Protocol for the Examination of Specimens From Patients With Carcinomas of the Lip and Oral Cavity Protocol applies to all invasive carcinomas of the oral cavity, including lip and tongue. Mucosal melanoma is included. Lymphomas and sarcomas are not included. Version: LipOralCavity 3.3.0.0 Based on AJCC/UICC TNM, 7th edition Protocol web posting date: August 2016 Procedures • Biopsy • Resection Authors Raja R. Seethala, MD* Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA Ilan Weinreb, MD Department of Anatomical Pathology, University Health Network, Toronto, ON Diane L. Carlson, MD Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY Jonathan B. McHugh, MD Department of Pathology, University of Michigan, Ann Arbor, MI Louis B. Harrison, MD Department of Radiation Oncology, Beth Israel Medical Center, St. Luke’s and Roosevelt Hospitals, New York, NY Mary S. Richardson, MD, DDS Department of Pathology, Medical University of South Carolina, Charleston, SC Jatin Shah, MD Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY Robert L Ferris, MD, PhD Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA Bruce M. Wenig, MD Department of Pathology and Laboratory Medicine, Beth Israel Medical Center, St. Luke’s and Roosevelt Hospitals, New York, NY Lester D. R. Thompson, MD† Department of Pathology, Southern California Permanente Medical Group, Woodland Hills, CA For the Members of the Cancer Committee, College of American Pathologists * Denotes primary author. † Denotes senior author. All other contributing authors are listed alphabetically. Previous contributors: Richard Zarbo, MD, DMD; Jennifer L. Hunt; Leon Barnes, MD; Gary Ellis, MD, John Chan, MD.
Protocol for the Examination of Specimens From Patients With Carcinomas of the Lip and Oral Cavity
Aug 05, 2022
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Lip and Oral CavityProtocol for the Examination of Specimens From Patients With Carcinomas of the Lip and Oral Cavity Protocol applies to all invasive carcinomas of the oral cavity, including lip and tongue. Mucosal melanoma is included. Lymphomas and sarcomas are not included. Version: LipOralCavity 3.3.0.0 Based on AJCC/UICC TNM, 7th edition Protocol web posting date: August 2016 Procedures • Biopsy • Resection Authors Raja R. Seethala, MD* Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA Ilan Weinreb, MD Department of Anatomical Pathology, University Health Network, Toronto, ON Diane L. Carlson, MD Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY Jonathan B. McHugh, MD
Department of Pathology, University of Michigan, Ann Arbor, MI Louis B. Harrison, MD Department of Radiation Oncology, Beth Israel Medical Center, St. Luke’s and Roosevelt Hospitals, New York,
NY Mary S. Richardson, MD, DDS
Department of Pathology, Medical University of South Carolina, Charleston, SC Jatin Shah, MD Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY Robert L Ferris, MD, PhD Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA Bruce M. Wenig, MD
Department of Pathology and Laboratory Medicine, Beth Israel Medical Center, St. Luke’s and Roosevelt Hospitals, New York, NY
Lester D. R. Thompson, MD† Department of Pathology, Southern California Permanente Medical Group, Woodland Hills, CA
For the Members of the Cancer Committee, College of American Pathologists * Denotes primary author. † Denotes senior author. All other contributing authors are listed alphabetically.
Previous contributors: Richard Zarbo, MD, DMD; Jennifer L. Hunt; Leon Barnes, MD; Gary Ellis, MD, John Chan, MD.
Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
2
© 2016 College of American Pathologists (CAP). All rights reserved. The College does not permit reproduction of any substantial portion of these protocols without its written authorization. The College hereby authorizes use of these protocols by physicians and other health care providers in reporting on surgical specimens, in teaching, and in carrying out medical research for nonprofit purposes. This authorization does not extend to reproduction or other use of any substantial portion of these protocols for commercial purposes without the written consent of the College.
The CAP also authorizes physicians and other health care practitioners to make modified versions of the Protocols solely for their individual use in reporting on surgical specimens for individual patients, teaching, and carrying out medical research for non-profit purposes.
The CAP further authorizes the following uses by physicians and other health care practitioners, in reporting on surgical specimens for individual patients, in teaching, and in carrying out medical research for non-profit purposes: (1) Dictation from the original or modified protocols for the purposes of creating a text-based patient record on paper, or in a word processing document; (2) Copying from the original or modified protocols into a text-based patient record on paper, or in a word processing document; (3) The use of a computerized system for items (1) and (2), provided that the protocol data is stored intact as a single text-based document, and is not stored as multiple discrete data fields.
