Head and Neck Pathology

Goals and Objectives

Level: PGY-2, PGY-3, PGY-4 and PGY-5

***Starting July 1, 2022, the resident will spend one day per week signing out ocular pathology with the ocular pathologists (see separate ocular pathology goals and objectives)***

In the CBD cohort, junior residents are considered to be PGY-1 and PGY-2; senior residents are considered to be PGY-3 and PGY-4.  PGY-5 CBD residents are also considered to be senior residents and within the CBD curriculum. The goal is to allow for independence in the form of independent sign out, intraoperative consultations and supervision of junior residents and Pathologist Assistants.

For surgical sign out in Anatomical Pathology residency training, there is no separation of cases based on complexity.  Due to the nature of Anatomical Pathology (all cases are ultimately reviewed and finalized by a supervising staff), a resident in any training level can review the glass slides and write up a preliminary report on any surgical pathology case.

  • Ordering of any ancillary studies (histochemical stains, immunohistochemical stains, molecular testing) will initially be done under staff supervision for junior residents.  This is done in order to conserve tissue and prevent tissue waste that may limit the staff pathologist's ability to render a diagnosis. 
    • Based on the resident's experience and abilities they will eventually be permitted to order additional ancillary stains for straightforward, routine cases without consulting the staff pathologist.
    • Regardless of training level, any challenging case for which the resident is unsure of cell lineage or is unable to formulate a differential diagnosis that would be resolved by ancillary testing, the resident must consult the staff pathologist before ordering any ancillary stains.
    • It is expected that senior residents, including PGY-5 residents, would be able to initiate a preliminary panel of ancillary studies for routine cases.  This is ultimately at the discretion of their supervising staff.
  • Grossing of routine specimens can be handled by a resident at any training level.  Complex specimens, which for H&N/endocrine pathology include laryngectomy, radical neck dissections (including extended and modified), composite resections ± mandible or maxilla, or other specimens, should be done by residents that are able to demonstrate a complete understanding of the anatomical and imaging findings as well as the surgical procedure.  Junior residents must obtain staff approval or be supervised by a senior resident for a complex specimen. 

It is expected that the first gynecologic pathology rotation by a junior resident will result in the mastery of normal histology, knowledge of the various surgical procedures encountered and the ability to diagnose common entities. 

It is also expected that the junior residents will review the gross report and correct any typographical errors, assess the completeness of the grossing and correctly report the specimen site, laterality and procedure in the diagnostic section of the surgical pathology report.

Subsequent H&N/endocirne pathology rotations by senior residents will be built upon the above foundation and include the ability to formulate reasonable differential diagnoses as well as to work up challenging cases.  A senior resident should be able to produce a draft surgical pathology report that includes the elements listed above, along with the appropriate diagnosis, completion of a synoptic report (if indicated) and an appropriately completed microscopic description and/or comment field.  This draft report should also be free of typographical errors. The supervising staff pathologist is expected to provide an appropriate volume of cases for review based on the PGY-1 and PGY-2 resident’s level of training in these areas with the understanding that greater responsibility and workload will be taken on in PGY-3.

Additionally, while junior residents are expected to be present at all interdisciplinary rounds in these major subspecialties, they are not expected to present cases while a more senior resident is on service. If there is no senior resident on service, the junior resident will be responsible for obtaining slides of appropriate cases and working with the staff pathologist in order to present cases which are appropriate for their level of training.

Staff pathologists are required to be present at all interdisciplinary rounds during which a resident is presenting, particularly for junior residents.

Senior residents are expected to independently prepare for and present cases at H&N aand Endocrine interdisciplinary rounds, and, with staff pathologist supervision and guidance, answer questions and take part in discussion during said rounds.

The PGY-5 year is one of senior leadership and the resident should be able to assume responsibility for organizing the service and supervising junior residents and students. The resident should have mastery of the information contained in standard texts and be prompt in using the literature to solve specific problems. The resident will be responsible for presentations at conferences and for teaching junior residents and students on a routine basis. The PGY-5 should begin to have an understanding of the role of the practitioner in an integrated health care delivery system and to be aware of the issues in health care management facing patients and physicians. 

Based on the Royal College guidelines and recommendations, following the completion of their surgical pathology rotations and EPAs, CBD residents should be ready for independent sign out.

