Neck dissection is almost exclusively done for assessment of lymph node involvement by metastatic malignancy.
Determine the type of neck dissection procedure:
Radical: removal of neck lymph node groups I through V, sternocleidomastoid (SCM), internal jugular vein, and spinal accessory nerve.
Modified radical: similar to radical but spares at least one non-nodal structure (i.e. SCM, internal jugular vein, spinal accessory nerve)
Extended radical: similar to radical but also includes additional lymph node groups (e.g. retropharyngeal, paratracheal, parotid, suboccipital, upper mediastinal).
Selective: removal of some (not all) of the neck lymph node groups, as designated by the surgeon
En bloc dissections should be oriented using anatomic landmarks, including the submandibular gland (anterosuperior), SCM (runs from superoposterior toward inferoanterior), and internal jugular vein (runs along medial surface of SCM). Surgical designators (e.g. sutures, clips), when present, are also helpful. Note whether it is a unilateral or bilateral dissection.
Measure the entire specimen and its components (fat of lymph node levels, submandibular gland, internal jugular vein, sternocleidomastoid muscle (SCM).
Open the internal jugular vein along its length and note the inner lining appearance, adherence to surrounding structures, and involvement (or lack thereof) by tumor and/or thrombus.
Divide the specimen into the various lymph node levels, referring to a diagram as necessary:
Level I: Submental (sublevel IA) and submandibular (sublevel IB, includes submandibular gland) triangles, anterior to SCM
Level II: Surrounding the upper third of the internal jugular vein (divided into sublevels IIA and IIB)
Level III: Surrounding the middle third of the internal jugular vein
Level IV: Surrounding the lower third of the internal jugular vein
Level V: Posterior triangle, including spinal accessory (sublevel VA) and supraclavicular/transverse cervical (sublevel VB) lymph nodes, posterior to SCM
Other regional lymph node levels which may be included:
Level VI: Anterior (central) compartment, including pretracheal, paratracheal, midline prelaryngeal (Delphian), and perithyroidal lymph nodes
Level VII: Superior mediastinal lymph nodes
Dissect and separate the individual lymph nodes from the fat of their respective levels.
Measure the smallest and the largest lymph nodes. Note whether any appear obviously involved by tumor.
Lymph nodes < 4 mm (after fat is removed) are submitted as a single piece (i.e. intact). Carefully nick the capsule with a blade to assist in formalin penetration.
Lymph nodes > 5 mm are bisected perpendicular to the long axis and, if necessary, further sectioned into 2-3 mm slices.
If a lymph node is macroscopically involved by tumor, the surrounding soft tissue should be left attached to the node, in order to identify possible extranodal extension.
Lymph nodes: entirely submit, divided into the appropriate levels. If a lymph node is extremely large and obviously replaced by tumor, submit two or three representative sections from areas with the greatest degree of suspected extranodal extension.
Unsectioned (i.e. intact or uncut) lymph nodes:
Do not submit more than four lymph nodes in a single cassette.
Lymph nodes submitted in the same cassette should be of the same approximate size.
Specify in the section code the number of lymph nodes in the cassette.
Sectioned (i.e. bisected or serially sectioned) lymph nodes:
Never put more than one sectioned lymph node in a cassette! However, it is acceptable to put more than one slice from the same lymph node in a cassette.
Specify in the section code whenever a single lymph node has been placed in one or more than one cassette.
Received without fixative/in formalin, labeled _____ and “_____”, is a __ x __ x __ cm left/right/bilateral selective/modified radical/ standard radical/extended radical neck dissection consisting of submandibular gland/sternocleidomastoid muscle/internal jugular vein/lymph node levels __ through __. The specimen is oriented in person by the surgeon/by sutures (long = _____, short = _____). The submandibular gland (__ x __ x __ cm) has a tan-brown, lobulated cut surface, with/without tumor. The sternocleidomastoid muscle (__ x __ x __ cm) is red-brown and _____ (adherent to adjacent lymph nodes, involved/uninvolved by tumor. The internal jugular vein (__ cm length, __ cm diameter) has a _____ (smooth vs. rough, color) inner lining and is _____ (adherent to adjacent lymph nodes, involved/uninvolved by tumor). The measurements for the lymph node-containing soft tissue levels are as follows: level I = __ x __ x __ cm, level II = __ x __ x __ cm, level III = __ x __ x __ cm, level IV = __ x __ x __ cm, level V = __ x __ x __ cm. Multiple lymph nodes, ranging from __ to __ cm in diameter, are identified in all levels. The majority have _____ (color, texture) cut surfaces; however, __ (number) within level(s) _____ are _____ (color, firm, necrotic, matted). The lymph nodes are entirely submitted.
#__ = submandibular gland
#__ = sternocleidomastoid muscle
#__ = internal jugular vein from area suspicious for tumor involvement (level IV)
#__ & #__ = level I lymph nodes: #__ = one bisected lymph node; #__ = four unsectioned lymph nodes.
#__ & #__ = level II lymph nodes: #__ = three unsectioned lymph nodes; #__ = two unsectioned lymph nodes; #__ = one trisected lymph node
#__ - #__ = level III lymph nodes: #__ - #__ = one sectioned lymph node; #__ - #__ = four unsectioned lymph nodes per cassette
#__ - #__ = level IV lymph nodes: #__ - #__ = one sectioned lymph node suspicious for tumor; #__ - #__ = three unsectioned lymph nodes per cassette; T = four unsectioned lymph nodes
#__ & #__ = level V lymph nodes: #__ - #__ = one sectioned lymph node; #__ = two unsectioned lymph nodes