Other than uses (1), (2), and (3) above, the CAP does not authorize any use of the Protocols in electronic medical records systems, pathology informatics systems, cancer registry computer systems, computerized databases, mappings between coding works, or any computerized system without a written license from the CAP.
Any public dissemination of the original or modified protocols is prohibited without a written license from the CAP.
The College of American Pathologists offers these protocols to assist pathologists in providing clinically useful and relevant information when reporting results of surgical specimen examinations of surgical specimens. The College regards the reporting elements in the “Surgical Pathology Cancer Case Summary” portion of the protocols as essential elements of the pathology report. However, the manner in which these elements are reported is at the discretion of each specific pathologist, taking into account clinician preferences, institutional policies, and individual practice.
The College developed these protocols as an educational tool to assist pathologists in the useful reporting of relevant information. It did not issue the protocols for use in litigation, reimbursement, or other contexts. Nevertheless, the College recognizes that the protocols might be used by hospitals, attorneys, payers, and others. Indeed, effective January 1, 2004, the Commission on Cancer of the American College of Surgeons mandated the use of the required data elements of the protocols as part of its Cancer Program Standards for Approved Cancer Programs. Therefore, it becomes even more important for pathologists to familiarize themselves with these documents. At the same time, the College cautions that use of the protocols other than for their intended educational purpose may involve additional considerations that are beyond the scope of this document.
The inclusion of a product name or service in a CAP publication should not be construed as an endorsement of such product or service, nor is failure to include the name of a product or service to be construed as disapproval.
Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
3
CAP Lip and Oral Cavity Protocol Revision History Version Code The definition of version control and an explanation of version codes can be found at www.cap.org (search: cancer protocol terms). Summary of Changes The following changes have been made since the October 2013 release. The following data elements were modified: Tumor Site Tumor Size (changed “see Comment” to “explain”) Histologic Type Histologic Grade (changed to “required only if applicable”; added note) Specimen Margins (was “Margins”) Treatment Effect Lymph-Vascular Invasion Perineural Invasion Distant Metastasis Clinical History The following data elements were added: Tumor Bed (Separately Submitted) Margins Extranodal Extension The following data elements were deleted: Specimen Specimen Integrity Specimen Size Specimen Laterality
CAP Approved Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
+ Data elements preceded by this symbol are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management.
4
Surgical Pathology Cancer Case Summary Protocol web posting date: August 2016 LIP AND ORAL CAVITY: Excisional Biopsy, Resection Select a single response unless otherwise indicated. Procedure (select all that apply) ___ Excisional biopsy ___ Resection ___ Glossectomy (specify): ____________________________ ___ Mandibulectomy (specify): ____________________________ ___ Maxillectomy (specify): ____________________________ ___ Palatectomy ___ Neck (lymph node) dissection (specify): ____________________________ ___ Other (specify): _______________________________ ___ Not specified Specimen Laterality (select all that apply) ___ Right ___ Left ___ Midline ___ Not specified Tumor Site (select all that apply) (Note A) ___ Vermilion border upper lip ___ Vermilion border lower lip ___ Mucosa of upper lip ___ Mucosa of lower lip ___ Commissure of lip ___ Lateral border of tongue ___ Ventral surface of tongue ___ Dorsal surface of tongue ___ Anterior two-thirds of tongue ___ Upper gingiva ___ Lower gingiva ___ Anterior floor of mouth ___ Floor of mouth ___ Hard palate ___ Buccal mucosa ___ Vestibule of mouth ___ Upper ___ Lower ___ Alveolar process ___ Upper ___ Lower ___ Mandible ___ Maxilla ___ Other (specify): __________________________ ___ Not specified
CAP Approved Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
+ Data elements preceded by this symbol are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management.
5
Tumor Focality ___ Single focus ___ Multifocal (specify): ____________________________ Tumor Size Greatest dimension: ___ cm + Additional dimensions: ___ x ___ cm ___ Cannot be determined (explain): ___________________________ + Tumor Thickness (pT1 and pT2 tumors) (Note B) + 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) (Note C) Squamous Cell Carcinoma ___ Squamous cell carcinoma, conventional Variants of Squamous Cell Carcinoma ___ Acantholytic squamous cell carcinoma ___ Adenosquamous carcinoma ___ Basaloid squamous cell carcinoma ___ Lymphoepithelial carcinoma (nonnasopharyngeal) ___ Papillary squamous cell carcinoma ___ Spindle cell squamous cell carcinoma ___ Verrucous carcinoma
___ Giant cell carcinoma Carcinomas of Minor Salivary Glands ___ Mucoepidermoid carcinoma ___Low grade ___ Intermediate grade ___ High grade ___ Adenoid cystic carcinoma ___ Low grade ___ Intermediate grade ___ High grade ___ Polymorphous low-grade adenocarcinoma +___Cribriform adenocarcinoma of minor salivary origin ___ Salivary duct carcinoma ___ Carcinoma ex pleomorphic adenoma (malignant mixed tumor) ___ Low-grade ___ High-grade ___ Invasive
CAP Approved Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
+ Data elements preceded by this symbol are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management.
