Major Salivary Glands

Incisional Biopsy, Excisional Biopsy, Resection

Specimen

___ Parotid gland

___ Superficial lobe only

___ Deep lobe only

___ Total parotid gland

___ Submandibular gland

___ Sublingual gland

Received

___ Fresh

___ In formalin

___ Other (specify):

Procedure (select all that apply)

___ Incisional biopsy

___ Excisional biopsy

___ Resection, parotid gland

___ Superficial parotidectomy

___ Total parotidectomy

___ Resection, submandibular gland

___ Resection, sublingual gland

___ Neck (lymph node) dissection (specify): ____________________

___ Other (specify): ____________________

___ Not specified

*Specimen Integrity

*___Intact

*___Fragmented

Specimen Size

Greatest dimensions: _______ × _______ × _______ cm

*Additional dimensions (if more than 1 part): _______ × _______ × _______ cm

Specimen Laterality

___ Right

___ Left

___ Bilateral

___ Not specified

Tumor Site (select all that apply)

___ Parotid gland

___Superficial lobe

___Deep lobe

___Entire parotid gland

___ Submandibular gland

___ Sublingual gland

___ Other (specify): ____________________

___ Not specified

Tumor Focality

___ Single focus

___ Bilateral

___ Multifocal (specify): ____________________

Tumor Size

Greatest dimension: _______ cm

*Additional dimensions: _______ × _______ cm

___ Cannot be determined

*Tumor Description (select all that apply)

*___Encapsulated/circumscribed

*___Invasive

*___Solid

*___Cystic

*___Other (specify): ____________________

*Macroscopic Extent of Tumor (extent of invasion)

*Specify: ____________________

Histologic Type (select all that apply)

___ 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

___ Carcinosarcoma (true malignant mixed tumor)

___ Clear cell adenocarcinoma

___ Cystadenocarcinoma

___ Epithelial-myoepithelial carcinoma

___ Large cell carcinoma

___ Low-grade cribriform cystadenocarcinoma

___ Lymphoepithelial carcinoma

___ Metastasizing pleomorphic adenoma

___ 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

___ Sebaceous adenocarcinomas

___ Sebaceous adenocarcinoma

___ Sebaceous lymphadenocarcinoma

___ Sialoblastoma

___ Small cell (neuroendocrine) carcinoma

___ Squamous cell carcinoma, primary

___ Undifferentiated carcinoma, large cell type

___ Other (specify): ____________________

___ Carcinoma, type cannot be determined

Histologic Grade

___ Not applicable

___ GX: Cannot be assessed

___ G1: Well differentiated

___ G2: Moderately differentiated

___ G3: Poorly differentiated

___ Other (specify): ____________________

*Microscopic Tumor Extension

*Specify: ____________________

Margins

___ Cannot be assessed

___ Margins uninvolved by carcinoma

Distance of tumor from closest margin: _______ mm or _______ cm

Specify margin, if possible: ____________________

___ Margin(s) involved by carcinoma

Specify margin(s) if possible: ____________________

*Treatment Effect (applicable to carcinomas treated with neoadjuvant therapy)

*___Not identified

*___Present (specify): ____________________

*___Indeterminate

Lymph-Vascular Invasion

___ Not identified

___ Present

___ Indeterminate

Perineural Invasion

___ Not identified

___ Present

___ Indeterminate

Lymph Nodes, Extranodal Extension

___ Not identified

___ Present

___ Indeterminate

Pathologic Staging (pTNM)

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

___ m (multiple primary tumors)

___ r (recurrent)

___ y (post-treatment)

Primary Tumor (pT)†

___ pTX: Cannot be assessed

___ pT0: No evidence of primary tumor

___ pT1: Tumor ≤ 2 cm in greatest dimension without extraparenchymal extension

___ pT2: Tumor > 2 cm but ≤ 4 cm in greatest dimension without extraparenchymal extension

___ pT3: Tumor > 4 cm &/or tumor with extraparenchymal extension

___ pT4a: Moderately advanced tumor

Tumor invades skin, mandible, ear canal, &/or facial nerve

___ pT4b: Very advanced local disease

Tumor invades skull base &/or pterygoid plates &/or encases carotid artery

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

___ pN2: Metastasis in a single ipsilateral lymph node, > 3 cm but ≤ 6 cm in greatest dimension, or in multiple lymph nodes none > 6 cm in greate4st dimension, or in bilateral or contralateral lymoph nodes, none > 6 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: ____________________

*Additional Pathologic Findings (select all that apply)

*___Sialadenitis

*___Tumor associated lymphoid proliferation (TALP)

*___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. †There is no category of carcinoma in situ (pTis) relative to carcinomas of salivary glands (major, minor). #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 Carcinomas of the Salivary Glands.” Web posting date October 2009, www.cap.org.