MALIGNANT SALIVARY GLAND
NEOPLASMS
STRUCTURED REPORTING
PROTOCOL
(1st Edition 2013)
Core Document versions:
•
•
AJCC Cancer Staging Manual 7th edition (including errata corrected with
5th reprint 10th Aug 2010).
World Health Organization Classification of Tumours Pathology and
Genetics: Head and Neck Tumours.2005
i
ISBN: 978-1-74187-799-1
Publications number (SHPN) (CI): 120395
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o
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o
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First published: November 2013, 1st Edition (Version 1.0)
ii
Disclaimer
The Royal College of Pathologists of Australasia ("College") has developed these
protocols as an educational tool to assist pathologists in reporting of relevant
information for specific cancers. While each protocol includes “standards” and
“guidelines” which are indicators of ‘minimum requirements’ and
‘recommendations’, the protocols are a first edition and have not been through a
full cycle of use, review and refinement. Therefore, in this edition, the inclusion of
“standards” and “guidelines” in each document are provided as an indication of
the opinion of the relevant expert authoring group, but should not be regarded as
definitive or as widely accepted peer professional opinion. The use of these
standards and guidelines is subject to the clinician’s judgement in each individual
case.
The College makes all reasonable efforts to ensure the quality and accuracy of the
protocols and to update the protocols regularly. However subject to any
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iii
Contents
Scope ..................................................................................................... v
Abbreviations ........................................................................................ vi
Definitions ............................................................................................ vii
Introduction ........................................................................................... 1
Authority and development .................................................................... 3
1
Pre-analytical ................................................................................ 5
2
Specimen handling and macroscopic findings ............................... 7
3
Microscopic findings .................................................................... 11
4
Ancillary studies findings ............................................................. 17
5
Synthesis and overview ............................................................... 19
6
Structured checklist .................................................................... 22
7
Formatting of pathology reports.................................................. 44
Appendix 1
Pathology request information and surgical
handling procedures ................................................. 45
Appendix 2
Guidelines for formatting of a pathology report ........ 49
Appendix 3
Example of a pathology report .................................. 51
Appendix 4
WHO histological classification of tumours
of the salivary glands ................................................ 53
Appendix 5
Examples of grading of mucoepidermoid
carcinoma ................................................................. 55
References ........................................................................................... 57
iv
Scope
This protocol contains standards and guidelines for the preparation of a structured
report for malignant neoplasms of the salivary glands, specifically epithelial and
myoepithelial tumours. Standards and guidelines for preparation of structure
protocols for other soft tissue neoplasms and lymphomas affecting salivary glands
follow different protocols published separately.
Structured reporting aims to improve the completeness and usability of pathology
reports for clinicians, and improve decision support for cancer treatment. The
protocol provides the framework for the reporting of any salivary gland
neoplasms, whether as a minimum data set or fully comprehensive report.
v
Abbreviations
AFIP
Armed Forces Institute of Pathology
AJCC
American Joint Committee on Cancer
IHC
Immunohistochemistry
IHI
Individual health identifier
LIS
Laboratory Information System
MRN
Medical Record Number
NHI
National Health Index number (NZ)
PBS
Pharmaceutical Benefits Scheme
RCPA
Royal College of Pathologists of Australasia
TNM
tumour-node-metastasis
UHI
Unique Health Identifier
UICC
International Union Against Cancer
WHO
World Health Organization
vi
Definitions
The table below provides definitions for general or technical terms used in this
protocol. Readers should take particular note of the definitions for ‘standard’,
‘guideline’ and ‘commentary’, because these form the basis of the protocol.
Ancillary
study
An ancillary study is any pathology investigation that may form part
of a cancer pathology report but is not part of routine histological
assessment.
Clinical
information
Patient information required to inform pathological assessment,
usually provided with the specimen request form, also referred to as
“pre-test information”.
Commentary
Commentary is text, diagrams or photographs that clarify the
standards (see below) and guidelines (see below), provide examples
and help with interpretation, where necessary (not every standard or
guideline has commentary).
Commentary is used to:
•
define the way an item should be reported, to foster
reproducibility
•
explain why an item is included (e.g. how does the item assist
with clinical management or prognosis of the specific cancer).
•
cite published evidence in support of the standard or guideline
•
state any exceptions to a standard or guideline.
In this document, commentary is prefixed with ‘CS’ (for commentary
on a standard) or ‘CG’ (for commentary on a guideline), numbered to
be consistent with the relevant standard or guideline, and with
sequential alphabetic lettering within each set of commentaries (e.g.
CS1.01a, CG2.05b).
General
commentary
General commentary is text that is not associated with a specific
standard or guideline. It is used:
•
to provide a brief introduction to a chapter, if necessary
•
for items that are not standards or guidelines but are included
in the protocol as items of potential importance, for which
there is currently insufficient evidence to recommend their
inclusion. (Note: in future reviews of protocols, such items
may be reclassified as either standards or guidelines, in line
with diagnostic and prognostic advances, following evidentiary
review).
vii
Guideline
Guidelines are recommendations; they are not mandatory, as
indicated by the use of the word ‘should’. Guidelines cover items that
are not essential for clinical management, staging or prognosis of a
cancer, but are recommended.
Guidelines include key observational and interpretative findings that
are fundamental to the diagnosis and conclusion. Such findings are
essential from a clinical governance perspective, because they
provide a clear, evidentiary decision-making trail.
Guidelines are not used for research items.
In this document, guidelines are prefixed with ‘G’ and numbered
consecutively within each chapter (e.g. G1.10).
Macroscopic
findings
Measurements, or assessment of a biopsy specimen made by the
unaided eye.
Microscopic
findings
In this document, the term ‘microscopic findings’ refers to histomorphological assessment.
Predictive
factor
A predictive factor is a measurement that is associated with response
or lack of response to a particular therapy.
Prognostic
factor
A prognostic factor is a measurement that is associated with clinical
outcome in the absence of therapy or with the application of a
standard therapy. It can be thought of as a measure of the natural
history of the disease.
Standard
Standards are mandatory, as indicated by the use of the term ‘must’.
Their use is reserved for core items essential for the clinical
management, staging or prognosis of the cancer and key information
(including observations and interpretation) that is fundamental to the
diagnosis and conclusion. These elements must be recorded and at
the discretion of the pathologist included in the pathology report
according to the needs of the recipient of the report.
The summation of all standards represents the minimum dataset for
the cancer.
In this document, standards are prefixed with ‘S’ and numbered
consecutively within each chapter (e.g. S1.02).
Structured
report
A report format which utilises standard headings, definitions and
nomenclature with required information.
Synoptic
report
A structured report in condensed form (as a synopsis or precis).
viii
Synthesis
Synthesis is the process in which two or more pre-existing elements
are combined, resulting in the formation of something new.
The Oxford dictionary defines synthesis as “the combination of
components or elements to form a connected whole”.
In the context of structured pathology reporting, synthesis represents
the integration and interpretation of information from two or more
modalities to derive new information.
ix
Introduction
Salivary gland neoplasms
Malignant salivary gland neoplasms are derived from the gland parenchyma and
are generally uncommon lesions.1-2 When they do occur there is wide variation in
their histological features and also in their clinical behaviour.3 The frequency of
salivary gland malignancies ranges from 0.4 to 13.5 cases per 100000
population.1 They account for between 5 - 6% of head and neck cancers and 0.31% of malignancies of all body sites.1-2 They can arise in the major salivary
glands, minor glands or rarely ectopic sites. Malignant neoplasms arising in minor
salivary glands are classified using the same staging principle as for other
primary mucosal malignancies and include predictive factors associated with the
specific histological type.3 Surgical removal of salivary gland neoplasms usually
involves partial excision of the gland including the tumour mass or, alternatively
by complete excision of the entire gland.
Benefits of structured reporting
Structured pathology reports with standardised definitions for each component
have been shown to significantly enhance the completeness and quality of data
provided to clinicians, and have been recommended both in North America and
the United Kingdom.4-7
The College of American Pathologists and the Royal College of Pathologists (UK)
have recently published useful protocols for the reporting of head and neck
cancer.8-9 These have been widely used in recent years in Australia and New
Zealand, usually in modified formats to suit local requirements and preferences. A
protocol endorsed by the Royal College of Pathologists of Australasia and other
local organisations involved in the management of salivary gland neoplasms is
therefore needed. The authors have not attempted to ‘re-invent the wheel’ but
have borrowed freely from pre-existing publications. The intention is to provide
pathologists with a dataset that is comprehensive, easy to use, and in keeping
with local capacities and practice.
Importance of histopathological reporting
Information from pathology reports has a key role in the rational planning of
patient management, which is used to guide clinical decision making. It is vital
that head and neck pathology reports contain all of the information required to
determine correct tumour staging. This will allow clinicians to make appropriate
adjuvant therapy recommendations and provide accurate information regarding
prognosis.10
1
Design of this protocol
This structured reporting protocol provides a complete framework for the
assessment and documentation of all the pathological features of malignant
salivary gland neoplasms.
Mandatory elements (standards) are differentiated from those that are not
mandatory but represent best practice (guidelines). Consistency and speed of
reporting is improved by the use of discrete data elements recorded from the
checklist. However, the pathologist is encouraged to include free text or narrative
to document any other relevant issues, to give reasons for coming to a particular
opinion and to explain any points of uncertainty.
The structure provided by the following chapters, headings and subheadings
describes the elements of information and their groupings, but does not
necessarily represent the format of either a pathology report (Chapter 7) or
checklist (Chapter 6). These, and the structured pathology request form
(Appendix 1) are templates that represent information from this protocol,
organised and formatted differently to suit different purposes.
Key documentation
•
Guidelines for Authors of Structured Cancer Pathology Reporting Protocols,
Royal College of Pathologists of Australasia, 200911
•
The Pathology Request–Test–Report Cycle — Guidelines for Requesters and
Pathology Providers, Royal College of Pathologists of Australasia, 200412
•
AJCC Cancer Staging Manual, 7th edition, American Joint Committee on
Cancer, 201013
•
Pathology and Genetics: Head and Neck Tumours. World Health Organization
Classification of Tumours, IARC Press, Lyon, 20053
Changes since the last edition
Not applicable
2
Authority and development
This section provides details of the committee involved in developing this protocol
and the process by which it was developed.
Protocol developers
This protocol was developed by an expert committee, with assistance from
relevant stakeholders.
Expert committee
Professor Richard M. Logan (Lead author), Oral and Maxillofacial Pathologist
Professor Jane Dahlstrom (Chair), Pathologist
Dr Sophie Otto, Pathologist
Dr Brandon Nguyen, Radiation Oncologist
Associate Professor Hedley G. Coleman, Oral and Maxillofacial Pathologist
Professor Guan Chong, Surgeon
Acknowledgements
The salivary gland neoplasms expert committee wish to thank all the pathologists
and clinicians who contributed to the discussion around this document.
Stakeholders
Anatomical Pathology Advisory Committee (APAC)
Australian Cancer Network
Australian and New Zealand Head and Neck Cancer Society
Cancer Australia
Cancer Council ACT
Cancer Council NSW
Cancer Council Queensland
Cancer Council SA
Cancer Council Tasmania
Cancer Council Victoria
Cancer Council Western Australia
Cancer Institute NSW
Cancer Services Advisory Committee (CanSAC)
Cancer specific expert groups – engaged in the development of the protocols
Faculty of Oral and Maxillofacial Pathology, The Royal College of Pathologists of
Australasia (FOMP)
National Round Table Working Party for Structured Pathology Reporting of Cancer
NSW Head and Neck Group
The Royal Australasian College of Surgeons (RACS)
3
The Royal Australian and New Zealand College of Radiologists (RANZCR)
The Royal College of Pathologists of Australasia (RCPA)
Other Reviewers
ACT Health
Australian Association of Pathology Practices Inc (AAPP)
Australian Commission on Safety and Quality in Health Care
Cancer Voices
Clinical Oncology Society of Australia (COSA)
Department of Health and Ageing
Grampians Integrated Cancer Services (GICS)
Health Informatics Society of Australia (HISA)
Independent Review Group of Pathologists
Medical Software Industry Association (MSIA)
National Coalition of Public Pathology (NCOPP)
National E-Health Transition Authority (NEHTA)
National Pathology Accreditation Advisory Council (NPAAC)
New Zealand Guidelines Group (NZGG)
NSW Department of Health
Peter MacCallum Cancer Institute
Queensland Cooperative Oncology Group (QCOG)
Representatives from laboratories specialising in anatomical pathology across
Australia
Royal Australasian College of Physicians (RACP)
Southern Cancer Network, Christchurch, New Zealand
Southern Melbourne Integrated Cancer Service (SMICS)
Standards Australia
The Medical Oncology Group of Australia
The Royal Australian College of General Practitioners (RACGP)
Victorian Cooperative Oncology Group (VCOG)
Western Australia Clinical Oncology Group (WACOG)
Secretariat
Meagan Judge, Royal College of Pathologists of Australasia
Development process
This protocol has been developed following the nine-step process set out in
Guidelines for Authors of Structured Cancer Pathology Reporting Protocols.11
Where no reference is provided, the authority is the consensus of the expert
group.
4
1
Pre-analytical
This chapter relates to information that should be recorded on receipt of the
specimen in the laboratory.
The pathologist is reliant on the quality of information received from the clinicians
or requestor. Some of this information may be received in generic pathology
request forms, however, the additional information required by the pathologist
specifically for the reporting of salivary gland neoplasms is outlined in
Appendix 1. Appendix 1 also includes a standardised request information sheet
that may be useful in obtaining all relevant information from the requestor.
Surgical handling procedures affect the quality of the specimen and
recommendations for appropriate surgical handling are included in Appendix 1.
S1.01
S1.02
All demographic information provided on the request form and
with the specimen must be recorded.
CS1.01a
The Royal College of Pathologists of Australasia (RCPA) The
Pathology Request-Test-Report Cycle — Guidelines for
Requesters and Pathology Providers must be adhered to.14
This document specifies the minimum information to be
provided by the requesting clinician for any pathology test.
CS1.01b
The patient’s ethnicity must be recorded, if known. In
particular whether the patient is of aboriginal or Torres
Strait islander origin. This is in support of a government
initiative to monitor the health of indigenous Australians
particularly in relation to cancer.
CS1.01c
The patient’s health identifiers may include the patient’s
Medical Record Number as well as a national health number
such as a patient’s Medicare number (Australia), Individual
Healthcare Identifier (IHI) (Australia) or the National
Healthcare Identifier (New Zealand).
All clinical information as documented on the request form must
be recorded verbatim.
CS1.02a
The request information may be recorded as a single text
(narrative) field or it may be recorded discretely.
S1.03
The pathology accession number of the specimen must be
recorded.
S1.04
The principal clinician involved in the patient’s care and
responsible for investigating the patient must be recorded.
CS1.04a
Knowledge of the clinical presentation is an essential part
of the WHO classification yet it may not be available for a
number of reasons:
•
The clinical assessment and staging may be incomplete
at the time of biopsy.
5
•
The pathology request is often authored by the clinician
performing the biopsy rather than the clinician who is
investigating and managing the patient.
•
The identity of this clinician is often not indicated on
the pathology request form
In practice therefore, it is important in such cases that the
reporting pathologist should be able to communicate with
the managing clinician for clarification.
G1.01
Any clinical information received in other communications from the
requestor or other clinician should be recorded together with the source
of that information.
6
2 Specimen handling and macroscopic
findings
This chapter relates to the procedures required after the information has been
handed over from the requesting clinician and the specimen has been received in
the laboratory.
Specimen handling

