e> pleo%orp'ic adeno%a ?%alignant %i>ed tu%or@
Clear cell adenocarcino%a
!ucoepider%oid carcino%a:
1pit'elial)%yoepit'elial carcino%a
!yoepit'elial carcino%a ?%alignant %yoepit'elio%a@
6ncocytic carcino%a
Poly%orp'ous low)grade adenocarcino%a
(ali/ary duct carcino%a
6t'er
Neuroendocrine Carcinoma
5ypical carcinoid tu%or ?well di&&erentiated neuroendocrine carcino%a@
#typical carcinoid tu%or ?%oderately di&&erentiated neuroendocrine carcino%a@
(%all cell ?undi&&erentiated@ carcino%a ?poorly di&&erentiated neuroendocrine carcino%a@
Co%bined ?or co%posite@ s%all cell carcino%a neuroendocrine type
KK
Mucosal Malignant Melanoma
K
+ot included in 936 classi&ication.
KK
Represents a carcino%a s'owing co%bined &eatures o& s%all cell neuroendocrine carcino%a associated wit' a
sDua%ous or adenocarcino%atous co%ponent.
C
C. +istologic 8rade
"or 'istologic types o& carcino%as t'at are a%enable to grading = 'istologic grades are suggested as s'own
below. 9'en a tu%or %ani&ests %ore t'an 1 grade o& di&&erentiation t'e surgical report %ust designate bot' t'e
'ig'est and t'e %ost pre/alent tu%or grades.
JL
4rade I Cannot be assessed
4rade 1 9ell di&&erentiated
4rade 2 !oderately di&&erentiated
4rade = Poorly di&&erentiated
5'is grading syste% does not apply to all sali/ary gland tu%ors. 5'e 'istologic ?%icroscopic@ grading o& sali/ary
gland carcino%as 'as been s'own to be an independent predictor o& be'a/ior and plays a role in opti%i2ing
t'erapy.
N)11
"urt'er t'ere is o&ten a positi/e correlation between 'istologic grade and clinical stage. "or t'e
%aMority o& sali/ary gland carcino%as t'ere is only a single 'istologic grade and classi&ication alone deter%ines
t'e 'istologic grade ?eg acinic cell carcino%a is a 'istologically low)grade carcino%a< sali/ary duct carcino%a is a
'istologically 'ig')grade carcino%a@. 9it' so%e e>ceptions 'istologic grading is predicated on cyto%orp'ologic
&eatures. 7n t'is 'istologic grading sc'e%e = 'istologic grades are suggested as &ollows:
4rade 1 9ell di&&erentiated V Low)grade
4rade 2 !oderately di&&erentiated V 7nter%ediate)grade
4rade = Poorly di&&erentiated V 3ig')grade
4rade I Cannot be assessed
9'en a tu%or %ani&ests %ore t'an 1 grade o& di&&erentiation t'e surgical report %ust designate bot' t'e 'ig'est
and t'e %ost pre/alent tu%or grades. 7n so%e carcino%as 'istologic grading %ay be based on growt' pattern
suc' as in adenoid cystic carcino%a &or w'ic' a 'istologic 'ig')grade /ariant 'as been recogni2ed based on t'e
percentage o& solid growt'.
N
5'ose adenoid cystic carcino%as s'owing =0P or greater o& solid growt' pattern are
11
!ac,ground 4ocumentation +ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
considered to be 'istologically 'ig')grade carcino%as.
NR12
5'e 'istologic grading o& %ucoepider%oid carcino%a
includes a co%bination o& growt' pattern c'aracteristics ?eg cystic solid neurotropis%@ and cyto%orp'ologic
&indings ?eg anaplasia %itoses necrosis@.
1=)1J

4. Surgical Margins
Reporting o& surgical %argins s'ould include in&or%ation regarding t'e distance o& in/asi/e carcino%a carcino%a
in situ or 'ig' grade dysplasia ?%oderate to se/ere@ &ro% t'e surgical %argin. Closeness o& t'e abo/e
%icroscopically less t'an J %% &ro% t'e surgical border s'ould be noted in t'e report. Presence o& t'e abo/e
lesions &ound wit'in J %% o& t'e surgical border carry a signi&icant ris- &or subseDuent local recurrence.
1L)1O

Reporting o& surgical %argins &or carcino%as o& t'e %inor sali/ary glands s'ould &ollow t'ose used &or sDua%ous
cell carcino%a o& oral ca/ity. 5'ere is no category o& carcino%a in situ relati/e to carcino%as o& sali/ary glands
?%aMor %inor@.
.nli-e t'e oral ca/ity and laryn> intraepit'elial dysplasias including non-eratini2ing and -eratini2ing dysplasias as
well as carcino%a in situ o& t'e nasal ca/ity and paranasal sinuses are unco%%on especially as an isolated
clinical andEor 'istopat'ologic lesion. 7n t'e sinonasal tract w'en carcino%a in situ is identi&ied it usually is seen
in association wit' an in/asi/e carcino%a. 7n t'is setting t'e sa%e criteria detailed in t'e oral ca/ity and laryngeal
protocols apply ?see Protocol &or t'e 1>a%ination o& (peci%ens &ro% Patients wit' Carcino%as o& t'e Lip and
6ral Ca/ity and Protocol &or t'e 1>a%ination o& (peci%ens &ro% Patients wit' Carcino%as o& t'e Laryn>@.