6
___ Intracapsular (noninvasive) ___ Acinic cell carcinoma ___ Adenocarcinoma, not otherwise specified
___ Low grade ___ Intermediate grade ___ High grade
___ Basal cell adenocarcinoma ___ Carcinoma, type cannot be determined ___ Carcinosarcoma ___ (Hyalinizing) clear cell carcinoma ___ Cystadenocarcinoma ___ Epithelial-myoepithelial carcinoma ___ Mucinous adenocarcinoma (colloid carcinoma) ___ Myoepithelial carcinoma (malignant myoepithelioma) ___ Oncocytic carcinoma ___ Other (specify): ____________________________ Adenocarcinoma, Non-Salivary Gland Type ___ Adenocarcinoma, not otherwise specified ___ Low grade ___ Intermediate grade ___ High grade ___ Other (specify): ____________________________ Neuroendocrine Carcinoma ___ Typical carcinoid tumor (well differentiated neuroendocrine carcinoma) ___ Atypical carcinoid tumor (moderately differentiated neuroendocrine carcinoma) ___ Large cell carcinoma, neuroendocrine type (poorly differentiated neuroendocrine carcinoma) ___ Small cell carcinoma, neuroendocrine type (poorly differentiated neuroendocrine carcinoma) ___ Combined (or composite) small cell carcinoma, neuroendocrine type with (specify type):
___________________________________ ___ Mucosal melanoma ___ Other (specify): ____________________________ ___ Carcinoma, type cannot be determined Histologic Grade (Note D) (required only if applicable)# ___ GX: Cannot be assessed ___ G1: Well differentiated ___ G2: Moderately differentiated ___ G3: Poorly differentiated ___ Other (specify): ____________________________ # Note: The Histologic Grade section is only applicable to squamous cell carcinomas of the lip and oral cavity. + Microscopic Tumor Extension + Specify: ____________________________
CAP Approved Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
+ Data elements preceded by this symbol are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management.
7
Specimen Margins (select all that apply) (Notes E and F) ___ Cannot be assessed ___ Margins uninvolved by invasive tumor
Distance from closest margin: Specify distance: ____ mm ___ Cannot be determined Specify location of closest margin, per orientation, if possible: ____________________________ + Location and distance of other close margins (Note E): ____________________________
___ Margins involved by invasive tumor Specify margin(s), per orientation, if possible: ____________________________ ___ Margins uninvolved by in situ disease# (Note E) Distance from closest margin:
Specify distance: ____ mm ___ Cannot be determined Specify location of closest margin, per orientation, if possible: ____________________________
___ Margins involved by in situ disease# (Note E) Specify margin(s), per orientation, if possible: ____________________________ Tumor Bed (Separately Submitted) Margins (Notes E and F) (required only if applicable) ___ Margin Orientation ___ Oriented to true margin surface ___ Unoriented to true margin surface ___ Margins uninvolved by invasive tumor
+Specify distance to true margin surface: ____ mm (if oriented and sectioned perpendicularly) ___ Margins uninvolved by in situ disease# (Note E)
+Specify distance to true margin surface: ____ mm (if oriented and sectioned perpendicularly) ___ Margins involved by invasive tumor Specify margin(s), per part labeling, if possible: ____________________________ ___ Margins involved by in situ disease# (Note E)
Specify margin(s), per orientation, if possible: ____________________________ #Note: Applicable only to squamous cell carcinoma and its histologic variants, as well as to mucosal melanoma. + Treatment Effect (applicable to carcinomas treated with neoadjuvant therapy) + ___ Not identified + ___ Present (specify): ____________________________ + ___ Cannot be determined Lymph-Vascular Invasion ___ Not identified ___ Present ___ Cannot be determined Perineural Invasion (Note G) ___ Not identified ___ Present ___ Cannot be determined Pathologic Staging (pTNM) (Note H) TNM Descriptors (required only if applicable) (select all that apply) ___ m (multiple primary tumors) ___ r (recurrent) ___ y (posttreatment)
CAP Approved Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
+ Data elements preceded by this symbol are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management.