Pathologists may be requested to provide tissue samples from fresh
specimens for tissue banking or research purposes. The decision to
provide tissue should only be made when the pathologist is confident
that doing so will not compromise the diagnostic process and interfere
with the assessment of important parameters that may influence patient
prognosis and management such as the measurement of tumour size or
distance of surgical margins. As a safeguard, research use of the
specimen may be postponed until the diagnostic process is complete.
Complications may arise however if suitability for research requires a
fresh specimen to be kept frozen and in such instances the diagnostic
process takes precedence and the tissue will be fixed for routine
processing.

Images (such as macroscopic photographs and / or specimen
radiography) of the gross specimen showing the overall conformation of
the neoplasm and, especially in the case of complicated resections,
images showing the relation of the neoplasm to the resection margins,
are desirable, and useful for multidisciplinary meetings. Placement of
arrows and labels indicating important anatomical structures is desirable,
and images should always include a scale.

The specimen must be handled in a systematic and thorough
fashion to ensure completeness and accuracy of pathological
data.
•
The pathological findings from examination of resection specimens
are important in guiding the patient’s subsequent clinical
management; for example, in predicting a patient’s prognosis, or
in deciding whether adjuvant therapy is indicated. Hence, these
specimens must be handled in a systematic and thorough fashion
to ensure the completeness and accuracy of the pathological data.
•
Specimens are best received fresh and without delay if tissue
banking is part of the standard protocol. The subsequent fixation,
macroscopic assessment and sampling for histology are crucial.
Despite the pressure on the pathologist for rapid turnaround,
adequate fixation and processing of biopsies as well as resection
specimens is vital for high quality pathology. Full fixation
facilitates obtaining thin transverse slices through the neoplasm
and it has also been shown to increase lymph node yield.
•
The specimen needs to be thoroughly examined before sectioning.
7
•
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 corkboard.
•
The application of paints/indelible inks to the specimen is crucial
in assessing the surgical margins on histological slides. In most
cases, a single colour ink will suffice. Multiple colours may be
necessary to accurately identify specific margins of the resection.
It is important that the ink is dry before sectioning to prevent ink
tracking and seepage from creating a false margin.15
Macroscopic findings
S2.01
The labelling of the specimen must be recorded.
S2.02
The specimen type must be recorded.
CS2.02a
Options include:
•
incisional biopsy
•
excisional biopsy of minor gland
•
resection of submandibular gland
•
extended resection of submandibular gland
(surgeon to indicate extent of anatomical resection)
•
resection of sublingual gland
•
superficial parotidectomy +/- facial nerve sacrifice
•
total parotidectomy
•
•
facial nerve preservation
•
facial nerve sacrifice
•
extended radical total parotidectomy
(includes resection of parotid gland, facial
nerve, masseter muscle, zygoma and
mandible)
neck dissection (nodal levels included in the
dissection should be listed):
o
selective
o
modified radical
o
radical
o
extended radical
8
•
other (specify)
G2.01
The integrity of the specimen should be recorded as intact or
fragmented.
S2.03
Record if the specimen is received fresh or in formalin.
S2.04
The specimen should be measured in 3 dimensions.
S2.05
The size, site (including laterality) and appearance of the
tumour (lesion) must be recorded.
CS2.05a
Tumour size is an important prognostic factor in neoplasms
of the salivary gland.16 The maximum dimension relates to
T stage and prognosis. The prognosis of stage III or IV
neoplasms is poor regardless of histological grade.
The benefit of adjuvant radiotherapy is also dependent on
the size of the neoplasm with little benefit shown in terms
of survival advantage in neoplasms that are less than
4cm.16
S2.06
Macroscopic evidence of extraparenchymal extension of the
tumour must be recorded.
CS2.06a
S2.07
Neck dissection (if present) must be described and measured.
CS2.07a
S2.08
In the AJCC staging system, extraparenchymal extension
qualifies for a T3 tumour. This does not include extension
into the skin, mandible, ear canal, facial nerve, base of
skull, pterygoid plates or encasement of the carotid artery,
which are classified as T4 tumours.
Record the laterality and type of neck dissection.
The number of lymph nodes in each level and size of the
largest node per level must be recorded if available.
CS2.08a
This should include the following lymph node groups:
submental (level IA), submandibular (level IB), upper
jugular (level IIA and IIB), middle jugular (level III), lower
jugular (level IV), posterior triangle (level VA and VB).13
Use of a template board or transparency diagram may
assist the pathologist in localising the different levels of the
neck dissection. The onus however rests with the surgeon
to orientate and label the nodal groups with the use of
sutures, ties or by pinning the neck dissection specimen
out and labelling the corkboard. Anatomical lymph node
groups may also be submitted in separate specimen
containers.
All lymph node tissue should be submitted for histological
examination, where possible.
CS2.08b
Lymph nodes measuring up to 6mm or less in maximum
dimension are embedded whole.17-18
9
Nodes measuring 6-15mm around the equator are bisected
longitudinally through the hilum and embedded in total in
one casette.17-18
Nodes larger than 15mm around the equator are bisected
and one half resliced at 90 degrees to the original plane of
bisection.13,17-18
Enlarged nodal masses and the largest lymph node should
be measured in millimetres.13, 17
For enlarged nodes, greater than 10mm and for
macroscopically involved nodes with or without apparent
fixation to the surrounding tissue, the surrounding surgical
margin should also be sampled.17
All enlarged nodes, specifically those larger than 10 mm
and any with apparent fixation to surrounding tissue should
be examined for the presence of extracapsular extension
and/or invasion of adjacent muscles, blood vessels, nerves
must be documented.13,19
G2.02
S2.09
A descriptive or narrative field should be provided to record any other
macroscopic information that may not be recorded in the above
standards and guidelines, and that would normally form part of the
macroscopic description.
CG2.02a
The traditional macroscopic narrative recorded at the time
of specimen dissection is often reported separately from
the cancer dataset. Although this remains an option, it is
recommended that macroscopic information be recorded
within the overall structure of this protocol.
CG2.02b
Much of the information recorded in a traditional
macroscopic narrative is covered in the standards and
guidelines above and in many cases, no further description
is required.
CG2.02c
Evidence of macroscopically visible tumour or
extracapsular spread should be noted.
CG2.02d
If photographs and radiological images are taken or
diagrams are drawn this should be recorded in the
macroscopic narrative.
The nature and sites of all blocks must be recorded.
10
3
Microscopic findings
Microscopic findings relates to purely histological (morphological) assessment.
Information derived from multiple investigational modalities, or from two or more
chapters, is described in Chapter 5.
S3.01
The histological tumour type and subtype must be recorded.
CS3.01a
S3.02
The histological type of salivary gland neoplasm is an
important predictor of biological behaviour and should be
recorded according to the WHO classification3 (see Appendix
4).
Histological grade must be recorded (where relevant).
CS3.02a
Specific grading systems have not been developed for all
salivary gland neoplasms. In many instances, specific
tumours characteristically demonstrate either high or low
grade behaviour (e.g. salivary duct carcinoma compared with
polymorphous low grade adenocarcinoma)16 (See Table 1
below). , Alternatively a histologic subtype of a specific
tumour may be associated with high-grade behaviour (e.g.
solid type adenoid cystic carcinoma) and in these instances
the histological description and diagnosis will be sufficient to
indicate behaviour.20 If there are histological features
indicating low or high-grade behaviour that is not typical for
the tumour, these can be indicated in the report.20
In the case of mucoepidermoid carcinoma, specific grading
systems have been developed (WHO classification of
tumours3) (Appendix 5).
Table 1: Prognostic factors in salivary adenocarcinoma
Salivary adenocarcinomas
Low
grade
High
grade
Polymorphous low grade
adenocarcinoma
+
Acinic cell carcinoma
+
Basal cell adenocarcinoma
+
Cribriform adenocarcinoma
+
Mammary analogue secretory
carcinoma
+
+
Myoepithelial carcinoma
+
+
Cystadenocarcinoma
+
Epithelial-Myoepithelial carcinoma
+
11
+
Mucoepidermoid carcinoma
+
+
Adenoid cystic carcinoma
+
+
Adenocarcinoma, not otherwise
specified
+
+
Squamous cell carcinoma
+
+
Carcinoma ex-pleomorphic adenoma
+
Salivary duct carcinoma
+
Oncocytic carcinoma
+
Undifferentiated carcinoma
+
Reprinted from Speight PM and Barrett AW (2009). Prognostic
factors in malignant tumours of the salivary glands. British
Journal of Oral and Maxillofacial Surgery 47:587-593 with
permission from Elsevier.
CS3.02b
Mucoepidermoid carcinoma
Grading of mucoepidermoid carcinoma previously involved
making an assessment of the number of mucous cells in the
neoplasm. An increased number of mucous cells and higher
volume of mucus production are associated with less
aggressive neoplasms that are less likely to metastasise.
Neoplasms that are predominantly epidermoid in nature are
deemed higher risk for metastasis.16
The development of more objective grading systems for
mucoepidermoid carcinoma have been contentious, but the
use of such systems may remove some subjectivity from the
assessment. The modified AFIP grading system for example,
scores specific histopathological features and can be used to
provide an objective grading of neoplasms3 (refer to Appendix
5). If a specific grading system is applied, it should be
specified in the report.
Generally, mucoepidermoid carcinoma arising within the
submandibular gland generally has a poorer prognosis.2
Mucoepidermoid carcinoma with MECT1-MAML2 translocation
is reported to have a better prognosis than those tumours
without the translocation (see CS4.02b).21
CS3.02c
Acinic cell carcinoma
Histological grading systems for acinic cell carcinoma are
inconsistent. Factors such as increased mitoses, necrosis,
neural invasion, pleomorphism and stromal hyalinisation have
been associated with increased neoplasm aggressiveness. The
cell proliferation marker Ki-67 has been suggested to indicate
a neoplasms behaviour with increased aggressiveness in
neoplasms with >5% of cells staining.3
12
The location of acinic cell carcinomas is important, with
submandibular gland tumours demonstrating more aggressive
behaviour than parotid tumours.3 Furthermore, acinic cell
carcinomas arising in minor salivary glands are less
aggressive than those that arise in major glands.3
CS3.02d
Mammary analogue secretory carcinoma
Mammary analogue secretory carcinoma (MASC) is a recently
described tumour that has features similar to acinic cell
