Protocol for the Examination of Lip and Oral Cavity Specimens

Lester D. R. Thompson, MD

Lip and Oral Cavity
	Incisional Biopsy, Excisional Biopsy, Resection
*Specimen (select all that apply)*
_ _ _ _ Vermillion border of upper lip
_ _ _ _ Vermillion border of lower lip
_ _ _ _ Mucosa of upper lip
_ _ _ _ Mucosa of lower lip
_ _ _ _ Commissure of lip
_ _ _ _ Lateral border of tongue
_ _ _ _ Ventral surface of tongue, not otherwise specified (NOS)
_ _ _ _ Dorsal surface of tongue, NOS
_ _ _ _ Anterior 2/3 of tongue, NOS
_ _ _ _ Upper gingiva (gum)
_ _ _ _ Lower gingiva (gum)
_ _ _ _ Anterior floor of mouth
_ _ _ _ Floor of mouth, NOS
_ _ _ _ Hard palate
_ _ _ _ Buccal mucosa (inner cheek)
_ _ _ _ Vestibule of mouth
	_ _ _ _ Upper
	_ _ _ _ Lower
_ _ _ _ Alveolar process
	_ _ _ _ Upper
	_ _ _ _ Lower
_ _ _ _ Mandible
_ _ _ _ Maxilla
_ _ _ _ Other (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ Not specified
*Received*
_ _ _ _ Fresh
_ _ _ _ In formalin
_ _ _ _ Other (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
*Procedure (select all that apply)*
_ _ _ _ Incisional biopsy
_ _ _ _ Excisional biopsy
_ _ _ _ Resection
	_ _ _ _ Glossectomy (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
	_ _ _ _ Mandibulectomy (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
	_ _ _ _ Maxillectomy (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
	_ _ _ _ Palatectomy
_ _ _ _ Neck (lymph node) dissection (specify):_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ Other (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ Not specified
**Specimen Integrity*
*_ _ _ _Intact
*_ _ _ _Fragmented
*Specimen Size*
	Greatest dimensions:_ _ _ _ _ _ _ _ _ _ x_ _ _ _ _ _ _ _ _ _ x_ _ _ _ _ _ _ _ _ _ cm
	*Additional dimensions (if more than 1 part):_ _ _ _ _ _ _ _ _ _ x_ _ _ _ _ _ _ _ _ _ x_ _ _ _ _ _ _ _ _ _ cm
*Specimen Laterality*
_ _ _ _ Right
_ _ _ _ Left
_ _ _ _ Bilateral
_ _ _ _ Midline
_ _ _ _ Not specified
*Tumor Site (select all that apply)*
_ _ _ _ Vermillion border of upper lip
_ _ _ _ Vermillion border of lower lip
_ _ _ _ Mucosa of upper lip
_ _ _ _ Mucosa of lower lip
_ _ _ _ Commissure of lip
_ _ _ _ Lateral border of tongue
_ _ _ _ Ventral surface of tongue, NOS
_ _ _ _ Dorsal surface of tongue, NOS
_ _ _ _ Anterior 2/3 of tongue, NOS
_ _ _ _ Upper gingiva (gum)
_ _ _ _ Lower gingiva (gum)
_ _ _ _ Anterior floor of mouth
_ _ _ _ Floor of mouth, NOS
_ _ _ _ Hard palate
_ _ _ _ Buccal mucosa (inner cheek)
_ _ _ _ Vestibule of mouth
	_ _ _ _ Upper
	_ _ _ _ Lower
_ _ _ _ Alveolar process
	_ _ _ _ Upper
	_ _ _ _ Lower
_ _ _ _ Mandible
_ _ _ _ Maxilla
_ _ _ _ Other (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ Not specified
*Tumor Focality*
_ _ _ _ Single focus
_ _ _ _ Multifocal (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
*Tumor Size*
	Greatest dimension:_ _ _ _ _ _ _ _ _ _ cm
	*Additional dimensions:_ _ _ _ _ _ _ _ _ _ x_ _ _ _ _ _ _ _ _ _ cm
**Tumor Thickness (pT1 and pT2 tumors)*
	*Tumor thickness:_ _ _ _ _ _ _ _ _ _ mm
	*Intact surface mucosa:_ _ _ _ _ _ _ _ _ _ or ulcerated surface:_ _ _ _ _ _ _ _ _ _
**Tumor Description (select all that apply)*
	*Gross subtype
		*_ _ _ _ Polypoid
		*_ _ _ _ Exophytic
		*_ _ _ _ Endophytic
		*_ _ _ _ Ulcerated
*_ _ _ _ Sessile
*_ _ _ _ Other (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
*Macroscopic Extent of Tumor
	*Specify: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
*Histologic Type (select all that apply)*
_ _ _ _ Squamous cell carcinoma, conventional
_ _ _ _ Variants of squamous cell carcinoma
	_ _ _ _ Acantholytic squamous cell carcinoma
	_ _ _ _ Adenosquamous carcinoma
	_ _ _ _ Basaloid squamous cell carcinoma
	_ _ _ _ Carcinoma cuniculatum
	_ _ _ _ Papillary squamous cell carcinoma
	_ _ _ _ Spindle cell squamous carcinoma
	_ _ _ _ Verrucous carcinoma
_ _ _ _ Lymphoepithelial carcinoma (non-nasopharyngeal)
_ _ _ _ Carcinomas of minor salivary glands
	_ _ _ _ Acinic cell carcinoma
	_ _ _ _ Adenoid cystic carcinoma
	_ _ _ _ Adenocarcinoma, not otherwise specified (NOS)
		_ _ _ _ Low grade
