Tadrous P.J. Diagnostic criteria handbook in histopathology: a surgical pathology vade mecum
Подождите немного. Документ загружается.
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Management 29
Clinical Audit
r
One audit cycle / loop involves: the monitoring of current practice → compare current practice to set
standards → identify bottlenecks / areas for improvement → results inform changes in practice (=
‘closing the loop’ because the cycle is now repeated – i.e. audit should be continuous)
r
Data for audit is gathered from: lab computers, IQC, EQA, request forms, reports, audit forms, ques-
tionnaires, re-examination of a sub-set of specimens, monthly budget statements, invoices, etc.
r
Why do audit? Clinical Governance (linked to quality assurance, risk management and PDPs)
to meet the requirements of CPA, Cancer Peer Review, CHAI, Monitor, PbR, etc.
for CPD (education, appraisal and revalidation)
funding and time should be built into job descriptions (as SPAs)
± help from: local Audit Offices, RCPath College Audit Committee.
r
Some examples of what may be audited:
requests (appropriateness, sufficiency of clinical information, etc.)
reports (content / utility and compare to RCPath Standards and Datasets)
quality of cut-up
correlation (with cytology / haematology / clin. chemistry / clin. outcome)
turnaround times (routine, urgent, FS, autopsy, etc.; identify bottlenecks)
cost per test
clinical care (e.g. Mortality Meetings where PM reports inform clinical practice).
The Calman-Hine Report, Cancer Networks and MDTs
The Calman-Hine Report 1995
r
The report delivered a framework for cancer care that aimed to make high standards of care uniformly
available to all patients eliminating the ‘postcode lottery’ of cancer outcome measures.
r
It proposed the concept of ‘cancer networks’ made up of PCTs, cancer units and cancer centres with
clearly defined referral and follow-up policies.
r
Cancer units were seen as, typically, DGHs with expertise to diagnose and treat the most common
cancers. A ‘lead clinician’ should be appointed for each unit to co-ordinate cancer services.
r
Cancer centres were seen as large central / teaching hospitals which could treat and manage all can-
cers common and uncommon. These centres would normally be the only locations to provide certain
specialist serves across the network e.g. radiotherapy.
r
Anatomical site-specific specialisation should occur and be expanded esp. in centres but also in units.
Surgical specialisation and nurse specialists were specifically mentioned in the report but now special-
isation in histopathology too is becoming more the norm.
r
They emphasised the importance of multidisciplinary team (MDT) working and the collection of
statistics through cancer registration, both of which were already taking place to some extent.
Implementation of Calman-Hine w.r.t. Histopathology
r
The establishment of multidisciplinary teams (MDTs) comprising:
lead clinician (could be any of the medical members of the MDT)
histopathologist, surgeon, radiologist, oncologist, nurse ± others e.g. physiotherapist
MDT co-ordinator: sets up multidisciplinary team meetings (MDMs), assembles patient-lists
for distribution to pathology / radiology, etc. so they can get reports ready, records outcomes
of meetings, collects patient notes.
r
Pathologists working in cancer units / centres will take part in regular (usu. weekly) MDMs where
cancer patients’ radiology, pathology, surgical, oncological and nursing management and follow up are
reviewed and further management decisions made and recorded.
r
The RCPath have developed National Datasets for cancer reporting for anatomical site-specific cancers
which:
aim to make the standard of examination of cancer specimens uniform across the UK
aim to facilitate cancer registration
state that all pathologists reporting cancer should take part in appropriate EQA schemes
state that there should be a ‘lead pathologist’ for each specialty in each department who is
responsible for co-ordinating and ensuring the uniform application of the dataset standards.
This has fuelled the drive towards specialisation in pathology.
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Management 30
r
Implementation of Calman-Hine via the DoH ‘NHS Cancer Plan’ (2000) has made newmonies available
for cancer networks which may be used e.g. for purchasing teleconferencing equipment to allow MDMs
with staff across hospital sites. This may also help fund pathology e.g. the need for a new consultant
histopathology post to deal with the increased work-load from new surgical consultants.
r
Cancer Peer Review: to ensure National Cancer Standards (including cancer network standards on e.g.
waiting times) are being met there will be annual Cancer Peer Review inspections of regional services.