carcinoma.22 These neoplasms have variable growth patterns
including solid areas, papillary cystic and microcystic spaces
which contain PAS positive material.22-23 They are
characterised by the ETV6-MTRK3 translocation.22-25
It has been suggested that although slightly more aggressive
than acinic cell carcinoma, the clinical outcome is similar.24
CS3.02e
Adenoid cystic carcinoma
Various histological patterns are associated with adenoid
cystic carcinomas. Tubular and cribriform patterns are
considered to be less aggressive compared to solid forms.3,26
It has been suggested that neoplasms that have more than
30% solid component should be considered as high-grade
neoplasms.20
CS3.02f
Carcinoma ex pleomorphic adenoma
Non-invasive carcinoma ex pleomorphic adenoma generally
behave in a similar fashion to benign pleomorphic adenoma
and are associated with a good prognosis.3 Invasive
carcinoma ex pleomorphic adenomas are considered
aggressive neoplasms. Minimally invasive carcinoma
(<1.5mm of invasion) are considered low-grade variants.3,20
CS3.02g
Polymorphous low-grade adenocarcinoma
Although these neoplasms are classified as low-grade
according to their name, up to a third recur locally or
metastasise to regional lymph nodes.16 Some studies have
demonstrated a link between lymph node metastases and
papillary cystic growth pattern.27
Cribriform adenocarcinoma of the tongue is a subtype of
polymorphous low-grade adenocarcinoma and is associated
with increased lymph node metastases.28
CS3.02h
Salivary duct carcinoma
Salivary duct carcinoma, although uncommon, is a high-grade
aggressive adenocarcinoma with poor prognosis3
Histologically the neoplasm has features similar to intraductal
and infiltrating mammary duct carcinoma. The ductal
component is demonstrates a cribriform growth pattern of
epithelioid cells whilst the infiltrating component may have
solid or papillary areas with psammoma bodies.3 Cytologically
13
the neoplastic cells have pleomorphic nuclei with prominent
nucleoli; prominent mitotic activity is also observed.3 Spindle
cell or sarcomatoid variants have also been described.3
CS3.02i
Minor salivary gland tumours
Malignant neoplasms arising in minor salivary glands are
classified using the same staging principle as for other
primary mucosal malignancies and include predictive factors
associated with the specific histological type.3
S3.03
Tumour size must be recorded.
CS3.03a
S3.04
Neoplasm size is an important factor relating to the outcome
of salivary gland neoplastic disease.16 The prognosis of stage
III or IV neoplasms is poor regardless of histological grade.
Lesions that are less than 4cm in size generally have a better
prognosis.16
The involvement of adjacent structures must be recorded.
CS3.04a Involvement of skin, mandible, ear canal or facial nerve
confers a T4a classification while encasement of the carotid
artery or invasion of the skull base and pterygoid plates
indicates T4b disease.
S3.05
The presence of perineural involvement must be recorded.
CS3.05a
Evidence of perineural involvement may be diagnostically
useful for some neoplasms such as adenoid cystic carcinoma
and polymorphous low-grade adenocarcinoma.16
The prognostic significance of perineural involvement varies
between studies. From a radiation oncology perspective, it is
important to specify if this involves a named nerve, the size
or diameter of the involved nerve and the length of
involvement. This provides useful information for risk
assessment in determining whether to include the nerve back
to the base of skull in the radiation target volume.
S3.06
The presence or absence of lymphovascular invasion must be
recorded.
CS3.06a
S3.07
There is a need to distinguish between retraction artefact and
intravascular embolisation. Vascular invasion usually occurs in
‘thin walled’ vessels and involvement of muscular vessels is
rare. Identify vascular invasion only when tumour emboli are
within clear spaces that are completely lined by endothelial
cells.19 The detection of vascular invasion implies the
increased likelihood of successful metastatic spread by the
tumour.9,29-31
The status of the surgical resection margins must be recorded.
CS3.07a
This includes both the surface mucosa at the edge of excision
as well as the submucosal and deeper soft tissues around the
14
neoplasm.
S3.08
CS3.07b
In routine examination and assessment the tissue shrinkage
as a result of fixation is not taken into account. This may
result in 30-47% reduction in the margin width when
compared to the in-situ clinical width. The measurement from
the closest surgical margin(s) must be documented. The UK
guidelines for recording the status of the mucosal and deep
margins designate margins of >5mm as clear, 1-5mm as
close and < 1mm or with histological cut-through as
involved.9 It is recommended that these be adopted.9
CS3.07c
Involved margin(s) are associated with an increased risk of
local recurrence and this should be recorded.32 Specifically
this should include location and extent of involvement
(measurement of linear extend of marginal involvement). If
multiple margins are involved these features should be
specified for each margin.
The cervical lymph node status must be recorded.
CS3.08a
If lymph nodes have been received, for each anatomical level
record the total number of nodes identified and the number of
nodes involved.
CS3.08b
Measure and document the size of the largest metastatic
deposit. This is an important criteria in determining the nodal
stage in the AJCC TNM staging system.13
CS3.08c
The number of positive nodes may be uncertain due to
matting of the nodes and in such circumstances an estimate
of the number of nodes is required as well as maximum
dimension and level(s) of nodes involved. This confers (at
least) a pN2B status for the patient.13 If the maximum
dimension were greater than 6cm, a status of N3 would be
recorded.
CS3.08d
The prognostic significance of isolated tumour cells (ITC collections of cells totalling < 0.2mm) and micro metastases
(<2mm in diameter) is uncertain and should be recorded and
included in the total number of involved lymph nodes.19
CS3.08e
The presence or absence of extracapsular spread should be
recorded. Studies suggest that extracapsular spread in
salivary gland neoplasms specifically mucoepidermoid
carcinoma and adenoid cystic carcinoma is associated with
poor prognosis.2,33 Whilst generally the evidence for the
importance of extracapsular spread specifically in salivary
gland neoplasms is limited2,33 it is suggested that this should
be recorded for the purposes of further study into its
significance.
If present, describe the microscopic extracapsular spread as
being present or absent and include the measurement of the
extent (in mm) from the original nodal capsule.18,19 Describe
the number of nodes with extracapsular spread; if only one
node is affected count the number of foci of extracapsular
15
spread in that node. Describe any structures that may be
involved by the extranodal tumour. Permeation of perinodal
lymphatics should also be documented, however this does not
constitute extra-capsular spread.19 Measure the distance from
perinodal surgical margins.
If it is uncertain whether there is extracapsular spread,
additional serial sections should be examined and if there is
still ambiguity it should be recorded as present.9
G3.01
Any additional relevant comments should be recorded.
Sentinel node biopsy
This has been suggested as a technique which may potentially avoid the need and
morbidity associated with neck dissections, but at present it is not part of
standard patient care and remains an experimental procedure in head and neck
cancer.9 Likewise there is limited evidence for its use in salivary gland
malignancies.34-35
16
4
Ancillary studies findings
Ancillary studies may be used to determine lineage, clonality or disease
classification or subclassification; as prognostic biomarkers; or to indicate the
likelihood of patient response to specific biologic therapies. Research continues
into various prognostic biomarkers, however at the present time there are no
specific molecular markers that are used in routine clinical practice to assist
clinicians in predicting the neoplasms behaviour or response to therapy for
salivary gland neoplasms.
The few ancillary tests that may be required in certain situations will be listed by
technique. No ancillary tests are currently used on a routine basis for the
diagnosis of salivary gland neoplasms.
Immunohistochemistry (IHC) staining
S4.01
The results of any immunohistochemistry, if performed, must be
incorporated into the pathology report.
CS4.01a
In general the use of IHC is non-specific for differentiating
many salivary gland neoplasms.3 For example, labelling for
CD117 (c-kit) has been used to differentiate between
adenoid cystic carcinoma and polymorphous low-grade
adenocarcinoma.36 There is variability between studies.
CS4.01b
IHC studies may assist in the resolution of differential
diagnosis problems. Myoepithelial markers and cytokeratins
may assist in the differentiation of clear cell carcinoma and
clear cell variants of myoepithelioma or epithelialmyoepithelial carcinoma.3
CS4.01c
Labelling of high molecular weight cytokeratins may be
useful in the diagnosis of mucoepidermoid carcinoma where
the epidermoid component is sparse.3
CS4.01d
The use of Ki-67 labelling index has been suggested by
some authors to differentiate higher-grade neoplasms (e.g.
high grade acinic cell carcinomas). The prognostic
implications for this have not been established.3,37
CS4.01e
Salivary duct carcinomas show strong reactivity for
androgen receptors and positive membrane staining for
HER-2 protein. Overexpression of HER-2 has been shown
to correlate with high grade malignancy and poor
prognosis.38 Immunohistochemical studies are indicated
initially and if there is strong positive staining, the results
can be followed up with CISH (see CS4.02d).
CS4.01f
S100 and Mammaglobin may be useful in distinguishing
acinic cell carcinoma from mammary analogue secretory
carcinoma. However it should be noted that these markers
have been demonstrated in other salivary gland carcinomas
(polymorphous low-grade adenocarcinoma and adenoid
cystic carcinoma39 and therefore appreciation of the
histological features is important as well as demonstration
17
of the ETV6 translocation in the case of mammary analogue
secretory carcinoma (see CS4.02e).
In-situ Hybridisation
S4.02
The results of any in-situ hybridisation, if performed, must be
incorporated into the pathology report.
CS4.02a
At the present time in-situ hybridisation is not routinely
performed for salivary gland neoplasms. There is some
evidence that it may be useful in the diagnosis and as
prognostic markers for some salivary gland neoplasms. If
requested the results should be incorporated into the
pathology report.
CS4.02b
Mucoepidermoid carcinoma with MECT1-MAML2
translocation is reported to have a better prognosis than
those tumours without the translocation.21 However despite
this, the translocation has been reported in some
histologically high-grade and clinically aggressive tumours
and therefore it is important not to overlook traditional
clinical and histological parameters when assessing these
lesions.21
CS4.02c
EWSR1-ATF1 fusion is consistently found in hyalinising
clear cell carcinomas.40-41
CS4.02d
HER-2 expression in salivary duct carcinoma can be
demonstrated by CISH.42
CS4.02e
Demonstration of ETV6 translocation is useful in the
diagnosis of mammary analogue secretory carcinoma.25,43
and differentiating from acinic cell carcinoma and other