		_ _ _ _ Intermediate grade
		_ _ _ _ High grade
	_ _ _ _ Basal cell adenocarcinoma
	_ _ _ _ Carcinoma ex-pleomorphic adenoma (malignant mixed tumor)
		Grade
			_ _ _ _ Low grade
			_ _ _ _ High grade
		Invasion
			_ _ _ _ Intracapsular (noninvasive)
			_ _ _ _ Minimally invasive
			_ _ _ _ Invasive
	_ _ _ _ Carcinoma, type cannot be determined
	_ _ _ _ Carcinosarcoma
	_ _ _ _ Clear cell adenocarcinoma
	_ _ _ _ Cystadenocarcinoma
	_ _ _ _ Epithelial-myoepithelial carcinoma
	_ _ _ _ Mucoepidermoid carcinoma
		_ _ _ _ Low grade
		_ _ _ _ Intermediate grade
		_ _ _ _ High grade
	_ _ _ _ Mucinous adenocarcinoma (colloid carcinoma)
	_ _ _ _ Myoepithelial carcinoma (malignant myoepithelioma)
	_ _ _ _ Oncocytic carcinoma
	_ _ _ _ Polymorphous low-grade adenocarcinoma
	_ _ _ _ Salivary duct carcinoma
	_ _ _ _ Other (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ Adenocarcinoma, non-salivary gland type
	_ _ _ _ Adenocarcinoma, not otherwise specified (NOS)
		_ _ _ _ Low grade
		_ _ _ _ Intermediate grade
		_ _ _ _ High grade
	_ _ _ _ Other (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ Neuroendocrine carcinoma
	_ _ _ _ Typical carcinoid tumor (well-differentiated neuroendocrine carcinoma)
	_ _ _ _ Atypical carcinoid tumor (moderately differentiated neuroendocrine carcinoma)
	_ _ _ _ Small cell carcinoma (poorly differentiated neuroendocrine carcinoma)
	_ _ _ _ Combined (or composite) small cell carcinoma, neuroendocrine type
_ _ _ _ Other (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ Carcinoma, type cannot be determined
_ _ _ _ Mucosal malignant melanoma
*Histologic Grade*
_ _ _ _ Not applicable
_ _ _ _ GX: Cannot be assessed
_ _ _ _ G1: Well differentiated
_ _ _ _ G2: Moderately differentiated
_ _ _ _ G3: Poorly differentiated
_ _ _ _ Other (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
*Microscopic Tumor Extension
	*Specify: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
*Margins (select all that apply)*
_ _ _ _ Cannot be assessed
_ _ _ _ Margins uninvolved by invasive carcinoma
	Distance from closest margin:_ _ _ _ _ _ _ _ _ _ mm or_ _ _ _ _ _ _ _ _ _ cm
	Specify margin(s), per orientation, if possible: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ Margins involved by invasive carcinoma
	Specify margin(s), per orientation, if possible: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ Margins uninvolved by carcinoma in situ (includes moderate and severe dysplasia†)
	Distance from closest margin:_ _ _ _ _ _ _ _ _ _ mm or_ _ _ _ _ _ _ _ _ _ cm
	Specify margin(s), per orientation, if possible: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ Margins involved by carcinoma in situ (includes moderate and severe dysplasia†)
	Distance from closest margin:_ _ _ _ _ _ _ _ _ _ mm or_ _ _ _ _ _ _ _ _ _ cm
	Specify margin(s), per orientation, if possible: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ Not applicable
*Treatment Effect (applicable to carcinomas treated with neoadjuvant therapy)
*_ _ _ _Not identified
*_ _ _ _Present (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
*_ _ _ _Indeterminate
*Pathologic Staging (pTNM)*
	TNM descriptors (required only if applicable) (select all that apply)
		_ _ _ _ m (multiple primary tumors)
		_ _ _ _ r (recurrent)
		_ _ _ _ y (post-treatment)
	For all carcinomas (excluding mucosal malignant melanoma)
		Primary tumor (pT)
			_ _ _ _ pTX: Cannot be assessed
			_ _ _ _ pT0: No evidence of primary tumor
			_ _ _ _ pTis: Carcinoma in situ
			_ _ _ _ pT1: Tumor ≤ 2 cm in greatest dimension
			_ _ _ _ pT2: Tumor > 2 cm but ≤ 4 cm in greatest dimension
			_ _ _ _ pT3: Tumor > 4 cm in greatest dimension
			_ _ _ _ pT4a: Moderately advanced local disease
				Lip: Tumor invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin of face, i.e., chin or nose
				Oral cavity: Tumor invades adjacent structures only (e.g., through cortical bone [mandible, maxilla], into deep [extrinsic] muscle of tongue [genioglossus, hyoglossus, palatoglossus, and styloglossus], maxillary sinus, skin of face)
			_ _ _ _ pT4b: Very advanced local disease