E. >rientation of Specimen
Co%ple> speci%ens s'ould be e>a%ined and oriented wit' t'e assistance o& attending surgeons. Direct
co%%unication between t'e surgeon and pat'ologist is a critical co%ponent in speci%en orientation and proper
sectioning. 9'ene/er possible t'e tissue e>a%ination reDuest &or% s'ould include a drawing o& t'e resected
speci%en s'owing t'e e>tent o& t'e tu%or and its relation to t'e anato%ic structures o& t'e region. 5'e lines and
e>tent o& t'e resection can be depicted on preprinted ad'esi/e labels and attac'ed to t'e surgical pat'ology
reDuest &or%s.
F. Perineural &nvasion
5'e presence o& perineural in/asion ?neurotropis%@ is an i%portant predictor o& poor prognosis in 'ead and nec-
cancer o& /irtually all sites.
1R
5'e presence o& perineural in/asion ?neurotropis%@ in t'e pri%ary cancer is
associated wit' poor local disease control and regional control as well as being associated wit' %etastasis to
regional ly%p' nodes.
1R
"urt'er perineural in/asion is associated wit' decrease in disease)speci&ic sur/i/al and
o/erall sur/i/al.
1R
5'ere is con&licting data relati/e to an association between t'e presence o& perineural in/asion
and t'e de/elop%ent o& distant %etastasis wit' so%e studies s'owing an increased association wit' distant
%etastasis but ot'er studies not s'owing any correlation wit' distant %etastasis.
1R
5'e relations'ip between
perineural in/asion and prognosis is independent o& ner/e dia%eter.
20
#lt'oug' perineural in/asion o& s%all
unna%ed ner/es %ay not produce clinical sy%pto%s t'e reporting o& perineural in/asion includes ner/es o& all
si2es including s%all perip'eral ner/es ?ie less t'an 1 %% in dia%eter@. #side &ro% t'e i%pact on prognosis t'e
presence o& perineural in/asion also guides t'erapy. Concurrent adMu/ant c'e%oradiation t'erapy 'as been
s'own to i%pro/e outco%es in patients wit' perineural in/asion ?as well as in patients wit' e>tranodal e>tension
and bone in/asion@.
2122
4i/en t'e signi&icance relati/e to prognosis and treat%ent perineural in/asion is a
reDuired data ele%ent in t'e reporting o& 'ead and nec- cancers.
8. Extranodal Extension
5'e status o& cer/ical ly%p' nodes is t'e single %ost i%portant prognostic &actor in aerodigesti/e cancer. #ll
%acroscopically negati/e or eDui/ocal ly%p' nodes s'ould be sub%itted in toto. 4rossly positi/e nodes %ay be
partially sub%itted &or %icroscopic docu%entation o& %etastasis. Reporting o& ly%p' nodes containing %etastasis
s'ould include w'et'er t'ere is presence or absence o& e>tranodal e>tension ?11@. 5'is &inding consists o&
e>tension o& %etastatic tu%or present wit'in t'e con&ines o& t'e ly%p' node t'roug' t'e ly%p' node capsule into
t'e surrounding connecti/e tissue wit' or wit'out associated stro%al reaction. 7& %acroscopic e>a%ination
suggests 11 t'is tissue s'ould be sub%itted &or %icroscopic con&ir%ation. 11 is a predictor o& regional relapse
and a criterion &or postoperati/e radiot'erapy.
2=)2L
+. 'NM and Stage 8roupings
12
!ac,ground 4ocumentation +ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
5'e protocol reco%%ends t'e 5+! staging syste% o& t'e #%erican Joint Co%%ittee on Cancer ?#JCC@ and t'e
7nternational .nion #gainst Cancer ?.7CC@ &or nasal ca/ity and paranasal sinus cancer.
12N
6& note in t'e N
t'

edition o& t'e #JCC staging o& 'ead and nec- cancers
1
is t'e di/ision o& 5C lesions into 5Ca ?%oderately
ad/anced local disease@ and 5Cb ?/ery ad/anced local disease@ leading to t'e strati&ication o& stage 7G into stage
7G# ?%oderately ad/anced localEregional disease@ stage 7GB ?/ery ad/anced localEregional disease@ and stage
7GC ?distant %etastatic disease@.
5'e N
t'
edition o& t'e #JCC staging o& 'ead and nec- cancers includes %ucosal %alignant %elano%as.
1

#ppro>i%ately two)t'irds o& %ucosal %alignant %elano%as arise in t'e sinonasal tract one)Duarter are &ound in
t'e oral ca/ity and t'e re%ainder occur only sporadically in ot'er %ucosal sites o& t'e 'ead and nec-.
1
1/en s%all
cancers be'a/e aggressi/ely wit' 'ig' rates o& recurrence and deat'.