salivary gland tumours that demonstrate S100 and
Mammaglobin immunohistochemical staining.25
Cytogenetics
S4.03
The results of any cytogenetics, if performed, must be
incorporated into the pathology report.
CS4.03a
At the present time cytogenetic investigations are not
routinely performed for salivary gland neoplasms.
18
5
Synthesis and overview
Information that is synthesised from multiple modalities and therefore cannot
reside solely in any one of the preceding chapters is described here.
For example, tumour stage is synthesised from multiple classes of information –
clinical, macroscopic and microscopic.
By definition, synthetic elements are inferential rather than observational, often
representing high-level information that is likely to form part of the report
‘Summary’ or ‘Diagnosis’ section in the final formatted report.
Overarching case comment is synthesis in narrative format. Although it may not
necessarily be required in any given report, the provision of the facility for
overarching commentary in a cancer report is essential.
S5.01
The tumour stage and stage grouping based on the TNM staging
system of the AJCC Cancer Staging Manual (7th Edition)13 must
be recorded. (See Tables S5.01a and b below.)
Table S5.01a TNM staging#
T classification
Primary tumour
TX
Primary tumour cannot be assessed
T0
No evidence of primary tumour
T1
Tumour 2 cm or less in greatest dimension without
extraparenchymal extension*
T2
Tumour more than 2 cm but not more than 4 cm in greatest
dimension without extraparenchymal extension*
T3
Tumour more than 4 cm and/or tumour having
extraparenchymal extension*
T4a
Moderately advanced disease
Tumour invades skin, mandible, ear canal, and/or facial nerve
T4b
Very advanced disease
Tumour invades skull base and/or pterygoid plates and/or
encases carotid artery
N classification
Regional lymph nodes
NX
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Metastasis in a single ipsilateral lymph node, 3 cm or less in
greatest
dimension
N2
Metastasis in a single ipsilateral lymph node, more than 3 cm
19
but not more than 6 cm in greatest dimension, or in multiple
ipsilateral lymph nodes, none more than 6 cm in greatest
dimension, or in bilateral or contralateral lymph nodes, none
more than 6 cm in greatest dimension
N2a
Metastasis in a single ipsilateral lymph node, more than 3 cm
but not more than 6 cm in greatest dimension
N2b
Metastasis in multiple ipsilateral lymph nodes, none more
than 6 cm in greatest dimension
N2c
Metastasis in bilateral or contralateral lymph nodes, none
more than 6 cm in greatest dimension
N3
Metastasis in a lymph node, more than 6 cm in greatest
dimension
M classification
Distant metastasis
M0
No distant metatasis
M1
Distant metastasis
*Note: Extraparenchymal extension is clinical or macroscopic evidence of invasion
of soft tissues. Microscopic evidence alone does not constitute extraparenchymal
extension for classification purposes.
#Used with the permission of the American Joint Committee on Cancer (AJCC),
Chicago, Illinois. The original source for this material is the AJCC Cancer Staging
Manual, Seventh Edition (2010) published by Springer Science and Business
Media LLC, www.springerlink.com.
Table S5.01b Pathological stage grouping# .
Stage
I
II
III
T
N
M
T1
N0
M0
T2
N0
M0
T3
N0
M0
T1
N1
M0
T2
N1
M0
T3
N1
M0
IVA
T4a
N0
M0
T4a
N1
M0
T1
N2
M0
T2
N2
M0
T3
N2
M0
T4a
N2
M0
IVB
T4b
Any N
M0
Any T
N3
M0
IVC
Any T
Any N
M1
#Used with the permission of the American Joint Committee on Cancer (AJCC),
Chicago, Illinois. The original source for this material is the AJCC Cancer Staging
Manual, Seventh Edition (2010) published by Springer Science and Business
Media LLC, www.springerlink.com.
S5.02
The year of publication and edition of the cancer staging system
must be included in the report.
20
G5.01
The ‘Diagnostic summary’ section of the final formatted report should
include:
a) Type of operation (S1.02)
b) Anatomical site / laterality (S1.02)
c) Tumour type (S.01)
d) Histological grade (S3.02)
e) Tumour dimensions (S3.03)
f)
Extraglandular extension of tumour (S3.08)
g) Lymphovascular invasion (S3.06)
h) Perineural invasion (S3.05)
i)
Involved or close margins with measurements (S3.07)
j)
Type of neck dissection (if present) (S2.07)
k) Presence or absence of metastatic tumour in lymph nodes and level
of involved nodes (S3.08)
l)
Presence or absence of extra-capsular spread of tumour (S3.08)
m) Ki-67 index (S4.01)
n) Tumour stage (S5.01)
G5.02
A field for free text or narrative in which the reporting pathologist can
give overarching case comment should be provided.
CG5.02a
CG5.02b
This field may be used, for example, to:
•
list any relevant ancillary tests
•
document any noteworthy adverse gross and/or
histological features
•
express any diagnostic subtlety or nuance that is
beyond synoptic reporting
•
document further consultation or results still pending.
Use of this field is at the discretion of the reporting
pathologist.
21
6
Structured checklist
The following checklist includes the standards and guidelines for this protocol
which must be considered when reporting, in the simplest possible form. The
summation of all “Standards” is equivalent to the “Minimum Data Set” for
neoplasms of the salivary glands. For emphasis, standards (mandatory
elements) are formatted in bold font.
S6.01
The structured checklist provided below may be modified as
required but with the following restrictions:
a. All standards and their respective naming conventions,
definitions and value lists must be adhered to.
b. Guidelines are not mandatory but are recommendations and
where used, must follow the naming conventions, definitions
and value lists given in the protocol.
G6.01
G6.02
The order of
according to
described in
Reporting of
CG6.01a
Where the LIS allows dissociation between data entry and
report format, the structured checklist is usually best
formatted to follow pathologist workflow. In this situation,
the elements of synthesis or conclusions are necessarily at
the end. The report format is then optimised independently
by the LIS.
CG6.01b
Where the LIS does not allow dissociation between data
entry and report format, (for example where only a single
text field is provided for the report), pathologists may elect
to create a checklist in the format of the final report. In this
situation, communication with the clinician takes precedence
and the checklist design is according to principles given in
Chapter 7.
Where the checklist is used as a report template (see G6.01), the
principles in Chapter 7 and Appendix 2 apply.
CG6.02a
G6.03
information and design of the checklist may be varied
the laboratory information system (LIS) capabilities and as
Functional Requirements for Structured Pathology
Cancer Protocols.44
All extraneous information, tick boxes and unused values
should be deleted.
Additional comment may be added to an individual response where
necessary to describe any uncertainty or nuance in the selection of a
prescribed response in the checklist. Additional comment is not required
where the prescribed response is adequate.
22
Values in italics are conditional on previous responses.
Values in all caps are headings with sub values.
S/G
Item description
Response type
Conditional
Pre-analytical
S1.01
Demographic information
provided
S1.02
Clinical information provided
on request form
Text
OR
Structured entry as below:
Type of operation
Multi select value list (select all that apply):
•
incisional biopsy
•
excisional biopsy of minor gland
•
resection of submandibular gland
•
extended resection of submandibular
gland
•
resection of sublingual gland +/- facial
nerve sacrifice
•
superficial parotidectomy
•
total parotidectomy
o
facial nerve preservation
o
facial nerve sacrifice
o
extended radical total
23
If selective neck dissection,
modified radical neck dissection,
radical neck dissection, or
extended radical neck dissection
is selected record the laterality
and nodal levels included.
If extended resection of
submandibular gland record the
extent of anatomical resection
S/G
Item description
Response type
Conditional
parotidectomy (includes resection
of parotid gland, facial nerve,
masseter muscle, zygoma and
mandible)
•
•
Extent of anatomical
resection
Laterality of neck dissection
Nodal levels included
neck dissection
o
selective
o
modified radical
o
radical
o
extended radical
other (specify)
Text
Single select value list:
•
left
•
right
•
bilateral
Multi select value list (select all that apply):
•
submental (level IA)
•
submandibular (level IB)
•
upper jugular (level IIA)
•
upper jugular (level IIB)
•
middle jugular (level III)
•
lower jugular (level IV)
24
If other, record the other nodal
tissue submitted
S/G
Item description
Response type
Conditional
•
posterior triangle (level VA)
•
posterior triangle (level VB)
•
other (specify)
Note: if a bilateral neck dissection is performed,
record for each laterality
Other nodal tissue submitted
Anatomical site of neoplasm
Text
Multi select value list (choose all that apply:
•
Parotid gland - whole
•
Parotid gland - superficial lobe
•
Parotid gland - deep lobe
•
Submandibular gland
•
Sublingual gland
•
Minor salivary gland
•
Other
Site
Text
Other anatomical site
Text
Laterality of the lesion
Clinical history
Single selection value list:
•
Left
•
Right
Text
25
If minor salivary gland record
the site
If other, describe the other
anatomical site
S/G
Item description
Response type
Clinical TNM stage
Text
Clinical diagnosis or differential
diagnosis
Text
New primary cancer or
recurrence
Single selection value list:
Details
Pre-operative or prior
radiotherapy administered
Details
Conditional
•
New primary
•
Recurrence – regional (local)
•
Recurrence – distant metastasis
Text
Single selection value list:
•
None administered
•
Yes
Text
Any involvement of adjacent
structures
Text
S1.03
Pathology accession number
Alpha-numeric
S1.04
Principal clinician caring for
the patient
Text
G1.01
Other clinical information
received
Text
Macroscopic findings
S2.01
Specimen labelled as
If recurrence – distant
metastasis is selected record
details
Text
26
If yes, provide details
S/G
Item description
Response type
Conditional
S2.02
Specimen type
Multi select value list (choose all that
apply):
If minor salivary gland is
selected, record the site(s)
Site(s)
G2.01
S2.03
Specimen integrity
Specimen received
•
Parotid gland - whole
•
Parotid gland - superficial lobe
•
Parotid gland - deep lobe
•
Submandibular gland
•
Sublingual gland
•
Minor salivary gland
•
Neck dissection
•
Biopsy incisional
•
Biopsy excisional
•
Biopsy resection
•
Other (specify)
Text
Single selection value list:
•
Intact
•
Fragmented
Single selection value list:
•
Fresh
•
Formalin
27
S/G
Item description
Response type
S2.04
Specimen measurements
Numeric: __x__x__mm
S2.05
DESCRIPTION AND
MEASUREMENTS OF LESION
Size
Conditional
Numeric: __x__x__mm
Notes:
length x width x thickness
Site
Text
Notes:
Site should include laterality
Appearance
S2.06
S2.07
Macroscopic evidence of
extraparenchymal extension
Neck dissection
Text
Single selection value list:
•
Absent
•
Present
Single selection value list:
Type
•
Absent
•
Present
Single selection value list:
•
selective neck dissection
•
modified radical neck dissection
28
If present, record the type,
description (eg any anatomical
structures), laterality and
dimensions
S/G
Item description
Response type
Laterality of neck dissection
Dimensions
Conditional
•
radical neck dissection
•
extended radical neck dissection
Single selection value list:
•
Left
•
Right
•
Bilateral
Numeric: __x__x__mm
Notes:
length x width x thickness
Description