This may take the form of a series of interviews (by the Peer Review Panel) of the MDT members and
local chiefs of service. An MDT should prepare an operational policies folder containing all protocols
and SOPs (for histopathology, policies may include:
a) staging must be recorded according to the RCPath National Datasets standards
b) a designated pathologist must attend the MDMs
c) facilities must be available to store slides and blocks for an appropriate time
d) the lab must have appropriate accreditation).
The Peer Review Panel may ask questions arising from their prior study of this folder.
Freedom of Information Act, Data Protection Act, Pathology Reports and Caldicott Guardians
Freedom of Information Act 2000
r
Subject to specific exclusions, anyone has the right to receive any type of recorded information (incl.
emails, minutes, etc.) held by public authorities within 20 days of them requesting it.
r
Although enacted from 1
st
January 2005, the Act is retrospective.
r
Exclusions include requests relating to: audit functions, criminal investigations, living persons (i.e.
subject to the DPA), commercial sensitivity or if the information is available elsewhere.
r
Enquiries must be in writing and are usu. dealt with via the Chief Executive’s office.
Data Protection Act 1998 (DPA)
r
Replaces and updates the Data Protection Act 1984 which concentrated on electronic data
r
Now any personal data held on any type of file system including paper, electronic or otherwise is
covered by the Act
r
The data must be stored securely with safeguards to ensure security and avoid unauthorised access
r
Any data acquired must be done with prior informed consent with mention of what data is to be stored
and for what purposes it is to be used
r
The data must be dealt with according to ‘fair processing’ rules e.g.:
no more data must be recorded than is required for the stated purposes
the data must not be stored for longer than the stated purposes require
data should not be used for any other purpose without specific consent
data must not be released to another party except in a few well-defined circumstances (e.g. to
prevent or detect crime).
r
A designated local data controller must be nominated to oversee the Act is followed in collecting,
storing and processing of the data. The data controller must be registered on the Public Register of Data
Controllers by the Information Commissioner (the statutory body overseeing the register)
r
The subject has the right to see their data except where the data was given by a third party in confidence
(e.g. a reference) or where disclosure would unavoidably identify a third party
RCPath Guidance on the Handling of Pathology Reports
r
This is a partial summary only – see the report for full details and section on Storage and Disposal
below
r
Reports are part of the patient’s record so must be stored and processed in accordance with the DPA
r
Avoid using phone / fax / email for results due to lack of security e.g. verification of the identity of the
recipient(s) and that the location of the receiving fax machine is in a confidential place, etc.
r
Report information should only be given:
to the clinician who made the request
to the clinician’s delegates
to others involved in the clinical care where the information is relevant to their clinical deci-
sions.
to relevant authorities for reporting a notifiable disease
to relevant authorities when it is in the public interest
JWBK208-03 December 8, 2007 15:59 Char Count= 0
Management 31
to others with the expressed consent of the patient
to the patient via Trust procedures (according to the patient’s right under the DPA)
to the patient directly where the clinician has agreed the patient may know their results e.g. to
take appropriate action according to the monitoring of a previously diagnosed condition (but
if the results show new information it should be communicated via the clinician).
The Caldicott Report 1997 and Caldicott Guardians
r
Dame Fiona Caldicott was asked to examine the use of medical records by non-patient care staff (e.g.
for national statistics). She recommended, inter alia:
information may be used but must first be ‘de-identified’ by removing the name and address
and replacing this with NHS n˜o. and postcode
a network of patient data ‘guardians’ should be established throughout the NHS to safeguard
the protection and oversee the use of patient data in the NHS
only release information when absolutely necessary and give the minimum necessary with
access limited via a ‘need to know’ basis.
r
Potential problems with the Caldicott recommendations include:
NHS ‘Trace’ system allows name and address to be found from NHS n˜o.
postcode and age is sufficient to identify most people (except those in communal addresses).
r
A Caldicott Guardian must be appointed at each NHS institution (e.g. PCT / Trust) and must:
be a senior member of the health care or managerial staff
have their name and contact address held on the National Register of Caldicott Guardians
be involved in developing protocols governing the acceptable use of patient-identifiable data
within their organisation including the interaction with regional and local ethics committees
and the approval of IT system security protocols
develop and review protocols for transfer of patient identifiable information to third parties
such as the Child Support Agency and for statistical purposes.