8
For All Carcinomas Excluding Mucosal Melanoma Primary Tumor (pT) ___ pTX: Cannot be assessed ___ pT0: No evidence of primary tumor ___ pTis: Carcinoma in situ ___ pT1: Tumor 2 cm or less in greatest dimension ___ pT2: Tumor more than 2 cm but not more than 4 cm in greatest dimension ___ pT3: Tumor more than 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, ie, chin or nose
Oral cavity: Tumor invades adjacent structures only (eg, 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, and/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)# (Notes I through M) ___ pNX: Cannot be assessed ___ pN0: No regional lymph node metastasis ___ pN1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension ___ pN2a: Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest
dimension ___ pN2b: Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension ___ pN2c: Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension ___ pN3: Metastasis in a lymph node more than 6 cm in greatest dimension ___ No nodes submitted or found Number of Lymph Nodes Examined Specify: ____ ___ Number cannot be determined (explain): ____________________________ Number of Lymph Nodes Involved Specify: ____ + Size (greatest dimension) of the largest metastatic focus in the lymph node: ____ cm (Note L) ___ Number cannot be determined (explain): ____________________________ # Superior mediastinal lymph nodes are considered regional lymph nodes (level VII). Midline nodes are considered ipsilateral nodes. Distant Metastasis (pM) (required only if confirmed pathologically in this case) ___ pM1: Distant metastasis Specify site(s), if known: ____________________________ For Mucosal Melanoma (Note I) 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
CAP Approved Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
+ Data elements preceded by this symbol are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management.
9
Regional Lymph Nodes (pN) ___ pNX: Regional lymph nodes cannot be assessed ___ pN0: No regional lymph node metastases ___ pN1: Regional lymph node metastases present Distant Metastasis (pM) (required only if confirmed pathologically in this case) ___ pM1: Distant metastasis present
Specify site(s), if known: ____________________________ Extranodal Extension (required for all histologies except mucosal melanoma) ___ Not identified ___ Present + Distance from lymph node capsule: _____ mm ___ Cannot be determined + Additional Pathologic Findings (select all that apply) + ___ None identified + ___ Keratinizing dysplasia (Note N) + ___ Mild + ___ Moderate + ___ Severe (carcinoma in situ) + ___ Nonkeratinizing dysplasia (Note N) + ___ Mild + ___ Moderate + ___ Severe (carcinoma in situ) + ___ Inflammation (specify type): ____________________________ + ___ Epithelial hyperplasia + ___ Colonization + ___ Fungal + ___ Bacterial + ___ Other (specify): ____________________________ + Ancillary Studies (Note O) + Specify type(s): _______________________________ + Specify result(s): ______________________________ + Clinical History (select all that apply) + ___ Neoadjuvant therapy + ___ Yes (specify type): ____________________________ + ___ No + ___Cannot be determined + ___ Other (specify): ____________________________ + Comment(s)
Background Documentation Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
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Explanatory Notes Scope of Guidelines The reporting of oral cancer including the lip is facilitated by the provision of a case summary illustrating the features required for comprehensive patient care. However, there are many cases in which the individual practicalities of applying such a case summary may not be straightforward. Common examples include finding the prescribed number of lymph nodes, trying to determine the levels of the radical neck dissection, and determining if isolated tumor cells in a lymph node represent metastatic disease. Case summaries have evolved to include clinical, radiographic, morphologic, immunohistochemical, and molecular results in an effort to guide clinical management. Adjuvant and neoadjuvant therapy can significantly alter histologic findings, making accurate classification an increasingly complex and demanding task. This protocol tries to remain simple while still incorporating important pathologic features as proposed by the American Joint Committee on Cancer (AJCC) cancer staging manual, the World Health Organization classification of tumors, the TNM classification, the American College of Surgeons Commission on Cancer, and the International Union on Cancer (UICC). This protocol is to be used as a guide and resource, an adjunct to diagnosing and managing cancers of the oral cavity in a standardized manner. It should not be used as a substitute for dissection or grossing techniques and does not give histologic parameters to reach the diagnosis. Subjectivity is always a factor, and elements listed are not meant to be arbitrary but are meant to provide uniformity of reporting across all the disciplines that use the information. It is a foundation of practical information that will help to meet the requirements of daily practice to benefit both clinicians and patients alike. A. Anatomic Sites and Subsites for Lip and Oral Cavity (Figure 1) Lip External upper lip (vermilion border) External lower lip (vermilion border) Commissures Oral Cavity Buccal mucosa Mucosa of upper and lower lips Cheek mucosa Retromolar areas Bucco-alveolar sulci, upper and lower (vestibule of mouth) Upper alveolus and gingiva (upper gum) Lower alveolus and gingiva (lower gum) Hard palate Tongue Dorsal surface and lateral borders anterior to circumvallate papillae
(anterior two-thirds) Inferior (ventral) surface Floor of mouth The protocol applies to all carcinomas arising at these sites. 1 Mucosal Lip. The lip begins at the junction of the vermilion border with the skin and includes only the vermilion surface or that portion of the lip that comes in contact with the opposing lip. It is well defined into an upper and lower lip joined at the commissures of the mouth. Buccal Mucosa (Inner Cheek). This includes all the membrane lining of the inner surface of the cheeks and lips from the line of contact of the opposing lips to the line of attachment of mucosa of the alveolar ridge (upper and lower) and pterygomandibular raphe. Lower Alveolar Ridge. This refers to the mucosa overlying the alveolar process of the mandible, which extends from the line of attachment of mucosa in the buccal gutter to the line of free mucosa of the floor of the mouth. Posteriorly it extends to the ascending ramus of the mandible.
