Melanoma of the Skin

Procedure Type:
   Biopsy, shave
   Biopsy, punch
   Biopsy, incisional
   Excision
   Re-excision
   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 (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 classified
Superficial spreading melanoma
Nodular melanoma
Lentigo maligna melanoma
Acral-lentiginous melanoma
Desmoplastic and/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 ()

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:

Peripheral Margins:
   Cannot be assessed
   Uninvolved by invasive melanoma, distance of invasive melanoma from closest peripheral margin: mm at (required for excisions only)
   Involved by invasive melanoma at
   Uninvolved by melanoma in situ, distance of melanoma in situ from closest margin: mm at (required for excisions only)
   Involved by melanoma in situ at

Deep Margin:
   Cannot be assessed
   Uninvolved by invasive melanoma, distance of invasive melanoma from margin: mm at (required for excisions only)
   Involved by invasive melanoma at

Mitotic Index:
Less than 1 / mm2
Specify number / mm2
Other:

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 less than 75% of lesion
    Present, involving 75% or more of lesion
    Indeterminate

Growth Phase:
    Radial
    Vertical
    Indeterminate

Lymph Nodes (required only if lymph nodes are present in the specimen) :
       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)
m (multiple)
r (recurrent)
y (posttreatment)

Primary Tumor (pT):
pTX: Primary tumor cannot be assessed (eg, shave biopsy or regessed melanoma):
pT0: No evidence of primary tumor
pTis: Melanoma in situ (ie, not an invasive tumor: anatomic level I)
pT1: Melanoma 1.0 mm or less in thickness, with or without ulceration
pT1a: Melanoma 1.0 mm or less in thickness, no ulceration, <1 mitoses/mm2
pT1b: Melanoma 1.0 mm or less in thickness with ulceration and/or 1 or more mitoses/mm2
pT2: Melanoma 1.01 to 2 mm in thickness, with or without ulceration
pT2a: Melanoma 1.01 to 2.0 mm in thickness, no ulceration
pT2b: Melanoma 1.01 to 2.0 mm in thickness, with ulceration
pT3: Melanoma 2.01 to 4.0 mm in thickness, with or without ulceration
pT3a: Melanoma 2.01 to 4.0 mm in thickness, no ulceration
pT3b: Melanoma 2.01 to 4.0 mm in thickness, with ulceration
pT4: Melanoma greater than 4.0 mm in thickness, with or without ulceration
pT4a: Melanoma greater than 4.0 mm in thickness, no ulceration
pT4b: Melanoma greater than 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 to 3 regional nodes or 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 or more regional lymph nodes, or matted metastatic nodes, or in-transit metastasis or satellites(s) with metastasis in regional node(s)

   Number of lymph nodes identified:
   Number containing metastases 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:
       Nevus remnant
       Other (specify):

Comment(s):