Storage and Disposal of Pathological Specimens and Reports
r
Tissue blocks and slides should be incinerated (after minimum storage periods) in opaque containers.
r
Human material should be separated from clinical waste and have separate incineration events.
r
Fetuses born dead <24/40 may be incinerated as above but parents should be given the choice of other
disposal options (cremation / burial) e.g. via a consent form. Stillbirths >24/40 or any fetus born alive
<24/40 are defined as ‘human remains’ and are thus subject to death certification and disposal law (so
cannot be incinerated as surgical waste).
r
Tissue may be returned to the patients at their request provided:
hospital authorities are satisfied with the proposed disposal / storage methods
written notice of any hazards assoc
d
with the material are also given
the minimum storage period is served unless the tissue is not related to the medical record.
r
Tissue may be handed over to a police / law-enforcement officer provided (NB: exceptions apply):
the officer’s identity is confirmed (ask for ID card and n˜o. and record these ID details)
the officer shows either informed consent for the patient or the order of a judge (make a copy)
you ensure the officer’s health and safety and patient’s confidentiality w.r.t. packaging, etc.
r
Minimum storage periods are (NB: ‘permanently’ = at least 30 years):
wet tissue: 4 weeks after the final report is issued
paraffin blocks and material for EM/DNA analysis: permanently or lifetime of patient (DNA
and PM tissue/slides require consent / Coronial instruction – see Chapter 25: Autopsy)
histology / cytology slides incl. FS: 10 years (permanently for abnormal cervical smears)
records relating to IQC, CPA and inspections: 10 years
histology / autopsy reports, museum catalogues,patient-related correspondence, SOPs, images
made as part of the diagnostic process [not solely for communicat
n
e.g. MDTs]: permanently
request forms: 1 month after the final report is issued (permanently if they contain original
diagnostic or clinical information)
day books / specimen receipts, EQA records, telephoned advice logs: two years
research records / data: anonymised or destroyed six months after final publication of results
(data may be kept for 10 years to refute fraud allegations and must be kept for ≥15 years if
part of a trial for new therapies. The DPA provisions must be adhered to in these cases).
JWBK208-03 December 8, 2007 15:59 Char Count= 0
Management 32
r
No record (tissue, report or notes) older than 1660 should be destroyed. separate laws govern
r
No record pre-dating the NHS (dated ≤ 1948) should be destroyed.
these two issues
Screening Program Management
Definition of Important Statistics
r
Sensitivity = true test +ve cases / All
2
those with the disease
r
Specificity = true test −ve cases / All those without the disease
r
Predictive value of a positive test result = true test +ve cases / All who tested +ve (=PPV)
r
Predictive value of a negative test result = true test −ve cases / All who tested −ve (=NPV)
r
The predictive values depend on the prevalence of the disease in a population in addition to the
characteristics of the test method
r
False positive rate = false test +ve cases / All those with the disease
r
False negative rate = false test −ve cases / All those with the disease
Breast Screening Program (UK)
r
Three-yearly mammography is offered to women aged 50–70 years
r
Details on the calculation of the above stats w.r.t. breast histology and cytology are given in the NHSBSP
Publication n˜o. 50 (2001) with additional stats e.g. ‘absolute sensitivity’ (= n˜o. of C5 and B5 results
as numerator) vs. ‘complete sensitivity’ (= n˜o. of non-negative results as numerator)
r
Stats are calculated by screening program computer systems given the biopsy and histology results
r
Individual pathologists should regularly audit their own PPVs and other stats
r
Annual returns of stats are made via forms KC62 (completed by breast screening units) and KC63
(completed by health authorities)
Cervical Screening Program (UK)
r
Women are offered their first smear at age 25, then 3 yearly till 49, then 5 yearly till 64.
r
Details of definitions for individual screener and laboratory stats (such as sensitivity, PPV, etc.) are
given in the ABC document and form part of the annual returns (submitted on form KC61).
r
Each laboratory must keep its own performance continually under review by measuring and auditing
these statistics monthly in minuted departmental meetings.
r
Labs must aim to keep their performance to the achievable standards set out in the ABC document.
r
Annual returns of screening statistics from each laboratory must be provided via form KC61. This
includes biopsy histology as well as cytology results and screening statistics such as PPV.
r
Information provided by the cervical screening service also contributes to the annual returns on sexual
health (form KC60) by providing information on the n˜o. of major and minor smear abnormalities and
genital infections (HSV, HPV, Trichomonas, etc.)