1
5o re&lect t'is aggressi/e be'a/ior
pri%ary cancers li%ited to t'e %ucosa are considered 5= lesions. #d/anced %ucosal %elano%as are classi&ied
as 5Ca and 5Cb. 5'e anato%ic e>tent criteria to de&ine moderately advanced ?5Ca@ and very advanced ?5Cb@
disease are gi/en below. 5'e #JCC staging &or %ucosal %alignant %elano%as does not pro/ide &or t'e 'istologic
de&inition o& a 5= lesion< as t'e %aMority o& %ucosal %alignant %elano%as are in/asi/e at presentation %ucosal
based %elano%as ?5= lesions@ include t'ose lesions t'at in/ol/e eit'er t'e epit'eliu% andEor la%ina propria o& t'e
in/ol/ed site. Rare e>a%ples o& in situ %ucosal %elano%as occur but in situ %ucosal %elano%as are e>cluded
&ro% staging as t'ey are e>tre%ely rare.
1
For "ll Carcinomas Excluding Mucosal Malignant Melanoma
Pri%ary 5u%or: !a>illary (inus
5I Cannot be assessed
50 +o e/idence o& pri%ary tu%or
5is Carcino%a in situ
51 5u%or li%ited to t'e %a>illary sinus %ucosa wit' no erosion or destruction o& bone
52 5u%or causing bone erosion or destruction including e>tension into t'e 'ard palate andEor %iddle nasal
%eatus e>cept e>tension to posterior wall o& %a>illary sinus and pterygoid plates
5= 5u%or in/ades any o& t'e &ollowing: bone o& t'e posterior wall o& %a>illary sinus subcutaneous tissues
&loor or %edial wall o& orbit pterygoid &ossa et'%oid sinuses
5Ca 5u%or in/ades anterior orbital contents s-in o& c'ee- pterygoid plates in&rate%poral &ossa cribri&or%
plate sp'enoid or &rontal sinuses
5Cb 5u%or in/ades any o& t'e &ollowing: orbital ape> dura brain %iddle cranial &ossa cranial ner/es ot'er
t'an %a>illary di/ision o& trige%inal ner/e ?G2@ nasop'aryn> or cli/us
Pri%ary 5u%or: +asal Ca/ity and 1t'%oid (inus
5I Cannot be assessed
50 +o e/idence o& pri%ary tu%or
5is Carcino%a in situ
51 5u%or restricted to any one subsite wit' or wit'out bone in/asion
52 5u%or in/ading two subsites in a single region or e>tending to in/ol/e an adMacent region wit'in t'e
nasoet'%oidal co%ple> wit' our wit'out bone in/asion
5= 5u%or e>tends to in/ade t'e %edial wall or &loor o& t'e orbit %a>illary sinus palate or cribri&or% plate
5Ca 5u%or in/ades any o& t'e &ollowing: anterior orbital contents s-in o& nose or c'ee- %ini%al e>tension to
anterior cranial &ossa pterygoid plates sp'enoid or &rontal sinuses
5Cb 5u%or in/ades any o& t'e &ollowing: orbital ape> dura brain %iddle cranial &ossa cranial ner/es ot'er
t'an %a>illary di/ision o& trige%inal ner/e ?G2@ nasop'aryn> or cli/us
Regional Ly%p' +odes
?
+I Cannot be assessed
+0 +o regional ly%p' node %etastasis
+1 !etastasis in a single ipsilateral ly%p' node = c% or less in greatest di%ension
+2 !etastasis in a single ipsilateral ly%p' node %ore t'an = c% but not %ore t'an L c% in greatest
di%ension or in %ultiple ipsilateral ly%p' nodes none %ore t'an L c% in greatest di%ension or in
bilateral or contralateral nodes none %ore t'an L c% in greatest di%ension
1=
!ac,ground 4ocumentation +ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
+2a !etastasis in a single ipsilateral ly%p' node %ore t'an = c% but not %ore t'an L c% in greatest
di%ension
+2b !etastasis in %ultiple ipsilateral ly%p' nodes none %ore t'an L c% in greatest di%ension
+2c !etastasis in bilateral or contralateral ly%p' nodes none %ore t'an L c% in greatest di%ension
+= !etastasis in a ly%p' node %ore t'an L c% in greatest di%ension
?
!etastases at le/el G77 are considered regional ly%p' node %etastases. !idline nodes are considered ipsilateral
nodes.
Distant !etastasis
!0 +o distant %etastasis
!1 Distant %etastasis
For Mucosal Malignant Melanoma
Pri%ary 5u%or
5= !ucosal disease
5Ca !oderately ad/anced disease. 5u%or in/ol/ing deep so&t tissue cartilage bone or o/erlying s-in
5Cb Gery ad/anced disease. 5u%or in/ol/ing brain dura s-ull base lower cranial ner/es ?7I I I7 I77@
%asticator space carotid artery pre/ertebral space or %ediastinal structures
Regional Ly%p' +odes
+I Regional ly%p' nodes cannot be assessed
+0 +o regional ly%p' node %etastases
+1 Regional ly%p' node %etastases present
Distant !etastasis
!0 +o distant %etastasis
!1 Distant %etastasis present
By #JCCE.7CC con/ention t'e designation A5B re&ers to a pri%ary tu%or t'at 'as not been pre/iously treated.