Text
Notes:
Include for example any anatomical structures
S2.08
MACROSCOPIC LYMPH NODE
STATUS
submental (level IA)
Single selection value list:
•
Not received
•
Received
Numeric: ____ Lymph nodes
and
Numeric: with largest node _____mm
Notes:
Specify the number of lymph nodes and size of
29
If received, record the specific
lymph nodes levels received. If
bilateral is recorded in S2.07
record the levels for EACH
laterality.
S/G
Item description
Response type
Conditional
largest node eg 3 Lymph nodes with largest node
5mm
If bilateral neck dissection, record the level for
each laterality.
submandibular (level IB)
Numeric: ____ Lymph nodes
and
Numeric: with largest node _____mm
Notes:
Specify the number of lymph nodes and size of
largest node eg 3 Lymph nodes with largest node
5mm
If bilateral neck dissection, record the level for
each laterality.
upper jugular (level IIA)
Numeric: ____ Lymph nodes
and
Numeric: with largest node _____mm
Notes:
Specify the number of lymph nodes and size of
largest node eg 3 Lymph nodes with largest node
5mm
If bilateral neck dissection, record the level for
each laterality.
30
S/G
Item description
upper jugular (level IIB)
Response type
Conditional
Numeric: ____ Lymph nodes
and
Numeric: with largest node _____mm
Notes:
Specify the number of lymph nodes and size of
largest node eg 3 Lymph nodes with largest node
5mm
If bilateral neck dissection, record the level for
each laterality.
middle jugular (level III)
Numeric: ____ Lymph nodes
and
Numeric: with largest node _____mm
Notes:
Specify the number of lymph nodes and size of
largest node eg 3 Lymph nodes with largest node
5mm
If bilateral neck dissection, record the level for
each laterality.
lower jugular (level IV)
Numeric: ____ Lymph nodes
and
Numeric: with largest node _____mm
31
S/G
Item description
Response type
Conditional
Notes:
Specify the number of lymph nodes and size of
largest node eg 3 Lymph nodes with largest node
5mm
If bilateral neck dissection, record the level for
each laterality.
posterior triangle (level VA)
Numeric: ____ Lymph nodes
and
Numeric: with largest node _____mm
Notes:
Specify the number of lymph nodes and size of
largest node eg 3 Lymph nodes with largest node
5mm
If bilateral neck dissection, record the level for
each laterality.
posterior triangle (level VB)
Numeric: ____ Lymph nodes
and
Numeric: with largest node _____mm
Notes:
Specify the number of lymph nodes and size of
largest node eg 3 Lymph nodes with largest node
5mm
If bilateral neck dissection, record the level for
32
S/G
Item description
Response type
Conditional
each laterality.
G2.02
Other macroscopic comment
Text
S2.09
Block identification key
Text
Microscopic findings
S3.01
Histological tumour type
S3.02
HISTOLOGICAL GRADE
Single selection value list from WHO
Classification of Tumours. Pathology and
Genetics: Head and Neck Tumours.(2005)
Grading system
Text
Grade/score
Text
S3.03
Tumour size
Numeric: ___x__x__mm
S3.04
Involvement of adjacent
structures
Single selection value list:
Site(s)
•
Not applicable
•
Absent
•
Present
Multi select value list (select all that apply):
•
Skin
•
Mandible
33
If present, record all the sites
which apply.
S/G
S3.05
S3.06
S3.07
Item description
Response type
Perineural involvement
Lymphovascular invasion
Conditional
•
Ear canal
•
Facial nerve
•
Base of skull
•
Pterygoid plates
•
Carotid artery encasement
•
Other (specify)
Single selection value list:
•
Not identified
•
Present
Single selection value list:
•
Not identified
•
Present
SURGICAL MARGIN STATUS
Margin
Text (specify margin)
If not involved, specify the
distance to tumour.
AND
Single selection value list:
•
Not involved
•
Involved
34
S/G
Item description
Response type
Conditional
Notes:
Note that the margin and whether it is positive or
negative must be repeated for each surgical
margin.
Distance to tumour
S3.08
Numeric: ___mm
CERVICAL LYMPH NODE
STATUS
The lymph node status will be
conditional on specific nodal
levels received in S2.08 if any.
NOTE: If bilateral is recorded in
S2.07 record the levels for EACH
laterality.
submental (level IA)
Total number of nodes: __ Numeric
AND
Number of involved (positive) nodes: __
Numeric
submandibular (level IB)
Total number of nodes: __ Numeric
AND
Number of involved (positive) nodes: __
Numeric
upper jugular (level IIA)
Total number of nodes: __ Numeric
AND
Number of involved (positive) nodes: __
Numeric
35
The number of nodes per level
recorded in S2.08 should be
presented to the pathologist for
review at this point.
S/G
Item description
upper jugular (level IIB)
Response type
Conditional
Total number of nodes: __ Numeric
AND
Number of involved (positive) nodes: __
Numeric
middle jugular (level III)
Total number of nodes: __ Numeric
AND
Number of involved (positive) nodes: __
Numeric
lower jugular (level IV)
Total number of nodes: __ Numeric
AND
Number of involved (positive) nodes: __
Numeric
posterior triangle (level VA)
Total number of nodes: __ Numeric
AND
Number of involved (positive) nodes: __
Numeric
posterior triangle (level VB)
Total number of nodes: __ Numeric
AND
Number of involved (positive) nodes: __
Numeric
LARGEST METASTATIC
DEPOSIT
36
S/G
Item description
Response type
Location
Dimensions
Conditional
Text
Numeric: __x__x__mm
Notes:
length x width x thickness
Extracapsular spread
Extent of invasion from nodal
capsule
Single selection value list:
•
Absent
•
Present
Numeric: ___mm
Number of nodes with
extracapsular spread
Numeric: ___
Number foci /tongues of
extracapsular spread
Numeric: ___
Structures involved in
extracapsular spread
Distance from closest
perinodal surgical margins
If present, record the extent of
invasion from nodal capsule, the
number of nodes with
extracapsular spread, the
structures involved in
extracapsular spread, and the
distance from closest perinodal
surgical margins
If only 1 node record the number
foci /tongues of extracapsular
spread
Text
Numeric: ___mm
37
S/G
G3.01
Item description
Response type
Permeation of perinodal
lymphatics
Single selection value list:
Other microscopic comment
•
Absent
•
Present
Conditional
Text
Ancillary test findings
S4.01
IMMUNOHISTOCHEMICAL
STAINS
Performed
Antibodies
S4.02
Single selection value list:
•
No
•
Yes
•
Pending
If yes, record antibodies,
interpretation and clinical
significance.
List (as applicable):
•
Positive antibodies
•
Negative antibodies
•
Equivocal antibodies
Interpretation
Text
Clinical significance
Text
IN-SITU HYBRIDISATION
Performed
Single selection value list:
•
No
38
If yes, record performing lab,
results, conclusions and person
S/G
S4.03
Item description
Response type
•
Yes
•
Pending
Performing laboratory
Text
Result
Text
Conclusion
Text
Person responsible for
reporting
Text
Conditional
responsible for reporting.
CYTOGENETICS
Performed
Single selection value list:
•
No
•
Yes
•
Pending
Performing laboratory
Text
Result
Text
Conclusion
Text
Person responsible for
reporting
Text
Synthesis and overview
S5.01
PATHOLOGICAL AJCC
39
If yes, record performing lab,
results, conclusions and person
responsible for reporting.
S/G
Item description
Response type
Conditional
TUMOUR STAGING
Primary Tumour (pT)
Single selection value list:
TX
Primary tumour cannot be assessed
T0
No evidence of primary tumour
T1
Tumour 2 cm or less in greatest dimension
without extraparenchymal extension*
Tumour more than 2 cm but not more than
4 cm in greatest dimension without
extraparenchymal extension*
Tumour more than 4 cm and/or tumour
having extraparenchymal extension*
Moderately advanced disease. Tumour
invades skin, mandible, ear canal, and/or
facial nerve
Very advanced disease. Tumour invades
skull base and/or pterygoid plates and/or
encases carotid artery
T2
T3
T4a
T4b
Notes:
* Extraparenchymal extension is clinical or
macroscopic evidence of invasion of soft tissues.
Microscopic evidence alone does not constitute
extraparenchymal extension for classification
purposes.
40
S/G
Item description
Response type
Conditional
Regional Lymph Nodes (pN)
Single selection value list:
NX
N0
N1
Regional lymph nodes cannot be assessed
No regional lymph node metastasis
Metastasis in a single ipsilateral lymph
node, 3 cm or less in greatest dimension
N2 Metastasis in a single ipsilateral lymph
node, more than 3 cm but not more than 6
cm in greatest dimension, or in multiple
ipsilateral lymph nodes, none more than 6
cm in greatest dimension, or in bilateral or
contralateral lymph nodes, none more than
6 cm in greatest dimension
N2a Metastasis in a single ipsilateral lymph
node, more than 3 cm but not more than 6
cm in greatest dimension
N2b Metastasis in multiple ipsilateral lymph
nodes, none more than 6 cm in greatest
dimension
N2c Metastasis in bilateral or contralateral
lymph nodes, none more than 6 cm in
greatest dimension
N3 Metastasis in a lymph node, more than 6
cm in greatest dimension
Distant Metastasis (pM)
Anatomic Stage/Prognostic
Group
Single selection value list:
M0
No distant metastasis
M1
Distant metastasis
Single selection value list:
Stage
T
N
41
M
S/G
Item description
Response type
I
II
III
IVA
IVB
IVC
S5.02
G5.01
Conditional
T1
T2
T3
T1
T2
T3
T4a
T4a
T1
T2
T3
T4a
T4b
Any T
Any T
Year of publication and
edition of cancer staging
system
Numeric: year
Diagnostic summary
Text
N0
N0
N0
N1
N1
N1
N0
N1
N2
N2
N2
N2
Any N
N3
Any N
AND
Text: Edition eg 1st, 2nd etc
Include:
a) Type of operation (S1.02)
b) Anatomical site / laterality
(S1.02)
c) Tumour type (S.01)
d) Histological grade (S3.02)
e) Tumour dimensions (S3.03)
42
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M1
S/G
Item description
f)
Response type
Conditional
Extraglandular extension of
tumour (S3.08)
g) Lymphovascular invasion
(S3.06)
h) Perineural invasion (S3.05)
i)
Involved or close margins
with measurements (S3.07)
j)
Type of neck dissection (if
present) (S2.07)
k) Presence or absence of
metastatic tumour in lymph
nodes and level of involved
nodes (S3.08)
l)
Presence or absence of
extra-capsular spread of
tumour (S3.08)
m) Ki-67 index (S4.01)
n) Tumour stage (S5.01)
G5.02
Overarching comment
Text
43
7
Formatting of pathology reports
Good formatting of the pathology report is essential for optimising communication
with the clinician, and will be an important contributor to the success of cancer
reporting protocols. The report should be formatted to provide information clearly
and unambiguously to the treating doctors, and should be organised with their
interpretation of the report in mind. In this sense, the report differs from the
structured checklist, which is organised with the pathologists’ workflow as a
priority.
Uniformity in the format as well as in the data items of cancer reports between
laboratories makes it easier for treating doctors to understand the reports; it is
therefore seen as an important element of the systematic reporting of cancer. For
guidance on formatting pathology reports, please refer to Appendix 2.
44
Appendix 1
Pathology request
information and surgical handling
procedures
This appendix describes the information that should be collected before the
pathology test. Some of this information can be provided on generic pathology
request forms; any additional information required specifically for the reporting of
salivary gland neoplasms may be provided by the clinician on a separate request
information sheet. An example request information sheet is included below.
Elements which are in bold text are those which pathologists consider to be
required information. Those in non-bold text are recommended.
Also included in this appendix are the procedures that are recommended before
handover of specimens to the laboratory.
Patient information