Medical Expert

  • Demonstrate a working knowledge of the anatomy, histology and embryology of the head and neck including the larynx, oropharynx, nasopharynx, paranasal sinuses, auditory canal (including external ear), major salivary glands, nasal cavity, oral cavity, thyroid, parathyroids and adrenal gland (EPA: F#2)
  • Demonstrate skill in the gross dissection of common resection specimens from the H&N and endocrine organs including hemiglossectomy, thyroidectomy (lobectomy, hemithyroidectomy, subtotal/total/completion thyroidectomy), superficial parotidectomy, simple mucosal excisions, adrenalectomy, parathyroidectomy and other specimens, with particular attention to staging information (EPAs: TTD# 1A, F#1, C#2, C#3).
  • Demonstrate proficiency in interpretation of common biopsy specimens including those from major salivary glands, lymph nodes and mucosal biopsies (oral cavity, oropharynx, larynx, nasal and paranasal sinuses, nasopharynx, and other sites) (EPAs: TTD# 1A, F#1, C#2, C#3).
  • Demonstrate ability to deal with difficult gross specimens i.e. occult tumors, post neoadjuvant specimens, poorly oriented specimens (EPAs: C#2, C#3)
  • Demonstrate ability to gross large and/or complex H&N specimens i.e. total laryngectomies (with or without neck dissection(s)), composite resections, radical neck dissections (including extended or modified) (EPAs: C#2, C#3)
  • Demonstrate proficiency in the interpretation of mucosal and major salivary gland, and knowledge of lesions that cannot be adequately assessed in a limited biopsy sample (EPAs: F#2, C#4, C#5, TTP#1)
  • Acquire proficiency in the morphologic diagnosis, immunohistochemical work-up and staging of the spectrum of salivary gland tumors (EPAs: F#2, C#4, C#5, TTP#1).
  • Acquire proficiency in the morphologic diagnosis, immunohistochemical work-up and staging of the spectrum of thyroid tumours (EPAs: F#2, C#4, C#5, TTP#1).
  • Acquire proficiency in the morphologic diagnosis, immunohistochemical work-up and staging of the spectrum of primary mucosal tumors (EPAs: F#2, C#4, C#5, TTP#1).
  • Acquire proficiency in the morphologic diagnosis, immunohistochemical work-up and staging of the spectrum of odontogenic tumours (EPAs: F#2, C#4, C#5, TTP#1).
  • Acquire proficiency in the morphologic diagnosis, immunohistochemical work-up and staging of the spectrum of primary mesenchymal tumours of the H&N (EPAs: F#2, C#4, C#5, TTP#1).
  • Acquire proficiency to prepare well-organized, comprehensive reports that convey the appropriate staging and prognostic information in common H&N and endocrine oncology specimens including thyroid, mucosal tumours at all H&N sites, salivary gland and adrenal gland (EPAs: F#2, C#4, C#5, TTP#1).
  • Acquire knowledge of the spectrum of primary mucosal disease and tumours and the associated risk implications (EPAs: F#2, C#4, C#5, TTP#1)
  • Understand the unique role viruses such as human papillomavirus (HPV) and Epstein-Barr virus (EBV) play in the development of head and neck cancers (EPAs: F#2, C#4, C#5, TTP#1).
  • Understand the role genetic alterations play in the development of salivary gland tumours and know when to order ancillary molecular tests (EPAs: F#2, C#4, C#5, TTP#1).
  • Acquire proficiency in the interpretation of head and neck frozen sections (EPA: C#13).
  • Acquire knowledge in the use and interpretation of immunohistochemistry pertinent to H&N pathology, including PD-L1 immunohistochemistry (EPAs:  C#10, TTP#1)

Communicator/Collaborator

  • Obtain a relevant clinical history, including relevant laboratory and imaging results and interpreting this information in light of the clinical information and providing a summary to the supervising staff pathologist (EPA: TTD#2)
  • Demonstrate the ability to function at a junior staff pathologist level at H&N rounds and Endocrine Rounds by previewing cases to be presented, appropriately choosing histology slides to present, presenting the pertinent pathological features, and responding to questions regarding the cases (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)
  • Demonstrate the ability to teach aspects of H&N and endocrine pathology at teaching sessions including gross rounds and other teaching sessions. (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Gain an understanding of clinical aspects of H&N and endocrine disease, the management of thyroid disorders, HPV oropharyngeal cancers, squamous cell carcinomas in all H&N sites, including HPV-driven oropharyngeal carcinoma and EBV-related nasopharyngeal carcinomas (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Demonstrate the ability to teach and provide guidance for Pathologist Assistants in the appropriate gross examination of complex head and neck specimens (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Demonstrate the ability to teach surgery and oncology residents and medical students at interdisciplinary rounds, frozen sections or teaching sessions (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Gain a more thorough understanding of the clinical aspects of otolaryngology and head and neck surgery (through attendance at rounds and interaction with ENT surgeons) (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).

Manager

  • Understand the importance of quality control and quality assurance measures for immunohistochemical markers used in the diagnosis of H&N and endocrine lesions including preanalytical, analytical and postanalytical variables (EPAs: F#1, F#2, C#15, TTP#3)
  • Understand the value of proficiency testing for immunohistochemistry (EPAs: C#15, TTP#3).