Bowel Cancer Screening Program (UK)
r
Two-yearly, all NHS registered people aged 60–69 are sent an FOBt kit with foil-wrap return envelope.
r
The person mails the completed test to 1 of 5 centres (called ‘hubs’) to read the results.
r
≈ 2% will be ‘strong +ve’ and invited to attend nurse clinic at the hub where endoscopy is offered.
r
If patient accepts then endoscopy is arranged at their local ‘screening centre’.
r
If endoscopy is unsuitable then alternatives are considered (barium enema or virtual colonoscopy).
r
If the FOBt is weak +ve or spoilt a retest is requested. If −ve, repeat in two years.
Some Other Topics Relevant to Management
r
Appraisal: includes 360
◦
peer review (i.e. getting formal feedback from those on the receiving end
of your services), competency-based, objectives-based and trait-based appraisal. Keep an appraisal
portfolio for the purposes of revalidation.
r
Revalidation – requirement of the GMC for continued license to practise. The GMC may inspect a
doctor’s evidence of keeping up-to-date over any five-year period. For most hospital doctors’ evidence
of satisfactory participation in appraisal is sufficient. See www.gmc-uk.org/register/licensing/index.asp
r
Professional standards and sub-standard performance issues. See GMC documents ‘Good Medical
Practice’ (see also the RCPath version of this) and ‘Duties of a Doctor’ (regularly updated on the
2
The word ‘All’, in these definitions, refers to all who were tested, regardless of the test result.
JWBK208-03 December 8, 2007 15:59 Char Count= 0
Management 33
GMC’s website, www.gmc-uk.org), and the RCPath guidance document on dealing with substandard
performance. Know the requirements of the RCPath CPD scheme (e.g. must make annual returns and
accrue ≥ 250 CPD points per 5 year period)
r
CPA UK Ltd laboratory accreditation procedures: register with CPA → comply with the (>40) CPA
standards → receive CPA inspectors → full/conditional/deferred accreditation
r
The NHS Purchaser/ Provider contracting process and the role of ‘market testing’ in pathology (i.e.
the process of getting management consultants to receive bids from local and outside providers to see
whether an alternative supplier of pathology services could be more efficient / effective)
r
Team-building: good communication (inclusivity, regular meetings), departmental outings, etc.
r
The National Spine is the proposed UK-wide IT network infrastructure of the NHS which is be-
ing developed to allow healthcare staff anywhere to access medical details about patients (held
in National Spine Records – NSRs). It forms the basis of the Integrated Care Record Service
(ICRS – the nationally networked version of the current local electronic Patient Record or ePR).
SNOMED / SNOP coding is to be an integral component of the ICRS so these codes should be used
accurately
r
Government policy statements e.g. Hospital Medical Staffing: Achieving a Balance in 1986 created
the ‘staff grade’ as an NCCG post to alleviate the backlog of trainees – held for years in junior
posts – because of the lack of full consultant vacancies. This latter created problems as staff grade
doctors were not trained to (post-Calman) CCT level so could not upgrade to full consultants as more
posts became available and could not move to European posts either (this situation was alleviated when
NCCGs were later allowed to compete for StR positions). The Health of the Nation (1992–1997) was an
attempt to address major issues in public health by focusing on five areas (IHD/stroke, cancer, mental
illness, sexual health, accidents) setting targets and objectives that guided subsequent government
policies. The New NHS: Modern, dependable is a Labour White Paper (DoH, 1997) stating goals for
replacing the Conservative’s ‘internal market’ with ‘integrated care’ (equalise standards of care across
the country, reduce beurocracy, etc.). The NHS Plan (DoH, 2000) sets out the governments priorities
(over 10 years) for investing the extra resources it pledged in the March 2000 budget statement. This
includes goals for more beds, better quality catering, more doctors and nurses with reformed training
arrangements, cleaner wards, updated IT, shorter waiting times and The NHS Cancer Plan (DoH, 2000)
for implementing the Calman-Hine Report recommendations. The NHS Plan abolishes and supersedes
The Patient’s Charter originally published by the Conservatives in 1991
r
National Service Frameworks (NSFs) are documents detailing targets and standards for individual
disease categories e.g. diabetes, cancer, mental health, renal diseases, etc.