5'e sy%bol ApB re&ers to t'e pat'ologic classi&ication o& t'e 5+! as opposed to t'e clinical classi&ication and is
based on gross and %icroscopic e>a%ination. p5 entails a resection o& t'e pri%ary tu%or or biopsy adeDuate to
e/aluate t'e 'ig'est p5 category p+ entails re%o/al o& nodes adeDuate to /alidate ly%p' node %etastasis and
p! i%plies %icroscopic e>a%ination o& distant lesions. Clinical classi&ication ?c5+!@ is usually carried out by t'e
re&erring p'ysician be&ore treat%ent during initial e/aluation o& t'e patient or w'en pat'ologic classi&ication is not
possible.
Pat'ologic staging is usually per&or%ed a&ter surgical resection o& t'e pri%ary tu%or. Pat'ologic staging depends
on pat'ologic docu%entation o& t'e anato%ic e>tent o& disease w'et'er or not t'e pri%ary tu%or 'as been
co%pletely re%o/ed. 7& a biopsied tu%or is not resected &or any reason ?eg w'en tec'nically un&easible@ and i& t'e
'ig'est 5 and + categories or t'e !1 category o& t'e tu%or can be con&ir%ed %icroscopically t'e criteria &or
pat'ologic classi&ication and staging 'a/e been satis&ied wit'out total re%o/al o& t'e pri%ary cancer.
Stage 8roupings @ For "ll Cancers Except Mucosal Malignant Melanoma
(tage 0 5is +0 !0
(tage 7 51 +0 !0
(tage 77 52 +0 !0
(tage 777 51 +1 !0
52 +1 !0
5= +0+1 !0
(tage 7G# 51525= +2 !0
5Ca +0+1+2 !0
(tage 7GB 5Cb #ny + !0
#ny 5 += !0
(tage 7GC #ny 5 #ny + !1
1C
!ac,ground 4ocumentation +ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
Stage 8roupings @ For Mucosal Malignant Melanoma
(tage 777 5= +0 !0
(tage 7G# 5Ca +0 !0
5=)5Ca +1 !0
(tage 7GB 5Cb #ny + !0
(tage 7GC #ny 5 #ny + !1
'NM 4escriptors
"or identi&ication o& special cases o& 5+! or p5+! classi&ications t'e A%B su&&i> and AyB and ArB pre&i>es are used.
#lt'oug' t'ey do not a&&ect t'e stage grouping t'ey indicate cases needing separate analysis.
5'e A%B su&&i> indicates t'e presence o& %ultiple pri%ary tu%ors in a single site and is recorded in parent'eses:
p5?%@+!.
5'e AyB pre&i> indicates t'ose cases in w'ic' classi&ication is per&or%ed during or &ollowing initial %ulti%odality
t'erapy ?ie neoadMu/ant c'e%ot'erapy radiation t'erapy or bot' c'e%ot'erapy and radiation t'erapy@. 5'e
c5+! or p5+! category is identi&ied by a AyB pre&i>. 5'e yc5+! or yp5+! categori2es t'e e>tent o& tu%or
actually present at t'e ti%e o& t'at e>a%ination. 5'e AyB categori2ation is not an esti%ate o& tu%or prior to
%ulti%odality t'erapy ?ie be&ore initiation o& neoadMu/ant t'erapy@.
5'e ArB pre&i> indicates a recurrent tu%or w'en staged a&ter a docu%ented disease)&ree inter/al and is identi&ied
by t'e ArB pre&i>: r5+!.
"dditional 4escriptors
Residual 5u%or ?R@
5u%or re%aining in a patient a&ter t'erapy wit' curati/e intent ?eg surgical resection &or cure@ is categori2ed by a
syste% -nown as R classi&ication s'own below.
RI Presence o& residual tu%or cannot be assessed
R0 +o residual tu%or
R1 !icroscopic residual tu%or
R2 !acroscopic residual tu%or
"or t'e surgeon t'e R classi&ication %ay be use&ul to indicate t'e -nown or assu%ed status o& t'e co%pleteness
o& a surgical e>cision. "or t'e pat'ologist t'e R classi&ication is rele/ant to t'e status o& t'e %argins o& a surgical
resection speci%en. 5'at is tu%or in/ol/ing t'e resection %argin on pat'ologic e>a%ination %ay be assu%ed to
correspond to residual tu%or in t'e patient and %ay be classi&ied as %acroscopic or %icroscopic according to t'e
&indings at t'e speci%en %argin?s@.
&. Classification of Nec, 4issection
1. Radical nec- dissection
2. !odi&ied radical nec- dissection internal Mugular /ein andEor sternocleido%astoid %uscle spared
=. (electi/e nec- dissection ?(+D@ as speci&ied by t'e surgeon
a. (uprao%o'yoid nec- dissection
b. Posterolateral nec- dissection
c. Lateral nec- dissection
d. Central co%part%ent nec- dissection
C. (electi/e nec- dissection ?(+D@ as speci&ied by t'e surgeon )A(+DB wit' le/els and suble/els designated
?"igure 2@.