Health Advocate/Professional

  • Understand the importance of turn-around time for diagnostic biopsies due to the high level of stress experienced by patients with symptomatic H&N and endocrine disease (EPA: TTD#1B).
  • Gain an appreciation for the unique socioeconomic status of many patients with head and neck malignancies, and the physical and emotional difficulties posed by their therapy and rehabilitation (EPAs: C#4, C#5, TTP#1).
  • Understand the implications of a malignant diagnosis on the subsequent therapy provided to a patient, particularly as it relates to thyroid cancer and squamous cell carcinoma of the upper aerodigestive tract (EPAs: C#4, C#5, TTP#1).
  • Know when to appropriately consult an expert in H&N and endocrine pathology (EPAs: C#5, TTP#1).
  • Demonstrate an increasing ability to handle more of the clinical workload of the staff pathologist.  It is expected that PGY4 and PGY5 residents are able to handle the full clinical workload of the staff pathologist each day on service (EPAs: TTP#1, TTP#5, TTP#6).

Scholar

  • Consider conducting a case report, case series or more in-depth project on H&N and/or endocrine pathology material (EPAs: C#16, C#17, TTP#4)
  • Review the pertinent recent literature regarding advances in mucosal, salivary, odontogenic and endocrine malignancies, including the molecular pathogenesis of these malignancies (EPAs: C#9, C#10, C#15, C#16, TTP#4).
  • Develop and implement a personal education strategy to permit acquisition of the appropriate knowledge of head & neck pathology to fulfil the rotation specific objectives (EPA: C#17, TTP#4).

 

Instructional Tools

The resident will meet with the H&N/Endocrine Subspecialty Lead and go over this document and the overall aspects of the rotation the day before the rotation starts.

Grossing (EPAs: F1, C2, C3, TTP#2)

  • PGY2 level:
    • Although no grossing week is built into their rotation block, an expectation of grossing remains.  Residents will be expected to gross in the afternoon, particularly after 2 pm when more grossing benches become available.
    • The resident should gross at minimum the following specimen types during their first rotation:
      • At least 3 thyroidectomy specimens (including lobectomy, hemi-, subtotal and total thyroidectomy)
      • At least 3 hemiglossectomy
      • At least 1 superficial parotidectomy
      • At least 1 adrenalectomy specimen
      • At least 1 parathyroidectomy specimen
  • PGY3 and PGY4 level: Although no grossing week is built into their rotation block, an expectation of grossing remains.  By their end of their senior H&N/Endocrine pathology rotation, it is expected that the senior resident will gross:
    • At least one laryngectomy specimen
    • At least one radical (extended or modified) neck dissection
    • At least 2 composite resections
  • Senior residents, including PGY5 residents, are expected to supervise and teach junior trainees in the gross room (EPA: TTP#2)
  • Resident will complete a “grossing log” (shared filed created by the gross room director). The resident will review the slides of the case that he/she grossed and review it with the attending pathologist assigned to the case, if the slides are available before the end of the rotation. The attending will review the gross description and will complete the EPA (which may be initiated by the staff or the resident).

Microscopy

  • The resident will contact the attending pathologist that they are scheduled to sign cases with the day before in order to arrange time of sign out and distribute cases
  • Retrieve pertinent clinical and radiologic information from the electronic medical records system (EPA: TTD #2)
  • Review all of the slides, recognize normal histology and areas with lesional pathology.  Be able to adequately describe the lesional areas (EPAs: C#4, C#5)
  • Provide a diagnosis or a differential diagnosis of the identified lesion (EPAs: C#4, C#5, TTP#1)
  • Based on the differential diagnosis, be able to provide an ancillary testing panel to work through the proposed differential diagnosis (EPAs: C#5, C#10, TTP#1)
  • Be able to select the correct slide for ordering ancillary testing including PD-L1 (EPAs: C#5, C#9, C#10, TTP#1)

Prognostic Markers

  • Learn how to properly interpret immunohistochemistry for H&N prognostic markers including PD-L1 and P16 (EPAs: C#4, C#5, C#10, C#15)
  • Learn indicators for molecular testing in thyroid and H&N pathology (EPAs: C#5, C#9)
  • Learn how to interpret molecular tests in thyroid and H&N pathology (EPAs: C#5, C#9, C#15)

Rounds

  • PGY2 level: Resident is expected to attend and depending on their skill level, may be asked to present at interdisciplinary rounds (H&N rounds on Thursday at 12:15 and Endocrine Rounds last Thursday of month at 4:30 pm)on Wednesdays at 9:15 am) (EPAs: C#14, C#18)
  • PGY 3-5: Resident is expected to attend interdisciplinary conferences and present the cases. This implies reviewing the cases with the pathologist in charge beforehand and organizing the presentation in the appropriate format (EPAs: C#14, C#18, TTP#1, TTP#2, TTP#5, TTP#6)

Evaluation

  • Mid-rotation evaluation to be completed by the H&N/Endocrine section head with input from other H&N/endocrine pathologists.
  • Expectations will be graded according to the level of training

 

Recommended Reading

  • All chapters pertaining to H&N/endocrine pathology in Sternberg’s Diagnostic Surgical pathology
  • WHO Classification - Tumours of the Head and Neck
  • WHO Classification – Tumours of Endocrine Organs
  • All chapters pertaining to H&N and endocrine pathology in Robbins and Cotran - Pathologic Basis of Disease
  • CAP protocols for all H&N and endocrine malignancies

 

Updated April, 2022

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