r
Star ratings system: NHS hospitals may be awarded 0–3 stars according to how well they adhere to
certain targets called Performance Indicators (PIs) set by the CHAI. PIs are categorised as Key Targets
(e.g. waiting times in A&E), Patient Focus targets (e.g. patient questionnaire responses), Clinical Focus
targets (e.g. post-operative death rates) and Capacity Targets (e.g. record-keeping, working conditions
for staff)
r
Foundation hospitals: NHSFT status is an option for 3 star hospitals which allows them to raise local
funds, set individual pay scales and have more local control of other managerial decisions. They are
authorised and regulated by an Independent Regulator (called ‘Monitor’)
r
NHS Confederation: A body (with local branches e.g. the London NHS Confederation) that has rep-
resentatives from all organisations of the NHS (SHAs, PCTs, Hospital Trusts, Ambulance Trusts,
Mental Health Trusts, Care Trusts, etc.). The confederation lobbies Parliament and MPs on behalf of its
members and facilitates sharing of information between its members. See http://www.nhsconfed.org/
(accessed August 2007)
For other NHS issues see: http://www.nhs.uk/england/aboutTheNHS/default.cmsx (accessed August
2007).
r
The GMC publishes a document called Management for Doctors explaining the duties and standards
expected of doctors in management roles. Find it online under the ‘management guidance / ethical
guidance’ link in the ‘Standards’ section of the GMC web site (www.gmc-uk.org)
r
Aspects of employment law relating to non-discrimination e.g. issues of accessibility and building
design and achieving ‘positive about disabled people’ status as an employer (from the Employment
Service – now part of JobCentrePlus) by making and demonstrating certain specific commitments
(e.g. to interview any disabled applicant for a job if they fulfil the minimum criteria, to make every
effort to retain staff who subsequently become disabled, etc.). Also ‘equal opportunities’ (male/female),
racial equality and meeting certain management standards such as ‘Investors in People’ which requires
the use of development plans (for individuals and teams), taking action to implement these plans
JWBK208-03 December 8, 2007 15:59 Char Count= 0
Management 34
(guaranteed study-leave arrangements, etc.) and review / evaluation of the effectiveness and outcome
of such measures. See:
www.eoc.org.uk (Equal Opportunities Commission)
www.cre.gov.uk (Commission for Racial Equality)
www.drc-gb.org (Disability Rights Commission)
www.jobcentreplus.gov.uk (see Employer’s pages)
www.investorsinpeople.co.uk (Investors in People)
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Cut-Up and Reporting Guidelines 36
4. Cut-Up and Reporting Guidelines
Applied Anatomy
Brain
cdh
olf
ins
put
ic
1
2
3
L1
L2
3
1
4
4
cg
cc
L3
spl
u
p
hg
ge
mb
f
o
pg
ps
aq
a
sic
A5
A3
P1
P4
phg
collateral sulcus
th
rn
sn
cdt
put
gp
cla
su
b
icu
lum
cdt
fimbria
cp
HF
CA1,2,3
CA4
lgn
ic
A5A3P1P4
dorsal
ventral
superior
inferior
Cb1 Cb2
Cb3
Cb4
Lobar Boundaries Cerebral Blood Supply Cerebral Boundary Zones
Cerebellar Boundary Zone
s
The Hippocampus
TWS
Key
Cerebral Blood Supply
red anterior cerebral artery
green middle cerebral artery
blue posterior cerebral artery
Cerebral Boundary Zones
cyan boundary zone between the
posterior & middle cerebral
yellow anterior & middle cerebral
magenta anterior & posterior cerebral
TWS triple watershed region
Cerebellar Boundary Zones
cyan boundary between medial &
lateral branches of the
posterior inferior cerebellar
artery
yellow superior & posterior inferior
magenta anterior inferior & posterior
inferior
Slice Numbers
A5 fifth slice anterior to the
mammillary bodies (mb)
A3 third slice anterior to the mb
P1 first slice posterior to the mb
P4 fourth slice posterior to the mb
Cb1 left paramedian sagittal slice
of the cerebellum
Cb2 right paramedian sagittal slice
of the cerebellum
Cb3 horizontal slice through the
cerebellum just caudal to the
midpoint
Cb4 horizontal slice through the
cerebellum more caudally
than Cb3
ic internal capsule
ins insula
lgn lateral geniculate nucleus
mb mammillary body
phg parahippocampal gyrus
pg pineal gland
ps pituitary stalk
put putamen
rn red nucleus
sic superior & inferior
colliculi
sn substantia nigra
spl corpus callosum (splenium)
th thalamus
u uncus
Anatomical Landmarks
a anterior commissure
aq aqueduct of Sylvius
CA cornu ammonis (CA1 =
Sommer's sector)
cc corpus callosum (body)
cdh caudate nucleus (head)
cdt caudate nucleus (tail)
cg cingulate gyrus
cla claustrum
cp choroid plexus
f fornix (anterior column)
ge corpus callosum (genu)
gp globus pallidus
HF hippocampal fissure
ht hypothalamus
caudate
1. Corpus striatum (striate body) = putamen
2. Claustrum globus pallidus
3. Amygdaloid body
4. some clinicians might add: subthalamic nuclei &
substantia nigra
(NB: the caudate + putamen = the neostriatum,
sometimes just called 'the striatum' - do not confuse
with the 'corpus striatum' or that part of the visual
cerebral cortex called the area striata = striate cortex)
Blood Supply:
This is mainly from perforating branches of the
middle & posterior cerebral arteries e.g. the lateral
striate arteries that arise close to the origin of the
middle cerebral & enter the brain via the anterior
perforated substance at the base of the brain lateral
to the optic chiasm.