2O)=0
J. 1>tended radical nec- dissection as speci&ied by t'e surgeon
#. 6egional Lymph Nodes 2pN03* &solated 'umor Cells
1J
!ac,ground 4ocumentation +ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
7solated tu%or cells ?75Cs@ are single cells or s%all clusters o& cells not %ore t'an 0.2 %% in greatest di%ension.
Ly%p' nodes or distant sites wit' 75Cs &ound by eit'er 'istologic e>a%ination i%%uno'istoc'e%istry or non)
%orp'ologic tec'niDues ?eg &low cyto%etry D+# analysis poly%erase c'ain reaction TPCRU a%pli&ication o& a
speci&ic tu%or %ar-er@ s'ould be classi&ied as +0 or !0 respecti/ely. (peci&ic denotation o& t'e assigned +
category is suggested as &ollows &or cases in w'ic' 75Cs are t'e only e/idence o& possible %etastatic
disease.
2N=1=2
p+0 +o regional ly%p' node %etastasis 'istologically no e>a%ination &or isolated tu%or cells ?75Cs@
p+0?i)@ +o regional ly%p' node %etastasis 'istologically negati/e %orp'ologic ?any %orp'ologic
tec'niDue including 'e%ato>ylin)eosin and i%%uno'istoc'e%istry@ &indings &or 75Cs
p+0?iH@ +o regional ly%p' node %etastasis 'istologically positi/e %orp'ologic ?any %orp'ologic
tec'niDue including 'e%ato>ylin)eosin and i%%uno'istoc'e%istry@ &indings &or 75Cs
p+0?%ol)@ +o regional ly%p' node %etastasis 'istologically negati/e non)%orp'ologic ?%olecular@ &indings
&or 75Cs
p+0?%olH@ +o regional ly%p' node %etastasis 'istologically positi/e non)%orp'ologic ?%olecular@ &indings
&or 75Cs
"or purposes o& pat'ologic e/aluation ly%p' nodes are organi2ed by le/els as s'own in "igure 2.
==
Figure /. 5'e si> suble/els o& t'e nec- &or describing t'e location o& ly%p' nodes wit'in le/els 7 77 and G. Le/el 7# sub%ental
group< le/el 7B sub%andibular group< le/el 77# upper Mugular nodes along t'e carotid s'eat' including t'e subdigastric group<
le/el 77B upper Mugular nodes in t'e sub%uscular recess< le/el G# spinal accessory nodes< and le/el GB t'e supracla/icular
and trans/erse cer/ical nodes. "ro%: "lint P9 et al eds. #ummings 'tolaryngology( )ead and Nec* $urgery. Jt' ed.
P'iladelp'ia P#< (aunders: 2010. Reproduced wit' per%ission S 1lse/ier.
7n order &or pat'ologists to properly identi&y t'ese nodes t'ey %ust be &a%iliar wit' t'e ter%inology o& t'e regional
ly%p' node groups and wit' t'e relations'ips o& t'ose groups to t'e regional anato%y. 9'ic' ly%p' node groups
surgeons sub%it &or 'istopat'ologic e/aluation depends on t'e type o& nec- dissection t'ey per&or%. 5'ere&ore
surgeons %ust supply in&or%ation on t'e types o& nec- dissections t'at t'ey per&or% and t'e details o& t'e local
anato%y in t'e speci%ens t'ey sub%it &or e>a%ination or in ot'er %anners orient t'ose speci%ens &or
pat'ologists.
7& it is not possible to assess t'e le/els o& ly%p' nodes ?&or instance w'en t'e anato%ic land%ar-s in t'e e>cised
speci%ens are not speci&ied@ t'en t'e ly%p' node le/els %ay be esti%ated as &ollows: le/el 77 upper t'ird o&
internal Mugular ?7J@ /ein or nec- speci%en< le/el 777 %iddle t'ird o& 7J /ein or nec- speci%en< le/el 7G lower t'ird
o& 7J /ein or nec- speci%en all anterior to t'e sternocleido%astoid %uscle.
1L
!ac,ground 4ocumentation +ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
Level &. Su)mental 8roup 2Su)level &"3
Ly%p' nodes wit'in t'e triangular boundary o& t'e anterior belly o& t'e digastric %uscles and t'e 'yoid bone.
Level &. Su)mandi)ular 8roup 2Su)level &!3
Ly%p' nodes wit'in t'e boundaries o& t'e anterior and posterior bellies o& t'e digastric %uscle and t'e body o&
t'e %andible. 5'e sub%andibular gland is included in t'e speci%en w'en t'e ly%p' nodes wit'in t'is triangle are
re%o/ed.
Level &&. %pper #ugular 8roup 2Su)levels &&" and &&!3
Ly%p' nodes located around t'e upper t'ird o& t'e internal Mugular /ein and adMacent spinal accessory ner/e
e>tending &ro% t'e le/el o& t'e carotid bi&urcation ?surgical land%ar-@ or 'yoid bone ?clinical land%ar-@ to t'e s-ull
base. 5'e posterior boundary is t'e posterior border o& t'e sternocleido%astoid %uscle and t'e anterior
boundary is t'e lateral border o& t'e stylo'yoid %uscle.