Adequate demographic and request information should be
provided with the specimen.
•
Items relevant to cancer reporting protocols include:
•
•

patient name
•
date of birth
•
sex
•
identification and contact details of requesting doctor
•
date of request
The patient’s ethnicity should be recorded, if known. In particular
whether the patient is of aboriginal or Torres Strait islander origin.
This is in support of a government initiative to monitor the health
of indigenous Australians particularly in relation to cancer.
The patient’s health identifiers should be provided.
•
The patient’s health identifiers may include the patient’s Medical
Record Number as well as a national health number such as a
patient’s Medicare number (Australia), Individual Healthcare
Identifier (IHI) (Australia) or the National Healthcare Identifier
(New Zealand).
Clinical Information

The type of operation performed must be recorded.
•
It is important to state the nature of the surgical procedure for
example:
•
incisional biopsy
45
•
excisional biopsy of minor gland
•
resection of submandibular gland
•
extended resection of submandibular gland (surgeon to
indicate extent of anatomical resection)
•
resection of sublingual gland
•
superficial parotidectomy +/- facial nerve sacrifice
•
total parotidectomy
•
•
•

•
facial nerve preservation
•
facial nerve sacrifice
•
extended radical total parotidectomy (includes
resection of parotid gland, facial nerve, masseter
muscle, zygoma and mandible)
neck dissection (the laterality and nodal levels included in
the dissection should be listed):
o
selective
o
modified radical
o
radical
o
extended radical
other (specify)
The type of operation performed will influence the subsequent
handling of the specimen in the laboratory.
The anatomical site of the neoplasm should be recorded.
•
•
This may include:
•
Parotid gland - whole
•
Parotid gland - superficial lobe
•
Parotid gland - deep lobe
•
Submandibular gland
•
Sublingual gland
•
Minor salivary gland (specify site)
•
Other (specify)
Site is an important identifier especially when multiple biopsies
are performed. For carcinomas that may involve more than one
46
site it is recommended that the clinician identify all sites
involved and that if possible the principal site of involvement be
recorded.