Background Documentation Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
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Upper Alveolar Ridge. This refers to the mucosa overlying the alveolar process of the maxilla, which extends from the line of attachment of mucosa in the upper gingival buccal gutter to the junction of the hard palate. Its posterior margin is the upper end of the pterygopalatine arch. Retromolar Gingiva (Retromolar Trigone). This is the attached mucosa overlying the ascending ramus of the…
Department of Pathology, University of Michigan, Ann Arbor, MI Louis B. Harrison, MD Department of Radiation Oncology, Beth Israel Medical Center, St. Luke’s and Roosevelt Hospitals, New York,
NY Mary S. Richardson, MD, DDS
Department of Pathology, Medical University of South Carolina, Charleston, SC Jatin Shah, MD Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY Robert L Ferris, MD, PhD Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA Bruce M. Wenig, MD
Department of Pathology and Laboratory Medicine, Beth Israel Medical Center, St. Luke’s and Roosevelt Hospitals, New York, NY
Lester D. R. Thompson, MD† Department of Pathology, Southern California Permanente Medical Group, Woodland Hills, CA
For the Members of the Cancer Committee, College of American Pathologists * Denotes primary author. † Denotes senior author. All other contributing authors are listed alphabetically.
Previous contributors: Richard Zarbo, MD, DMD; Jennifer L. Hunt; Leon Barnes, MD; Gary Ellis, MD, John Chan, MD.
Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
2
© 2016 College of American Pathologists (CAP). All rights reserved. The College does not permit reproduction of any substantial portion of these protocols without its written authorization. The College hereby authorizes use of these protocols by physicians and other health care providers in reporting on surgical specimens, in teaching, and in carrying out medical research for nonprofit purposes. This authorization does not extend to reproduction or other use of any substantial portion of these protocols for commercial purposes without the written consent of the College.
The CAP also authorizes physicians and other health care practitioners to make modified versions of the Protocols solely for their individual use in reporting on surgical specimens for individual patients, teaching, and carrying out medical research for non-profit purposes.
The CAP further authorizes the following uses by physicians and other health care practitioners, in reporting on surgical specimens for individual patients, in teaching, and in carrying out medical research for non-profit purposes: (1) Dictation from the original or modified protocols for the purposes of creating a text-based patient record on paper, or in a word processing document; (2) Copying from the original or modified protocols into a text-based patient record on paper, or in a word processing document; (3) The use of a computerized system for items (1) and (2), provided that the protocol data is stored intact as a single text-based document, and is not stored as multiple discrete data fields.
Other than uses (1), (2), and (3) above, the CAP does not authorize any use of the Protocols in electronic medical records systems, pathology informatics systems, cancer registry computer systems, computerized databases, mappings between coding works, or any computerized system without a written license from the CAP.
Any public dissemination of the original or modified protocols is prohibited without a written license from the CAP.
The College of American Pathologists offers these protocols to assist pathologists in providing clinically useful and relevant information when reporting results of surgical specimen examinations of surgical specimens. The College regards the reporting elements in the “Surgical Pathology Cancer Case Summary” portion of the protocols as essential elements of the pathology report. However, the manner in which these elements are reported is at the discretion of each specific pathologist, taking into account clinician preferences, institutional policies, and individual practice.
The College developed these protocols as an educational tool to assist pathologists in the useful reporting of relevant information. It did not issue the protocols for use in litigation, reimbursement, or other contexts. Nevertheless, the College recognizes that the protocols might be used by hospitals, attorneys, payers, and others. Indeed, effective January 1, 2004, the Commission on Cancer of the American College of Surgeons mandated the use of the required data elements of the protocols as part of its Cancer Program Standards for Approved Cancer Programs. Therefore, it becomes even more important for pathologists to familiarize themselves with these documents. At the same time, the College cautions that use of the protocols other than for their intended educational purpose may involve additional considerations that are beyond the scope of this document.