Level &&&. Middle #ugular 8roup
Ly%p' nodes located around t'e %iddle t'ird o& t'e internal Mugular /ein e>tending &ro% t'e carotid bi&urcation
superiorly to t'e o%o'yoid %uscle ?surgical land%ar-@ or cricot'yroid notc' ?clinical land%ar-@ in&eriorly. 5'e
posterior boundary is t'e posterior border o& t'e sternocleido%astoid %uscle and t'e anterior boundary is t'e
lateral border o& t'e sterno'yoid %uscle.
Level &7. Lo:er #ugular 8roup
Ly%p' nodes located around t'e lower t'ird o& t'e internal Mugular /ein e>tending &ro% t'e o%o'yoid %uscle
superiorly to t'e cla/icle in&eriorly. 5'e posterior boundary is t'e posterior border o& t'e sternocleido%astoid
%uscle and t'e anterior boundary is t'e lateral border o& t'e sterno'yoid %uscle.
Level 7. Posterior 'riangle 8roup 2Su)levels 7" and 7!3
5'is group co%prises predo%inantly t'e ly%p' nodes located along t'e lower 'al& o& t'e spinal accessory ner/e
and t'e trans/erse cer/ical artery. 5'e supracla/icular nodes are also included in t'is group. 5'e posterior
boundary o& t'e posterior triangle is t'e anterior border o& t'e trape2ius %uscle t'e anterior boundary o& t'e
posterior triangle is t'e posterior border o& t'e sternocleido%astoid %uscle and t'e in&erior boundary o& t'e
posterior triangle is t'e cla/icle.
Level 7&. "nterior 2Central3 Compartment
Ly%p' nodes in t'is co%part%ent include t'e pre) and paratrac'eal nodes precricoid ?Delp'ian@ node and t'e
perit'yroidal nodes including t'e ly%p' nodes along t'e recurrent laryngeal ner/e. 5'e superior boundary is t'e
'yoid bone t'e in&erior boundary is t'e suprasternal notc' t'e lateral boundaries are t'e co%%on carotid arteries
and t'e posterior boundary by t'e pre/ertebral &ascia.
Level 7&&. Superior Mediastinal Lymph Nodes
!etastases at le/el G77 are considered regional ly%p' node %etastases< all ot'er %ediastinal ly%p' node
%etastases are considered distant %etastases.
Ly%p' node groups re%o/ed &ro% areas not included in t'e abo/e le/els eg scalene suboccipital and
retrop'aryngeal s'ould be identi&ied and reported &ro% all le/els separately. !idline nodes are considered
ipsilateral nodes.
A. Lymph Nodes
Lymph Node Num)er
3istological e>a%ination o& a selecti/e nec- dissection speci%en will ordinarily include L or %ore ly%p' nodes.
3istological e>a%ination o& a radical or %odi&ied radical nec- dissection speci%en will ordinarily include 10 or
%ore ly%p' nodes in t'e untreated nec-.
Measurement of 'umor Metastasis
5'e cross)sectional dia%eter o& t'e largest %etastasis in a ly%p' node containing %etastatic tu%or is %easured
in t'e gross speci%en at t'e ti%e o& %acroscopic e>a%ination or i& necessary on t'e 'istologic slide at t'e ti%e
1N
!ac,ground 4ocumentation +ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
o& %icroscopic e>a%ination. 5'ere is con&licting data in t'e literature on t'e signi&icance o& t'e si2e o& t'e largest
%etastatic ly%p' node on t'e ris- o& regional recurrence and a predictor o& poor o/erall sur/i/al.
1R
9'ile t'e
dia%eter o& t'e largest positi/e ly%p' node %ay potentially ser/e as a predictor o& outco%e it %ay not represent
an independent predictor o& outco%e w'en ot'er pat'ologic &actors are considered.
1R
L. Special Procedures for Lymph Nodes
#t t'e current ti%e no additional special tec'niDues s'ould be used ot'er t'an routine 'istology &or t'e
assess%ent o& nodal %etastases. 7%%uno'istoc'e%istry and PCR to detect isolated tu%or cells are considered
in/estigational tec'niDues at t'is ti%e.
M. 4ysplasia of the %pper "erodigestive 'ract 2%"4'3
1pit'elial dysplasias o& t'e nasal ca/ity and paranasal sinuses as a precursor lesion &or sinonasal carcino%as are
less co%%on and less well de&ined as co%pared to epit'elial dysplasias o& t'e oral ca/ity and t'e laryn>.
=C

"urt'er unli-e dysplastic lesions o& t'e oral ca/ity andEor t'e laryn> precursor lesions o& t'e nasal ca/ity and
paranasal sinuses are generally asy%pto%atic and t'ere&ore are not biopsied. 7nstead t'ey are identi&ied %ore
o&ten in association wit' anot'er lesion suc' as an in/asi/e carcino%a.