•
Sufficient information is required to localise the lesion for
subsequent therapy. A diagram or photograph can facilitate this.
•
Prognostic significance – the association between anatomical site
and survival may be explained by the tumour site’s influence on
metastasis to cervical lymph nodes.29,45
The laterality of the lesion should be recorded.
•
Laterality information is needed for identification purposes.

Clinical history should be recorded.

The clinical TNM stage should be recorded.

The clinical diagnosis or differential diagnosis should be recorded.
•

Providing the provisional clinical diagnosis or differential
diagnosis improves clinico-pathological correlation and improves
diagnostic accuracy.
Record if this is a new primary cancer or a recurrence of a
previous cancer, if known.
•
The term recurrence defines the return, reappearance or
metastasis of cancer (of the same histology) after a disease free
period.
Recurrence should be classified as distant metastases or regional
(local) recurrence.
Regional (local) recurrence refers to the recurrence of cancer
cells at the same site as the original (primary) tumour or the
regional lymph nodes.
Distant metastasis refers to the spread of cancer of the same
histologic type as the original (primary) neoplasm to distant
organs or distant lymph nodes.
•
The reporting of metastatic deposits, either resected or not
resected, is required for assessment of the metastatic (M) stage
of the neoplasm.13
•
The presence of involved non-regional lymph nodes stages the
neoplasm as M1.13
•
This information will provide an opportunity for previous reports
to be reviewed during the reporting process, which may provide
valuable information to the pathologist. This information also has
implications for recording cancer incidence and evidence-based
research.
47


If pre-operative or prior radiotherapy has been administered,
this should be recorded.
•
Pre-operative radiotherapy significantly alters the gross and
microscopic appearance of the neoplasm.
•
This information would prompt a comment on the extent of any
response to the treatment.
Any involvement of adjacent structures should be recorded.
•
With regard to extension of disease into areas that either have
or have not been resected, it is the responsibility of the surgeon
to report these deposits and, if indicated, mark these areas with
a suture or other marker.
Surgical handling

The specimen must be handled in a systematic and thorough
fashion by the surgeon and theatre staff.
•

