LIP AND ORAL CAVITY: Incisional Biopsy, Excisional Biopsy, Resection

Specimen:
   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, not otherwise specified (NOS)
   Dorsal surface of tongue, NOS
   Anterior two-thirds 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 Type:
   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 (cm):
Additional dimensions (if more than one part) (cm):

Specimen Laterality:
Right
Left
Bilateral
Midline
Not specified

Tumor Site:
   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, NOS
   Dorsal surface of tongue, NOS
   Anterior two-thirds 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
Cannot be determined:

Tumor Thickness (pT1 and pT2 tumors)
Tumor thickness (mm):
Intact surface mucosa:
Ulcerated surface:

Tumor Description
Gross subtype:
Polypoid
Exophytic
Endophytic
Ulcerated
Sessile
Other (specify):

Macroscopic Extent of Tumor:

Histologic Type:
   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):
        Low-grade
        High-grade
        Invasive:
            Minimally invasive
            Invasive
        Intracapsular (noninvasive)
       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:

Margins:
   Cannot be assessed
   Margins uninvolved by invasive carcinoma, distance from closest margin: at
   Margins involved by invasive carcinoma at
   Margins uninvolved by carcinoma in situ (includes moderate and severe dysplasia), distance from closest margin: at
   Margins involved by carcinoma in situ (includes moderate and severe dysplasia) at
   Not applicable

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:

m (multiple primary tumors)
r (recurrent)
y (post-treatment)

Primary Tumor (pT):
Non-mucosal malignant melanoma

    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.)
Mucosal Malignant Melanoma

    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):
Non-mucosal malignant melanoma

    pNX: Cannot be assessed
    pN0: No regional lymph node metastasis ( 0 / )
    pN1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension ( 1 / )
    pN2a: Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension ( 1 / )
    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 ( / )
Mucosal Malignant Melanoma

    pNX: Regional lymph nodes cannot be assessed
    pN0: No regional lymph node metastases ( 0 / )
    pN1: Regional lymph node metastases present ( / )

Size (greatest dimension) of the largest positive lymph node (cm):

Superior mediastinal lymph nodes are considered regional lymph nodes (level VII). Midline nodes are considered ipsilateral nodes.

Distant Metastasis (pM):
Not Applicable
pM1: Distant metastasis: Specify site(s), if known; Specify source of pathologic metastatic specimen

Additional Pathologic Findings:
   None identified
   Keratinizing dysplasia:
    Mild
    Moderate
    Severe (carcinoma in situ)
   Non-keratinizing dysplasia:
    Mild
    Moderate
    Severe (carcinoma in situ)
   Inflammation (specify type):
   Epithelial hyperplasia
   Colonization:
    Fungal
    Bacterial
   Other (specify):

Ancillary Studies:

Treatment History:
       Neoadjuvant therapy:
        Yes:
        No
        Indeterminate
       Other (specify):

Comment(s):