Melanoma of the Skin

Biopsy, Excision, Reexcision

Procedure (select all that apply)

____ Biopsy, shave

____ Biopsy, punch

____ Biopsy, incisional

____ Excision

____ Reexcision

____ Lymphadenectomy, sentinel node(s)

____ Lymphadenectomy, regional nodes (specify): ______________________________

____ Other (specify): ______________________________

____ Not specified

Specimen Laterality

____ Right

____ Left

____ Midline

____ Not specified

Tumor Site

Specify, if known: ______________________________

____ Not specified

Tumor Size (required only if tumor is grossly present)

Greatest dimension: __________ cm

^*Additional dimensions: __________ x __________ cm

____ Indeterminate

Macroscopic Satellite Nodule(s) (required for excision specimens only)

____ Not identified

____ Present

____ Indeterminate

^*Macroscopic Pigmentation

^*____ Not identified

^*____ Present, diffuse

^*____ Present, patchy/focal

^*____ Indeterminate

Histologic Type

Malignant melanoma

____ Melanoma, not otherwise specified

____ Superficial spreading melanoma

____ Nodular melanoma

____ Lentigo maligna melanoma

____ Acral-lentiginous melanoma

____ Desmoplastic &/or desmoplastic neurotropic melanoma

____ Melanoma arising from blue nevus

____ Melanoma arising in a giant congenital nevus

____ Melanoma of childhood

____ Nevoid melanoma

____ Persistent melanoma

____ Other (specify): ______________________________

Maximum Tumor Thickness

Specify: ___________ mm

At least __________ mm

____ Indeterminate

^*Clark (Anatomic) Level

^*____ I (melanoma in situ)

^*____ II (melanoma present in, but does not fill and expand, papillary dermis)

^*____ III (melanoma fills and expands papillary dermis)

^*____ IV (melanoma invades reticular dermis)

^*____ V (melanoma invades subcutaneum)

Ulceration

____ Present

____ Not identified

____ Indeterminate

Margins (select all that apply)

Peripheral margins

____ Cannot be assessed

____ Uninvolved by invasive melanoma

Distance of invasive melanoma from closest peripheral margin: ___________ mm (required for excisions only)

Specify location(s), if possible: ______________________________

____ Involved by invasive melanoma

Specify location(s), if possible: ______________________________

____ Uninvolved by melanoma in situ

Distance of melanoma in situ from closest margin: __________ mm (required for excisions only)

Specify location(s), if possible: ______________________________

____ Involved by melanoma in situ

Specify location(s), if possible: ______________________________

Deep margin

____ Cannot be assessed

____ Uninvolved by invasive melanoma

Distance of invasive melanoma from margin: __________ mm (required for excisions only)

Specify location(s), if possible: ______________________________

____ Involved by invasive melanoma

Specify location(s), if possible: ______________________________

Mitotic Index

____ < 1/mm²

Specify number/mm²: __________

Microsatellitosis

____ Not identified

____ Present

____ Indeterminate

Lymph-Vascular Invasion

____ Not identified

____ Present

____ Indeterminate

^*Perineural Invasion

^*____ Not identified

^*____ Present

^*____ Indeterminate

^*Tumor-infiltrating Lymphocytes

^*____ Not identified

^*____ Present, nonbrisk

^*____ Present, brisk

^*Tumor Regression

^*____ Not identified

^*____ Present, involving < 75% of lesion

^*____ Present, involving ≥ 75% of lesion

^*____ Indeterminate

^*Growth Phase (select all that apply)

^*____ Radial

^*____ Vertical

^*____ Indeterminate

Lymph Nodes (required only if lymph nodes are present in the specimen) (select all that apply)

Number of sentinel nodes examined: __________

Total number of nodes examined (sentinel and nonsentinel): __________

Number of lymph nodes with metastases: __________

^*Extranodal tumor extension

^*____ Present

^*____ Not identified

^*____ Indeterminate

^*Size of largest metastatic focus: __________ (mm) (for sentinel node)

^*Location of metastatic tumor (for sentinel node)

^*____ Subcapsular

^*____ Intramedullary

^*____ Subcapsular and intramedullary

Pathologic Staging (pTNM)

TNM descriptors (required only if applicable) (select all that apply)

____ m (multiple

____ r (recurrent)

____ y (post treatment)

Primary tumor (pT)

____ pTX: Primary tumor cannot be assessed (e.g., shave biopsy or regressed melanoma)

____ pT0: No evidence of primary tumor

____ pTis: Melanoma in situ (i.e., not an invasive tumor: Anatomic level 1)

pT1: Melanoma ≤ 1 mm in thickness, ± ulceration

____ pT1a: Melanoma ≤ 1.0 mm in thickness, no ulceration, < 1 mitosis/mm²

____ pT1b: Melanoma ≤ 1.0 mm in thickness with ulceration &/or ≥ 1 mitosis/mm²

pT2: Melanoma 1.01-2.0 mm in thickness, ± ulceration

____ pT2a: Melanoma 1.01-2.0 mm in thickness, no ulceration

____ pT2b: Melanoma 1.01-2.0 mm in thickness, with ulceration

pT3: Melanoma 2.01-4.0 mm in thickness, ± ulceration

____ pT3a: Melanoma 2.01-4.0 mm in thickness, no ulceration

____ pT3b: Melanoma 2.01-4.0 mm in thickness, with ulceration

pT4: Melanoma > 4.0 mm in thickness, ± ulceration

____ pT4a: Melanoma > 4.0 mm in thickness, no ulceration

____ pT4b: Melanoma > 4.0 mm in thickness, with ulceration

Regional lymph nodes (pN)

____ pNX: Regional lymph nodes cannot be assessed

____ pN0: No regional lymph node metastasis

pN1: Metastasis in 1 regional lymph node

____ pN1a: Clinically occult (microscopic) metastasis

____ pN1b: Clinically apparent (macroscopic metastasis

pN2: Metastasis in 2-3 regional lymph nodes or in intralymphatic regional metastasis without nodal metastasis

____ pN2a: Clinically occult (microscopic) metastasis

____ pN2b: Clinically apparent (macroscopic) metastasis

____ pN2c: Satellite or in-transit metastasis without nodal metastasis

____ pN3: Metastasis in ≥ 4 regional lymph nodes, or matted metastatic nodes, or in-transit metastasis or satellite(s) with metastasis in regional node(s)

____ No nodes submitted or found

Number of lymph nodes identified: ___________

Number containing metastasis identified macroscopically: __________

Number containing metastases identified microscopically: __________

Matted nodes

____ Present

____ Not identified

Distant metastasis (pM)

____ Not applicable

____ pM1: Distant metastasis (documented in this specimen)

^*____ pM1a: Metastasis in skin, subcutaneous tissues, or distant lymph nodes

^*____ pM1b: Metastasis to lung

^*____ pM1c: Metastasis to all other visceral sites or distant metastasis at any site associated with an elevated serum lactic dehydrogenase (LDH)

^*Specify site, if known: ______________________________

^*Additional Pathologic Findings (select all that apply)

^*____ Nevus remnant

^*____ Other (specify): ______________________________

Adapted with permission from College of American Pathologists, “Protocol for the Examination of Specimens from Patients with Melanoma of the Skin.” Posting date: November 2011, www.cap.org. ^*Data elements with asterisks are not required. These elements may be clinically important but are not yet validated or regularly used in patient management.