The Basal Ganglia
th
ht
Lobar Boundaries
cyan occipital lobe
yellow frontal lobe
magenta parietal lobe
grey temporal lobe
1. central sulcus
2. lateral sulcus
3. parieto-occipital sulcus
4. calcarine sulcus
L1. a line joining 3 to the
pre-occipital notch
notch formed by the (the
petrous temporal bone)
L2. a line from the end of 2
to the midpoint of L1
L3. a line from the pre-occipital
notch to the anterior end of 4
FIGURE 4.1 Brain
r
Charcot’s ‘artery of cerebral haemorrhage’ refers to the lenticulostriate branches of the middle cerebral
that enter the anterior perforated substance and supply the external capsule and basal ganglia.
r
Cerebral cortex terminology: apart from some regions considered phylogenetically old (olfactory and
hippocampal), the cortex has six layers and is called neocortex = isocortex = homogenetic cortex
Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum. Paul J. Tadrous
Copyright
C
2007 by John Wiley & Sons, Ltd. ISBN: 978-0-470-51903-5
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Cut-Up and Reporting Guidelines 37
Eyes
Optic nerve is nasal
& inferior to the mid point
The closest muscle to the optic nerve
is temporal and inferior to the mid point.
Superior oblique is
temporal & superior
(tendinous insertion)
LEFT
RIGHT
Long ciliary
arteries lie
horizontally
(Inferior oblique: muscular insertion, overlies the macula)
FIGURE 4.2 Eyes (orientation and measurements)
r
For orbital exenterations, the
caruncle and lower lid punctum
(which may be probed to find the
nasolacrimal duct margin) iden-
tify the medial aspect; longer
lashes and a fold identify the
upper lid.
TABLE 4.1 Normal values for a globe
globe (X,Y,Z) 22–23 mm
optic nerve 4mm
corneal (X) 12 mm
corneal (Y) 11 mm
iridocorneal angle 454
◦
(>30
◦
)
Neck
IA
IB
IIA IIB
III
IV
VA
VB
VI
VII
1
2
3
5
6
7
9
10
11
12
8
Key to Anatomical Landmarks:
1. jugular fossa
2. posterior border of submandibular salivary gland
3. inferior border of the digastric
4. mid-digastric tendon
5. internal jugular vein (anterior and posterior borders)
6. inferior border of the hyoid bone
7. anterior border of trapezius
8. accessory nerve (spinal part)
9 posterior / lateral border of sternocleidomastoid
10. inferior border of cricothyroid cartilage
11. posterior border of anterior scalene
12. superior border of manubrium sterni
Structures included in a Radical Neck Dissection:
A. LN from levels I-IV (at least)
B. submandibular salivary gland
C. internal jugular vein
D. sternocleidomastoid
E. accessory nerve (spinal part)
the last three are optional in a modified radical
Anatomical landmarks 2, 4, 5 & 9 are particularly
helpful in defining the levels in a radical neck
dissection specimen, as is the point at which the
omohyoid passes deep to the sternocleidomastoideus
(marks the dividing line between level III & IV).
4
FIGURE 4.3 Neck dissection (Lymph node Levels I–VII)
r
Nodal groups (for TNM) are: 1 =IA, 2 =IB, 3–5 = perijugular parts of II–IV, 6 (peri-accessory nerve,
spinal part) = VA, 7 (supraclavicular) = VB + partofIV,8= VI, [9–12 do not correspond to levels]
9 (retropharyngeal), 10 (parotid), 11 (buccal / facial), 12 (mastoid + occipital)
r
The ‘posterior triangle group’ comprises level VA + VB (≈groups 6 + 7)
Neck (Surface anatomy of the carotid sheath)
r
Trace a line from the sternoclavicular joint to the midpoint between the angle of the mandible and tip
of the mastoid process.
r
Beneath this line lie the carotid artery, the internal jugular vein, the deep cervical lymph nodes and the
vagus nerve.