The inclusion of a product name or service in a CAP publication should not be construed as an endorsement of such product or service, nor is failure to include the name of a product or service to be construed as disapproval.
Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
3
CAP Lip and Oral Cavity Protocol Revision History Version Code The definition of version control and an explanation of version codes can be found at www.cap.org (search: cancer protocol terms). Summary of Changes The following changes have been made since the October 2013 release. The following data elements were modified: Tumor Site Tumor Size (changed “see Comment” to “explain”) Histologic Type Histologic Grade (changed to “required only if applicable”; added note) Specimen Margins (was “Margins”) Treatment Effect Lymph-Vascular Invasion Perineural Invasion Distant Metastasis Clinical History The following data elements were added: Tumor Bed (Separately Submitted) Margins Extranodal Extension The following data elements were deleted: Specimen Specimen Integrity Specimen Size Specimen Laterality
CAP Approved Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
+ Data elements preceded by this symbol are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management.
4
Surgical Pathology Cancer Case Summary Protocol web posting date: August 2016 LIP AND ORAL CAVITY: Excisional Biopsy, Resection Select a single response unless otherwise indicated. Procedure (select all that apply) ___ Excisional biopsy ___ Resection ___ Glossectomy (specify): ____________________________ ___ Mandibulectomy (specify): ____________________________ ___ Maxillectomy (specify): ____________________________ ___ Palatectomy ___ Neck (lymph node) dissection (specify): ____________________________ ___ Other (specify): _______________________________ ___ Not specified Specimen Laterality (select all that apply) ___ Right ___ Left ___ Midline ___ Not specified Tumor Site (select all that apply) (Note A) ___ Vermilion border upper lip ___ Vermilion border lower lip ___ Mucosa of upper lip ___ Mucosa of lower lip ___ Commissure of lip ___ Lateral border of tongue ___ Ventral surface of tongue ___ Dorsal surface of tongue ___ Anterior two-thirds of tongue ___ Upper gingiva ___ Lower gingiva ___ Anterior floor of mouth ___ Floor of mouth ___ Hard palate ___ Buccal mucosa ___ Vestibule of mouth ___ Upper ___ Lower ___ Alveolar process ___ Upper ___ Lower ___ Mandible ___ Maxilla ___ Other (specify): __________________________ ___ Not specified
CAP Approved Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
+ Data elements preceded by this symbol are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management.
5
Tumor Focality ___ Single focus ___ Multifocal (specify): ____________________________ Tumor Size Greatest dimension: ___ cm + Additional dimensions: ___ x ___ cm ___ Cannot be determined (explain): ___________________________ + Tumor Thickness (pT1 and pT2 tumors) (Note B) + 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) (Note C) Squamous Cell Carcinoma ___ Squamous cell carcinoma, conventional Variants of Squamous Cell Carcinoma ___ Acantholytic squamous cell carcinoma ___ Adenosquamous carcinoma ___ Basaloid squamous cell carcinoma ___ Lymphoepithelial carcinoma (nonnasopharyngeal) ___ Papillary squamous cell carcinoma ___ Spindle cell squamous cell carcinoma ___ Verrucous carcinoma
___ Giant cell carcinoma Carcinomas of Minor Salivary Glands ___ Mucoepidermoid carcinoma ___Low grade ___ Intermediate grade ___ High grade ___ Adenoid cystic carcinoma ___ Low grade ___ Intermediate grade ___ High grade ___ Polymorphous low-grade adenocarcinoma +___Cribriform adenocarcinoma of minor salivary origin ___ Salivary duct carcinoma ___ Carcinoma ex pleomorphic adenoma (malignant mixed tumor) ___ Low-grade ___ High-grade ___ Invasive
CAP Approved Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
+ Data elements preceded by this symbol are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management.