N. "ncillary Studies
#t t'e current ti%e no additional special tec'niDues are reDuired ot'er t'an routine 'istology &or t'e assess%ent
o& nasal ca/ity and paranasal sinus carcino%as. 7%%uno'istoc'e%istry and in situ 'ybridi2ation ?7(3@ to detect
t'e presence o& /iruses ?eg 'u%an papillo%a/irus 1pstein)Barr /irus@ are considered in/estigational tec'niDues
at t'is ti%e.
6eferences
1. Patel ( ('a' JP. Part 77: 3ead and nec- sites. 7n: 1dge (B Byrd DR Carducci !# Co%pton C# eds.
A"## #ancer $taging Manual. Nt' ed. +ew ,or- +,: (pringer< 200R.
2. Barnes L 5se LL, 3unt JL Brandwein)4ensler ! Curtin 3C Bo&&etta P. 5u%ours o& t'e nasal ca/ity and
paranasal sinuses: 7ntroduction. 7n: Barnes L 1/eson J Reic'art P (idrans-y D eds +orld )ealth
'rgani,ation #lassification of -umours( Pathology and .enetics of )ead and Nec* -umours. Lyon "rance:
7#RC Press< 200J:12)1C.
=. Barnes L. 936 'istological classi&ication o& tu%ours o& t'e nasal ca/ity and paranasal sinuses. 7n: Barnes
1L 1/eson J9 Reic'art P (idrans-y D eds. +orld )ealth 'rgani,ation #lassification of -umours(
Pathology and .enetics of )ead and Nec* -umours. Lyon "rance: 7#RC Press< 200J:10.
C. Barnes L. +euroendocrine tu%ours. 7n: Barnes L 1/eson J9 Reic'art P et al eds. +orld )ealth
'rgani,ation #lassification of -umours( Pathology and .enetics of )ead and Nec* -umours. Lyon "rance:
7#RC Press< 200J.
J. Criss%an JD (a-r 9#. (Dua%ous neoplasia o& t'e upper aerodigesti/e tract.
7ntraepit'elial and in/asi/e sDua%ous cell carcino%a. 7n: Pilc' B: ed. )ead and Nec* $urgical Pathology.
P'iladelp'ia P#: Lippincott 9illia%s W 9il-ins< 2001:C2)C=.
L. !ills (1 4a&&ey !J "rierson 3" Jr. 5u%ors o& t'e upper aerodigesti/e tract and ear. 7n: Atlas of -umor
Pathology. =rd (eries. "ascicle 2L. 9as'ington DC: #r%ed "orces 7nstitute o& Pat'ology< 2000: 1L.
N. 1llis 4L #uclair PL. (ali/ary gland tu%ors: 4eneral considerations. 7n: (il/erberg (4 ed. -umors of the
$alivary .lands( A/!P Atlas of -umor Pathology. (eries C. "ascicle R. #r%ed "orces 7nstitute o& Pat'ology.
9as'ington DC. 200O:2N)CO.
O. (piro R3 3u/os #4 (trong 19. #denocarcino%a o& sali/ary gland origin: clinicopat'ologic study o& 20C
patients. Am " $urg. 1RO2<1CC:C2=)C=1.
R. (2anto P# Luna !# 5ortoledo !1 9'ite R#. 3istologic grading o& adenoid cystic carcino%a o& t'e sali/ary
glands. #ancer. 1ROC<OC:10L2)10LR.
10. (piro R3 5'aler 35 3ic-s 9" *'er .# 3u/os #4 (trong 19. 5'e i%portance o& clinical staging in %inor
sali/ary gland carcino%a. Am " $urg. 1RR1<1L2:==0)==L.
11. *ane 9J !cCa&&rey 5G 6lsen *D Lewis J1. Pri%ary parotid %alignancies: a clinical and pat'ologic re/iew.
Arch 'tolaryngol )ead Nec* $urg. 1RR1<11N:=0N)=1J.
12. 4reiner 5C Robinson R# !a/es !D. #denoid cystic carcino%a: a clinicopat'ologic study wit' &low
cyto%etric analysis. Am " #lin Pathol. 1ROR<R2:N11)N20.
1=. #uclair PL 4oode R* 1llis 4L. !ucoepider%oid carcino%a o& intraoral sali/ary glands: e/aluation and
application o& grading criteria in 1C= cases. #ancer. 1RR2<LR:2021)20=0.
1O
!ac,ground 4ocumentation +ead and Nec, - Nasal Cavity Paranasal Sinuses
+asalCa/ityParanasal(inus =.1.0.1
1C. 4oode R* #uclair PL 1llis 4L. !ucoepider%oid carcino%a o& t'e %aMor sali/ary glands: clinical and
'istopat'ologic analysis o& 2=C cases wit' e/aluation o& grading criteria. #ancer. 1RRO<O2:121N)122C.
1J. Brandwein !( 7/ano/ * 9allace D7 et al. !ucoepider%oid carcino%a: a clinicopat'ologic study o& O0
patients wit' special re&erence to 'istological grading. Am " $urg Pathol. 2001<2J:O=J)OCJ.