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Cut-Up and Reporting Guidelines 38
Larynx and Pharynx
C2
Nasopharynx
Oropharynx
Laryngopharynx
(= Hypopharynx)
cervical
oesophagus
sphenoid to lower border
of back of soft palate.
It contains the
'postnasal space'.
to upper border of
epiglottis (incl. the
posterior 1/3 of tongue)
to lower border of
cricoid cartilage (incl.
the post-cricoid
area)
sphenoid
Pharynx
= a funnel connecting the nasal & oral cavities to the oesophagus. The
anterior limits = back of nasal septum, palatoglossal fold, sulcus terminalis (& the
opening to the larynx). It is divided
into nasal, oral & laryngeal parts:
Tonsils of Waldeyer's Ring:
pharyngeal (= 'adenoids')
tubal
palatine (= 'tonsils')
lingual
palatoglossal fold
st
vp
ppf
lgef
mgef
aef
tc
cc
cricothyroid ligament
thyrohyoid membrane
hb pf
vc
cune
corn
aryt
oblique line (attachment for
sternothyroid, thyrohyoid &
inferior constrictor muscles)
arch of cc
lamina of cc
1
2
1
st
tracheal cartilage
Strap Muscles
(not illustrated)
= musculi infrahyoides
a) sternohyoid b) omohyoid c) thyrohyoid d) sternothyroid
tongue
lgef
ppf
vcvc
mgef
pf
superior
cornu of tc
lamina
of tc
eg
hb
vbf vcf
(respiratory lining
& underlying
mucous glands)
(squamous lining
& none / rare
mucous glands)
greater
cornu
of hb
3
4
5
6
tb
ac
pf
eg
v
s
vcf
vbf
qm
vbl
tgl
vcl
ce
Fibroelastic
Membrane:
ctl
cc
superior
cornu
of tc
inferior
cornu
of tc
7
Key to Figure:
Muscles
1. genioglossus
2. geniohyoid
3. aryepiglottic
4. oblique arytenoid
5. transverse arytenoid
6. posterior cricoarytenoid
7. vocalis
Anatomical Landmarks
ac anterior commissure
aef aryepiglottic fold
aryt arytenoid cartilage
s saccule (= sinus of
Morgagni = appendix
ventriculi laryngis)
st sulcus terminalis
tb tubercle of epiglottis
tc thyroid cartilage
tgl thyroglottic ligament
v ventricle
vbf vestibular fold
(= false vocal cord)
vbl vestibular ligament
vc vallecula(e)
vcf vocal fold
(= true vocal cord)
vcl vocal ligament
vp vallate papilla(e)
v
aef
eg
aryt
4, 5
cc
cc
tc
hb
pes
mgef
corn
deep base of tongue
Larynx (Spaces)
supraglottic
(green)
paraglottic
(infraglottic
part)
Reinke's (yellow)
subglottic
pre-epiglottic
paraglottic
(supraglottic
part)
hel
cc cricoid cartilage
ce conus elasticus
corn corniculate cartilage
ctl cricothyroid ligament
cune cuneiform cartilage
eg epiglottis
hb hyoid bone
hel hypoepiglottic ligament
lgef lateral glossoepiglottic fold
mgef median glossoepiglottic fold
pes pre-epiglottic space
pf piriform fossa
(= piriform sinus)
ppf palatopharyngeal fold
qm quadrangular membrane
Larynx (Regions)
1cm
}
Glottic
Subglottic
(begins 1cm below the
level of the true vocal cords)
(the glottis = the true vocal
cords & both commissures)
Supraglottic
(the 'epilarynx' = suprahyoid epiglottis,
aryepiglottic folds & arytenoids: i.e.
the region above the green line)
FIGURE 4.4 Larynx and pharynx
Notes on the larynx
r
The larynx extends from the epiglottis to the bottom of the cricoid cartilage. The epiglottic, corniculate
and cuneiform cartilages are elastic type (the others are hyaline).
r
The vestibule is that part of the lumen of the larynx proximal to the true cords.