6
___ Intracapsular (noninvasive) ___ Acinic cell carcinoma ___ Adenocarcinoma, not otherwise specified
___ Low grade ___ Intermediate grade ___ High grade
___ Basal cell adenocarcinoma ___ Carcinoma, type cannot be determined ___ Carcinosarcoma ___ (Hyalinizing) clear cell carcinoma ___ Cystadenocarcinoma ___ Epithelial-myoepithelial carcinoma ___ Mucinous adenocarcinoma (colloid carcinoma) ___ Myoepithelial carcinoma (malignant myoepithelioma) ___ Oncocytic carcinoma ___ Other (specify): ____________________________ Adenocarcinoma, Non-Salivary Gland Type ___ Adenocarcinoma, not otherwise specified ___ Low grade ___ Intermediate grade ___ High grade ___ Other (specify): ____________________________ Neuroendocrine Carcinoma ___ Typical carcinoid tumor (well differentiated neuroendocrine carcinoma) ___ Atypical carcinoid tumor (moderately differentiated neuroendocrine carcinoma) ___ Large cell carcinoma, neuroendocrine type (poorly differentiated neuroendocrine carcinoma) ___ Small cell carcinoma, neuroendocrine type (poorly differentiated neuroendocrine carcinoma) ___ Combined (or composite) small cell carcinoma, neuroendocrine type with (specify type):
___________________________________ ___ Mucosal melanoma ___ Other (specify): ____________________________ ___ Carcinoma, type cannot be determined Histologic Grade (Note D) (required only if applicable)# ___ GX: Cannot be assessed ___ G1: Well differentiated ___ G2: Moderately differentiated ___ G3: Poorly differentiated ___ Other (specify): ____________________________ # Note: The Histologic Grade section is only applicable to squamous cell carcinomas of the lip and oral cavity. + Microscopic Tumor Extension + Specify: ____________________________
CAP Approved Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
+ Data elements preceded by this symbol are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management.
7
Specimen Margins (select all that apply) (Notes E and F) ___ Cannot be assessed ___ Margins uninvolved by invasive tumor
Distance from closest margin: Specify distance: ____ mm ___ Cannot be determined Specify location of closest margin, per orientation, if possible: ____________________________ + Location and distance of other close margins (Note E): ____________________________
___ Margins involved by invasive tumor Specify margin(s), per orientation, if possible: ____________________________ ___ Margins uninvolved by in situ disease# (Note E) Distance from closest margin:
Specify distance: ____ mm ___ Cannot be determined Specify location of closest margin, per orientation, if possible: ____________________________
___ Margins involved by in situ disease# (Note E) Specify margin(s), per orientation, if possible: ____________________________ Tumor Bed (Separately Submitted) Margins (Notes E and F) (required only if applicable) ___ Margin Orientation ___ Oriented to true margin surface ___ Unoriented to true margin surface ___ Margins uninvolved by invasive tumor
+Specify distance to true margin surface: ____ mm (if oriented and sectioned perpendicularly) ___ Margins uninvolved by in situ disease# (Note E)
+Specify distance to true margin surface: ____ mm (if oriented and sectioned perpendicularly) ___ Margins involved by invasive tumor Specify margin(s), per part labeling, if possible: ____________________________ ___ Margins involved by in situ disease# (Note E)
Specify margin(s), per orientation, if possible: ____________________________ #Note: Applicable only to squamous cell carcinoma and its histologic variants, as well as to mucosal melanoma. + Treatment Effect (applicable to carcinomas treated with neoadjuvant therapy) + ___ Not identified + ___ Present (specify): ____________________________ + ___ Cannot be determined Lymph-Vascular Invasion ___ Not identified ___ Present ___ Cannot be determined Perineural Invasion (Note G) ___ Not identified ___ Present ___ Cannot be determined Pathologic Staging (pTNM) (Note H) TNM Descriptors (required only if applicable) (select all that apply) ___ m (multiple primary tumors) ___ r (recurrent) ___ y (posttreatment)
CAP Approved Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
+ Data elements preceded by this symbol are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management.
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For All Carcinomas Excluding Mucosal Melanoma Primary Tumor (pT) ___ pTX: Cannot be assessed ___ pT0: No evidence of primary tumor ___ pTis: Carcinoma in situ ___ pT1: Tumor 2 cm or less in greatest dimension ___ pT2: Tumor more than 2 cm but not more than 4 cm in greatest dimension ___ pT3: Tumor more than 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, ie, chin or nose
Oral cavity: Tumor invades adjacent structures only (eg, 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, and/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)# (Notes I through M) ___ pNX: Cannot be assessed ___ pN0: No regional lymph node metastasis ___ pN1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension ___ pN2a: Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest
dimension ___ pN2b: Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension ___ pN2c: Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension ___ pN3: Metastasis in a lymph node more than 6 cm in greatest dimension ___ No nodes submitted or found Number of Lymph Nodes Examined Specify: ____ ___ Number cannot be determined (explain): ____________________________ Number of Lymph Nodes Involved Specify: ____ + Size (greatest dimension) of the largest metastatic focus in the lymph node: ____ cm (Note L) ___ Number cannot be determined (explain): ____________________________ # Superior mediastinal lymph nodes are considered regional lymph nodes (level VII). Midline nodes are considered ipsilateral nodes. Distant Metastasis (pM) (required only if confirmed pathologically in this case) ___ pM1: Distant metastasis Specify site(s), if known: ____________________________ For Mucosal Melanoma (Note I) 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
CAP Approved Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
+ Data elements preceded by this symbol are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management.