1L. Bradley PJ et al. (tatus o& pri%ary tu%our surgical %argins in sDua%ous 'ead
and nec- cancer: prognostic i%plications. #urr 'pin 'tolaryngol Lead Nec* $urg. 200N<1J:NC)O1.
1N. Lara%ore 41 (cott CB al)(arra& ! et al. #dMu/ant c'e%ot'erapy &or
resectable sDua%ous cell carcino%as o& t'e 'ead and nec-: report on 7ntergroup (tudy 00=C. !nt " 0adiat
'ncol 1iol Phys. 1RR2<2=:N0J)N1=.
1O. :ele&s-y !J 3arrison LB "ass D1 #r%strong J4 ('a' JP (trong 19.
Postoperati/e radiation t'erapy &or sDua%ous cell carcino%as o& t'e oral ca/ity and orop'aryn>: i%pact o&
t'erapy on patients wit' positi/e surgical %argins. !nt " 0adiat 'ncol 1iol Phys. 1RR=<2J:1N)21.
1R. (%it' BD 3a&&ty B4. Prognostic &actors in patients wit' 'ead and nec- cancer. 7n: 3arrison LB (essions RB
3ong 9* eds. )ead and Nec* #ancer( A Multidisciplinary Approach. =rd ed. P'iladelp'ia P#: Lippincott
9illia%s W 9il-ins< 200R: J1)NJ.
20. "agan JJ Collins B Barnes L et al. Perineural in/asion in sDua%ous cell carcino%a o& t'e 'ead and nec-.
Arch 'tolaryngol )ead Nec* $urg. 1RRO<12C:L=N)LC0.
21. Cooper J( PaMa- 5" "orastiere ## et al. Postoperati/e concurrent radiot'erapy and c'e%ot'erapy &or 'ig')
ris- sDua%ous)cell carcino%a o& t'e 'ead and nec-. N Engl " Med. 200C<=J0:1R=N)1RCC.
22. Bernier J Do%enge C 62sa'in ! et al. Postoperati/e irradiation wit' or wit'out conco%itant c'e%ot'erapy
&or locally ad/anced 'ead and nec- cancer. N Engl " Med. 200C<=J0:1RCJ)1RJ2
2=. 9oolgar J 5rianta&yllou #. +ec- dissections: a practical guide &or t'e reporting 'istopat'ologist. #urr 2iag
Pathol. 200N<1=:CRR)J11.
2C. Lee%ans CR 5iwari R +auta JJ /an der 9aal 7 (now 4B. Regional ly%p' node in/ol/e%ent and its
signi&icance in t'e de/elop%ent o& distant %etastases in 'ead and nec- carcino%a. #ancer. 1RR=<N1:CJ2)
CJL.
2J. Jo'nson J5 Barnes 1L !eyers 1+ et al. 5'e e>tracapsular spread o& tu%ors in cer/ical node %etastases.
)ead Nec* $urg. 1RO1<10N:N2J)N2R
2L. 9oolgar J# Rogers (+ Lowe D Brown J( Gaug'n 1D. Cer/ical ly%p' node %etastasis in oral cancer: t'e
i%portance o& e/en %icroscopic e>tracapsular spread. 'ral 'ncol. 200=<=R:1=0)1=N.
2N. (obin L3 4ospodarowic2 !* 9itte-ind C3 eds 3!## -NM #lassification of Malignant -umors. N
t'
ed. +ew
,or- +,: 9iley)Liss< 200R.
2O. Robbins *5 et al. +ec- dissection classi&ication update. Arch 'tolaryngol )ead Nec* $urg. 2002<12O:NJ1)
NJO.
2R. Robbins 5* et al. Consensus state%ent on t'e classi&ication and ter%inology o& nec- dissection. Arch
'tolaryngol )ead Nec* $urg. 200O<1=C:J=L)J=O
=0. Robbins 5 !edina J1 9ol&e 45 Le/ine P# (essions RB Pruet C9. (tandardi2ing nec- dissection
ter%inology: o&&icial report o& t'e acade%y8s co%%ittee &or 'ead and nec- surgery and oncology. Arch
'tolaryngol )ead Nec* $urg. 1RR1<11N:L01)L0J.
=1. 9itte-ind C 4reene "L 3enson D1 3utter RGP (obin L3 eds. -NM $upplement( A #ommentary on
3niform 3se. =
rd
ed. +ew ,or-: 9iley)Liss< 200=
=2. (ingletary (1 4reene "L (obin L3. Classi&ication o& isolated tu%or cells: clari&ication o& t'e L
t'
edition o& t'e
#%erican Joint Co%%ittee on Cancer (taging !anual. #ancer. 200=<R0?12@:2NC0)2NC1.
==. "lint P9 et al eds. #ummings 'tolaryngology( )ead and Nec* $urgery. Ct' ed. P'iladelp'ia P#: (aunders<
2010.
=C. Pilc' B: BouDuot J 5'o%pson LDR. (Dua%ous cell carcino%a. 7n: Barnes L 1/eson J Reic'art P
(idrans-y D eds. +orld )ealth 'rgani,ation #lassification of -umours( Pathology and .enetics of )ead and
Nec* -umours. Lyon "rance: 7#RC Press< 200J.
1R