The pathological findings from examination of a surgical
specimen are important in guiding the patient’s subsequent
management. Hence the surgeon should handle the specimen in
a systematic and thorough fashion to ensure accuracy of
pathological data, resection margin status and pathological
stage.
The specimen should be correctly labelled, orientated or be capable of
orientation. The status of specific surgical margins is critical in
determining the need for, or extent of, further surgery or other
adjuvant therapies.46
•
Where there are no anatomical landmarks, specimen orientation
should be indicated with marking sutures or other techniques. If a
specimen is orientated, the orientation should be indicated on the
specimen request form (this may be facilitated by the use of a
diagram).
48
Example Request Information Sheet
The above Request Information Sheet is published to the RCPA website.
49
Appendix 2
Guidelines for formatting of
a pathology report
Layout
Headings and spaces should be used to indicate subsections of the report, and
heading hierarchies should be used where the Laboratory Information System
(LIS) allows it. Heading hierarchies may be defined by a combination of case, font
size, style and, if necessary, indentation.
•
Grouping like data elements under headings and using ‘white space’ assists in
rapid transfer of information.47
Descriptive titles and headings should be consistent across the protocol, checklist
and report.
When reporting on different neoplasm types, similar layout of headings and
blocks of data should be used, and this layout should be maintained over time.
•
Consistent positioning speeds data transfer and, over time, may reduce the
need for field descriptions or headings, thus reducing unnecessary information
or ‘clutter’.
Within any given subsection, information density should be optimised to assist in
data assimilation and recall.
•
Configuring reports in such a way that they group data elements into a single
unit will help to improve recall for the clinician. 47
•
‘Clutter’ should be reduced to a minimum.47 Thus, information that is not part
of the protocol (e.g. billing information, Snomed codes, etc) should not appear
on the reports or should be minimized.
•
Injudicious use of formatting elements (e.g. too much bold, underlining or use
of footnotes) constitutes clutter and may distract the reader from the key
information.
Where a structured report checklist is used as a template for the actual report,
any values provided in the checklist but not applying to the case in question must
be deleted from the formatted report.
Reports should be formatted with an understanding of the potential for the
information to mutate or be degraded as the report is transferred from the LIS to
other health information systems.
As a report is transferred between systems:
•
text characteristics such as font type, size, bold, italics and colour are often
lost
•
tables are likely to be corrupted as vertical alignment of text is lost when fixed
font widths of the LIS are rendered as proportional fonts on screen or in print
•
spaces, tabs and blank lines may be stripped from the report, disrupting the
formatting
•
supplementary reports may merge into the initial report.
50
Appendix 3
report
Example of a pathology
51
The above Request Information Sheet is published to the RCPA website.
52
Appendix 4 WHO histological
classification of tumours of the salivary
glands
Malignant epithelial tumours
Acinar cell carcinoma
Mucoepidermoid carcinoma
Adenoid cystic carcinoma
Polymorphous low grade adenocarcinoma
Epithelial-myoepithelial carcinoma
Clear cell adenocarcinoma, NOS
Basal cell adenocarcinoma
Sebaceous carcinoma
Sebaceous lymphadenocarcinoma
Cystadenocarcinoma
Low-grade cribiform cystadenocarcinoma
Mucinous adenocarcinoma
Oncocytic carcinoma
Salivary duct carcinoma
Adenocarcinoma, NOS
Myoepithelial carcinoma
Carcinoma ex pleomorphic adenoma
Carcinosarcoma, NOS
Metastasizing pleomorphic adenoma
Squamous cell carcinoma
Small cell carcinoma
Large cell carcinoma
Lymphoepithelial carcinoma
Sialoblastoma
8550/3
8430/3
8200/3
8525/3
8562/3
8310/3
8147/3
8410/3
8410/3
8440/3
8480/3
8290/3
8500/3
8140/3
8982/3
8941/3
8980/3
8940/1
8070/3
8041/3
8012/3
8082/3
8974/1
Benign epithelial tumors
Pleomorphic adenoma
Myoepithelioma
Basal cell adenoma
Warthin tumour
Oncocytoma
Canalicular adenoma
Sebaceous adenoma
Lymphadenoma
Sebaceous
Non-sebaceous
Ductal papillomas
Inverted ductal papilloma
Intraductal papilloma
Sialadenoma papilliferum
Cystadenoma
8503/0
8503/0
8406/0
8440/0
Soft tissue tumours
Haemangioma
9120/0
8940/0
8982/0
8147/0
8561/0
8290/0
8149/0
8410/0
8410/0
8410/0
Haematolymphoid tumours
53
Hodgkin lymphoma
Diffuse large B-cell lymphoma
Extranodal marginal zone B-cell lymphoma)
9680/3
9680/3
9699/3
Secondary tumours
a
Morphology code of the International Classification of Diseases for Oncology
(ICD-O) and the Systematized Nomenclature of Medicine (http://SNOMED.org).
Behaviour is coded /0 for benign tumours, /3 for malignant tumours, and /1 for
borderline or uncertain behaviour.
From: Barnes L, Eveson JW, Reichart P, Sidransky D. World Health Organization
Classification of Tumours. Pathology and Genetics of Head and Neck Tumours.
Voulme 9. IARC, Lyon, 2005. Reproduced with permission
54
Appendix 5
Examples of grading of
mucoepidermoid carcinoma
World Health Organisation3
Histopathologic feature
Point value
Cystic component <25%
2
Neural invasion
2
Necrosis
3
4 or more mitoses/ 10 hpf
3
Anaplasia
4
Tumour grade
Point score
Low (Grade 1)
0-4
Intermediate (Grade 2)
5-6
High (Grade 3)
7 or more
55
Brandwein48
Characteristic features
Defining features
Grade I
Prominent goblet cell component,
cyst formation intermediate cells
may be prominent circumscribed
growth pattern
Lack of grade III defining
features, lack of aggressive
invasion pattern
Grade II
Intermediate cells predominate
over mucinous cells mostly solid
tumour squamous cells may be
seen
Aggressive invasion pattern,
lack of grade III defining
features
Grade III
Squamous cells predominate
intermediate and mucinous cells
must also be present mostly solid
Necrosis perineural spread
vascular invasion bony invasion
>4 mitoses/10HPF high-grade
nuclear pleomorphism
Feature
Points
Intracystic component <25%
2
Tumour front invades in small nests and islands
2
Pronounced nuclear atypia
2
Lymphatic and or vascular invasion
3
Bony invasion
3
>4 mitoses/10HPF
3
Perineural spread
3
Necrosis
3
Grade I : 0 points
Grade II : 2-3 points
Grade III : >4 points
© Lippincott Williams & Wilkins. Brandwein MS, Ivanov K, Wallace DI, Hille JJ,
Wang B, Fahmy A, Bodian C, Urken ML, Gnepp DR, Huvos A, Lumerman H and
Mills SE (2001). Mucoepidermoid carcinoma: a clinicopathologic study of 80
patients with special reference to histological grading. Am J Surg Pathol 25:835845. Reproduced with permission.
56
References
1
Eveson JW (2011). Salivary tumours. Periodontology 2000 57:150-159.
2
McHugh CH, Roberts DB, El-Naggar AK, Hanna EY, Garden AS, Kies MS,
Weber RS and Kupferman ME (2011). Prognostic factors in
mucoepidermoid carcinoma of the salviary glands. Cancer doi:
10.1002/cncr.26697.
3
WHO (World Health Organization) (2005). World Health Organization
Classification of Tumours Pathology and Genetics: Head and Neck
Tumours. IARC Press, Lyon.
4
Cross SS, Feeley KM and Angel CA (1998). The effect of four interventions
on the informational content of histopathology reports of resected
colorectal carcinomas. J Clin Oncol 51(6):481–482.
5
Mathers M, Shrimankar J, Scott D, Charlton F, Griffith C and Angus B
(2001). The use of a standard proforma in breast cancer reporting. J Clin
Pathol 54(10):809–811.
6
Srigley JR, McGowan T, MacLean A, Raby M, Ross J, Kramer S and Sawka
C (2009). Standardized synoptic cancer pathology reporting: A populationbased approach. J Surg Oncol 99(8):517–524.
7
Gill AJ, Johns AL, Eckstein R, Samra JS, Kaufman A, Chang DK, Merrett
ND, Cosman PH, Smith RC, Biankin AV and Kench JG (2009). Synoptic
reporting improves histopathological assessment of pancreatic resection
specimens. Pathology 41(2):161–167.
8
CAP (College of American Pathologists) (2009). Cancer protocols and
checklists. Available from:
http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverrid
e=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cnt
vwrPtlt%7BactionForm.contentReference%7D=committees%2Fcancer%2F
cancer_protocols%2Fprotocols_index.html&_state=maximized&_pageLabel
=cntvwr online text.
9
RCP (Royal College of Pathologists) (2009). Datasets and tissue pathways.
Available from: http://www.rcpath.org/index.asp?PageID=254.
10
King B and Corry J (2009). Pathology reporting in head and neck cancer snapshot of current status. Head & Neck 31:227-231.
11
RCPA (Royal College of Pathologists of Australasia (2009 ). Guidelines for
Authors of Structured Cancer Pathology Reporting Protocols. RCPA, Surry
Hills NSW.
12
RCPA (Royal College of Pathologists of Australasia) (2004). The Pathology
Request-Test-Report Cycle — Guidelines for Requesters and Pathology
Providers, RCPA, Surry Hills, NSW.
13
Edge SE, Byrd DR, Compton CC, Fritz AG, Greene FL and Trotti A (eds)
(2010). AJCC Cancer Staging Manual 7th ed., New York, NY.: Springer.
57
14
RCPA (Royal College of Pathologists of Australasia) (2004). Chain of
Information Custody for the Pathology Request-Test-Report Cycle —
Guidelines for Requesters and Pathology Providers. RCPA, Surry Hills,
NSW.
15
Thomson LDR (2006). Head and Neck Pathology. Churchill Livingstone
Elsevier, China, 580-593.
16
Speight PM and Barrett AW (2009). Prognostic factors in malignant tumors
of the salivary glands. British Journal of Oral and Maxillofacial Surgery
47:587-593.
17
Speight P, Jones A, Napier S and Helliwell T (2008). Tissue Pathways for
Head and Neck Pathology. The Royal College of Pathologists, London.
18
Woolgar JA and Trianttafyllou A (2010). Lymph node metastases in head
and neck malignancies: assessment in practice and prognostic importance.
Diagnostic Histopathology 16(6):265-275.
19
Woolgar JA and Triantafyllou A (2009). Pitfalls and procedures in the
histopathological diagnosis of oral and oropharyngeal squamous cell
carcinoma and a review of the role of pathology in prognosis. Oral Oncol
45:361-385.
20
Seethala RR (2009). An update on grading of salivary gland carcinomas.
Head and Neck Pathol 3 69-77.
21
Seethala RR, Dacic S and Cieply K et al (2010). A reappraisal of the
MECT1/MAML2 translocation in salivary mucoepidermoid carcinomas. Am J
Surg Pathol 34(8):1106-1121.
22
Skalova A, Vanecek T and Sima R et al (2010). Mammary analogue
secretory carcinoma of salivary glands, containing the ETV6-NTRK3 fusion
gene: a hitherto undescribed salivary gland tumor entity. Am J Surg Pathol
34:599-608.
23
Griffith C, Seethala R and Chiosea SI (2011). Mammary analogue
secretory carcinoma: a new twist to the diagnostic dilemma of zymogen
granule poor acinic cell carcinoma. Virchows Archiv Int J Pathol.
459(1):117-118.
24
Chiosea SI, Griffith C, Assaad A and Seethala RR (2012).
Clinicopathological characterization of mammary analogue secretory
carcinoma of salivary glands. Histopathology 61:387-394.
25
Patel KR, Solomon IH, El-Mofty SK, Lewis JS Jr and Chernock RD (2013).
Mammaglobin and S-100 immunoreactivity in salivary gland carcinomas
other than mammary analogue secretory carcinoma. Hum Pathol
44(11):2501-2508.
26
Seethala RR (2011). Histologic grading and prognostic biomarkers in
salivary gland carcinomas. Adv Anat Pathol. 18(1):29-45.
27
Evans HL and Luna MA (2000). Polymorphous low grade adenocarcinoma:
a study of 40 cases with long-tgerm follow up and an evaluation of the
importance of papillary areas. Am J Surg Pathol 24:1319-1328.
58
28
Skalova A, Sima R, Kaspirkova-Nemcova J, Simpson RH, Elmberger G,
Leivo I, Di Palma S, Jirasek T, Gnepp DR, Weinreb I, Perez-Ordoñez B,
Mukensnabl P, Rychly B, Hrabal P and Michal M (2011). Cribriform
adenocarcinoma of minor salivary gland origin principally affecting the
tongue: characterization of new entity. Am J Surg Pathol. 35(8):11681176.
29
Woolgar JA (2006). Histological prognosticators in oral and oropharyngeal
squamous cell carcinoma. Oral Oncol 42:229-239.
30
Close LG, Burns DK and Reisch J (1987). Microvascular invasion in cancer
of the oral cavity and oropharynx. Arch Otolaryngol Head Neck Surg
113:1191-1195.
31
Min R, Siyi L, Wenjun Y, Ow A, Lizheng W, Minjun D and Chenping Z
(2012). Salivary gland adenoid cystic carcinoma with cervical lymph node
metastasis: a preliminary study of 62 cases. International Journal of Oral
and Maxillofacial Surgery 41(8):952-957.
32
Slootweg PJ, Hordijk GJ and Schade Y et al (2002). Treatment failure and
margin status in head and neck cancer. A critical view on the the potential
value of molecular pathology. Oral Oncol 38:500-503.
33
Bhayani MK, Yener M, El-Naggar AK, Garden A, Hanna EY, Weber RS and
Kupferman ME (2012). Prognosis and risk factors for early-stage adenoid
cystic carcinoma of the major salivary glands. Cancer 118: 2872-2878.
34
Moreno M, Moreno A and Tomé C (2008). Sentinel lymph node biopsy in
adenocarcinoma of minor salivary gland. Oral Oncol 44(3):305-308.
35
Fiorella R, Di Nicola V, Fiorella ML, Spinelli DA, Coppola F, Luperto P and
Madami L (2005). Major salivary gland disease. Multicentre study. Acta
Otorhinolaryngol Ital 25(3):182-190.
36
Epivatianos A, Poulopoulos A, Dimitrakopoulos I and Andreadis D et al
(2007). Application of α-smooth muscle actin and c-kit in the differential
diagnosis of adenoid cystic carcinoma from polymorphous low-grade
adenocarcinoma. Oral Oncology 43:67-76.
37
Luukkaa H, Klemi P, Leivo I, Vahlberg T and Grénman R (2006). Prognostic
significance of Ki-67 and p53 as tumor markers in salivary gland
malignancies in Finland: an evaluation of 212 cases. Acta Oncol. 45:669675.
38
Ettl T, Stiegler C, Zeitler K and Agaimy A et al (2012). EGFR, HER2,
survivin, and loss of pSTAT3 characterize high-grade malignancy in
salivary gland cancer with impact on prognosis. Hum Pathol. 43:921-931.
39
Bishop JA, Yonescu R, Batista D, Eisele DW and Westra WH (2013). Most
nonparotid "acinic cell carcinomas" represent mammary analog secretory
carcinomas. Am J Surg Pathol. 37(7):1053-1057.
40
Antonescu CR, Katabi N and Zhang L et al (2011). EWSR1-ATF1 fusion is a
novel and consistent finding in hyalinizing clear-cell carcinoma of salivary
gland. Genes Chromosomes Cancer 50:559-570.
59
41
Thway K and Fisher C (2012). Tumors with EWSR1-CREB1 and EWSR1ATF1 fusions: the current status. Am J Surg Pathol 36(7):e1-e11.
42
Johnson CJ, Barry MB, Vasef MA and Deyoung BR (2008). Her2/neu
expression in salivary duct carcinoma: an immunohistochemical and
chromogenic in situ hybridization study. Appl Immunohistochem Mol
Morphol. 16(1):54-58.
43
Skalova A (2013). Mammary analogue secretory carcinoma of salivary
gland origin: an update and expanded morphologic and
immunohistochemical spectrum of recently described entity. Head Neck
Pathol. 7 Suppl 1:S30-36.
44
Royal College of Pathologists of Australasia (2011). Functional
Requirements for Laboratory Information Systems to support Structured
Pathology Reporting of Cancer Protocols
http://www.rcpa.edu.au/Publications/StructuredReporting/LISFunctionalRe
quirements.htm.
45
Arthur K and Farr HW (1972). Prognostic significance of grade in
epidermoid carcinoma of the mouth and pharynx. Am J Surg Pathol
124:489-492.
46
Apple SK (2006). Variability in gross and microscopic pathology reporting
in excisional biopsies of breast cancer tissue. Breast J 12:145-149.
47
Valenstein PN (2008). Formatting pathology reports: applying four design
principles to improve communication and patient safety. Archives of
Pathology and Laboratory Medicine 132(1):84–94.
48
Brandwein MS, Ivanov K, Wallace DI, Hille JJ, Wang B, Fahmy A, Bodian C,
Urken ML, Gnepp DR, Huvos A, Lumerman H and Mills SE (2001).
Mucoepidermoid carcinoma: a clinicopathologic study of 80 patients with
special reference to histological grading. Am J Surg Pathol 25:835-845.
60