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Regional Lymph Nodes (pN) ___ pNX: Regional lymph nodes cannot be assessed ___ pN0: No regional lymph node metastases ___ pN1: Regional lymph node metastases present Distant Metastasis (pM) (required only if confirmed pathologically in this case) ___ pM1: Distant metastasis present
Specify site(s), if known: ____________________________ Extranodal Extension (required for all histologies except mucosal melanoma) ___ Not identified ___ Present + Distance from lymph node capsule: _____ mm ___ Cannot be determined + Additional Pathologic Findings (select all that apply) + ___ None identified + ___ Keratinizing dysplasia (Note N) + ___ Mild + ___ Moderate + ___ Severe (carcinoma in situ) + ___ Nonkeratinizing dysplasia (Note N) + ___ Mild + ___ Moderate + ___ Severe (carcinoma in situ) + ___ Inflammation (specify type): ____________________________ + ___ Epithelial hyperplasia + ___ Colonization + ___ Fungal + ___ Bacterial + ___ Other (specify): ____________________________ + Ancillary Studies (Note O) + Specify type(s): _______________________________ + Specify result(s): ______________________________ + Clinical History (select all that apply) + ___ Neoadjuvant therapy + ___ Yes (specify type): ____________________________ + ___ No + ___Cannot be determined + ___ Other (specify): ____________________________ + Comment(s)
Background Documentation Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
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Explanatory Notes Scope of Guidelines The reporting of oral cancer including the lip is facilitated by the provision of a case summary illustrating the features required for comprehensive patient care. However, there are many cases in which the individual practicalities of applying such a case summary may not be straightforward. Common examples include finding the prescribed number of lymph nodes, trying to determine the levels of the radical neck dissection, and determining if isolated tumor cells in a lymph node represent metastatic disease. Case summaries have evolved to include clinical, radiographic, morphologic, immunohistochemical, and molecular results in an effort to guide clinical management. Adjuvant and neoadjuvant therapy can significantly alter histologic findings, making accurate classification an increasingly complex and demanding task. This protocol tries to remain simple while still incorporating important pathologic features as proposed by the American Joint Committee on Cancer (AJCC) cancer staging manual, the World Health Organization classification of tumors, the TNM classification, the American College of Surgeons Commission on Cancer, and the International Union on Cancer (UICC). This protocol is to be used as a guide and resource, an adjunct to diagnosing and managing cancers of the oral cavity in a standardized manner. It should not be used as a substitute for dissection or grossing techniques and does not give histologic parameters to reach the diagnosis. Subjectivity is always a factor, and elements listed are not meant to be arbitrary but are meant to provide uniformity of reporting across all the disciplines that use the information. It is a foundation of practical information that will help to meet the requirements of daily practice to benefit both clinicians and patients alike. A. Anatomic Sites and Subsites for Lip and Oral Cavity (Figure 1) Lip External upper lip (vermilion border) External lower lip (vermilion border) Commissures Oral Cavity Buccal mucosa Mucosa of upper and lower lips Cheek mucosa Retromolar areas Bucco-alveolar sulci, upper and lower (vestibule of mouth) Upper alveolus and gingiva (upper gum) Lower alveolus and gingiva (lower gum) Hard palate Tongue Dorsal surface and lateral borders anterior to circumvallate papillae
(anterior two-thirds) Inferior (ventral) surface Floor of mouth The protocol applies to all carcinomas arising at these sites. 1 Mucosal Lip. The lip begins at the junction of the vermilion border with the skin and includes only the vermilion surface or that portion of the lip that comes in contact with the opposing lip. It is well defined into an upper and lower lip joined at the commissures of the mouth. Buccal Mucosa (Inner Cheek). This includes all the membrane lining of the inner surface of the cheeks and lips from the line of contact of the opposing lips to the line of attachment of mucosa of the alveolar ridge (upper and lower) and pterygomandibular raphe. Lower Alveolar Ridge. This refers to the mucosa overlying the alveolar process of the mandible, which extends from the line of attachment of mucosa in the buccal gutter to the line of free mucosa of the floor of the mouth. Posteriorly it extends to the ascending ramus of the mandible.
Background Documentation Head and Neck • Lip and Oral Cavity LipOralCavity 3.3.0.0
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Upper Alveolar Ridge. This refers to the mucosa overlying the alveolar process of the maxilla, which extends from the line of attachment of mucosa in the upper gingival buccal gutter to the junction of the hard palate. Its posterior margin is the upper end of the pterygopalatine arch. Retromolar Gingiva (Retromolar Trigone). This is the attached mucosa overlying the ascending ramus of the…
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