				Tumor invades masticator space, pterygoid plates, or skull base &/or encases internal carotid artery
					Note: Superficial erosion alone of bone/tooth socket by gingival primary is not sufficient to classify a tumor as T4
		Regional lymph nodes (pN)#
			_ _ _ _ pNX: Cannot be assessed
			_ _ _ _ pN0: No regional lymph node metastasis
			_ _ _ _ pN1: Metastasis in single ipsilateral lymph node, ≤ 3 cm in greatest dimension
			_ _ _ _ pN2a: Metastasis in single ipsilateral lymph node, > 3 cm but ≤ 6 cm in greatest dimension
			_ _ _ _ pN2b: Metastasis in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension
			_ _ _ _ pN2c: Metastasis in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension
			_ _ _ _ pN3: Metastasis in lymph node > 6 cm in greatest dimension
				Specify: Number examined:_ _ _ _ _ _ _ _ _ _
					Number involved:_ _ _ _ _ _ _ _ _ _
					*Size (greatest dimension) of largest positive lymph node:_ _ _ _ _ _ _ _ _ _
		Distant metastasis (pM)
			_ _ _ _ Not applicable
			_ _ _ _ pM1: Distant metastasis
				*Specify site(s), if known: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
				*Source of pathologic metastatic specimen (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
	For mucosal malignant melanoma
		Primary tumor (pT)
			_ _ _ _ pT3: Mucosal disease
			_ _ _ _ pT4a: Moderately advanced disease
					Tumor involving deep soft tissue, cartilage, bone, or overlying skin
			_ _ _ _ pT4b: Very advanced disease
					Tumor involving brain, dura, skull base, lower cranial nerves (IX, X, XI, XII), masticator space, carotid artery, prevertebral space, or mediastinal structures
		Regional lymph nodes (pN)
			_ _ _ _ pNX: Regional lymph nodes cannot be assessed
			_ _ _ _ pN0: No regional lymph node metastases
			_ _ _ _ pN1: Regional lymph node metastases present
		Distant metastases (pM)
			_ _ _ _ Not applicable
			_ _ _ _ pM1: Distant metastasis present
				*Specify site(s), if known: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
				*Source of pathologic metastatic specimen (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
*Additional Pathologic Findings (select all that apply)
*_ _ _ _ _ _ _ _ _ _None identified
*_ _ _ _ _ _ _ _ _ _Keratinizing dysplasia
	*_ _ _ _ _ _ _ _ _ _Mild
	*_ _ _ _ _ _ _ _ _ _Moderate
	*_ _ _ _ _ _ _ _ _ _Severe (carcinoma in situ)
*_ _ _ _ _ _ _ _ _ _Nonkeratinizing dysplasia
	*_ _ _ _ _ _ _ _ _ _Mild
	*_ _ _ _ _ _ _ _ _ _Moderate
	*_ _ _ _ _ _ _ _ _ _Severe (carcinoma in situ)
*_ _ _ _ _ _ _ _ _ _Inflammation (specify type): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
*_ _ _ _ _ _ _ _ _ _Epithelial hyperplasia
*_ _ _ _ _ _ _ _ _ _Colonization
	*_ _ _ _ _ _ _ _ _ _Fungal
	*Bacterial
*_ _ _ _ _ _ _ _ _ _Other (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
**Ancillary Studies*
	Specify type(s): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
	*Specify result(s): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
**Clinical History (select all that apply)*
*_ _ _ _ _ _ _ _ _ _Neoadjuvant therapy
	*_ _ _ _ _ _ _ _ _ _Yes (specify type): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
	*_ _ _ _ _ _ _ _ _ _No
	*_ _ _ _ _ _ _ _ _ _Indeterminate
*_ _ _ _ _ _ _ _ _ _Other (specify): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
*Data elements with asterisks are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management. †Applicable only to squamous cell carcinoma and histologic variants. #Superior mediastinal lymph nodes are considered regional lymph nodes (level VII). Midline nodes are considered ipsilateral nodes. Adapted with permission from College of American Pathologists, “Protocol for the Examination of Specimens from Patients with Carcinoma of the Lip and Oral Cavity.” Web posting date October 2009, www.cap.org.

Anatomic Stage/Prognostic Groups
Group	T	N	M
0	Tis	N0	M0
I	T1	N0	M0
II	T2	N0	M0
III	T3	N0	M0
	T1, T2, T3	N1	M0
	T1	N2	M0
	T2	N2	M0
	T3	N2	M0
IVA	T4a	N0	M0
	T4a	N1	M0
	T4a	N2	M0
	T4b	Any N	M0
IVB	Any T	N3	M0
IVC	Any T	Any N	M1
Adapted from 7th edition AJCC Staging Forms.