Head and Neck • Lip and Oral Cavity



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Head and Neck • Lip and Oral Cavity

LipOralCavity 3.2.0.0

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.

Based on AJCC/UICC TNM, 7th edition


Protocol web posting date: October 2013

Procedures


• Biopsy

• Resection



Authors


Raja R. Seethala, MD, FCAP*

Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA

Ilan Weinreb, MD, FCAP

Department of Anatomical Pathology, University Health Network, Toronto, ON

Diane L. Carlson, MD, FCAP

Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY

Jonathan B. McHugh, MD, FCAP

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, FACS

Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY

Robert L Ferris, MD, PhD, FACS

Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA

Bruce M. Wenig, MD, FCAP

Department of Pathology and Laboratory Medicine, Beth Israel Medical Center, St. Luke’s and Roosevelt Hospitals, New York, NY

Lester D. R. Thompson, MD, FCAP

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.

© 2013 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.



CAP Lip and Oral Cavity Protocol Revision History
Version Code

The definition of the version code can be found at www.cap.org/cancerprotocols.


Version: LipOralCavity 3.2.0.0
Summary of Changes

The following changes have been made since the June 2012 release.


Entire Document

“Mucosal malignant melanoma” was changed to “Mucosal melanoma.”


Excisional Biopsy, Resection
Procedure

“Incisional biopsy” was deleted.


Specimen Laterality

“Bilateral” was deleted and “(select all that apply)” was added, as follows:



Specimen Laterality (select all that apply)

___ Right

___ Left

___ Midline

___ Not specified
Histologic Type

Neuroendocrine Carcinoma

“Large cell carcinoma, neuroendocrine type (poorly differentiated neuroendocrine carcinoma)” was added.



Carcinomas of Minor Salivary Glands

Low, intermediate, and high grade were added to adenoid cystic carcinoma as follows:

___ Adenoid cystic carcinoma

___ Low grade

___ Intermediate grade

___ High grade


Margins

Reporting on margins was updated, as follows:

___ Cannot be assessed

___ Margins uninvolved by invasive carcinoma

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 D): ____________________

___ Margins involved by invasive carcinoma

Specify margin(s), per orientation, if possible: _______________

___ Margins uninvolved by carcinoma in situ (includes moderate and severe dysplasia#) (Note D)

Distance from closest margin:

Specify distance: ____ mm

___ Cannot be determined

Specify location of closest margin, per orientation, if possible: _______________

___ Margins involved by carcinoma in situ (includes moderate and severe dysplasia#) (Note D)

Specify margin(s), per orientation, if possible: _______________


# Applicable only to squamous cell carcinoma and histologic variants.



Pathologic Staging (pTNM)
Regional Lymph Nodes (pN)

Number of Lymph Nodes Involved

Size was changed from “largest positive lymph node” to largest metastatic focus in the lymph node.”

Extracapsular extension was added, as follows:

Extracapsular Extension

___ Not identified

___ Present

+ Distance from lymph node capsule: _____ mm

___ Indeterminate
Distant Metastasis (pM)

Deleted “Source of pathologic metastatic specimen (specify).”


Explanatory Notes
B. Histologic Type

Neuroendocrine carcinoma: added “Large cell carcinoma, neuroendocrine type (poorly differentiated neuroendocrine carcinoma).”


D. Histologic Grade

E. Surgical Margins

F. Orientation of Specimen

G. Perineural Invasion

O. Ancillary Testing

Edits were made to these notes.


K. Regional Lymph Nodes (pN0): Isolated Tumor Cells

Classification scheme for ITCs was deleted.


L. Lymph Nodes

Measurement of Tumor Metastasis

Deleted: There is conflicting data in the literature on the significance of the size of the largest metastatic lymph node on the risk of regional recurrence and a predictor of poor overall survival.24 While the diameter of the largest positive lymph node may potentially serve as a predictor of outcome, it may not represent an independent predictor of outcome when other pathologic factors are considered.24


References

References were updated.


Surgical Pathology Cancer Case Summary
Protocol web posting date: October 2013

LIP AND ORAL CAVITY: Excisional Biopsy, Resection
Select a single response unless otherwise indicated.

Specimen (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, 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 (select all that apply)


___ 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 (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, 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 (see Comment)
+ 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

___ Papillary squamous cell carcinoma

___ Spindle cell squamous cell carcinoma

___ Verrucous carcinoma
___ Giant cell carcinoma

___ Lymphoepithelial carcinoma (non-nasopharyngeal)



Carcinomas of Minor Salivary Glands


___ Acinic cell carcinoma

___ Adenoid cystic carcinoma

___ Low grade

___ Intermediate grade

___ High grade

___ 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 (Note C)

___ Invasive (Note C)

___ 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)

___ 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)


___ 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) (Notes E and F)


___ Cannot be assessed

___ Margins uninvolved by invasive carcinoma

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 D): ____________________________

___ Margins involved by invasive carcinoma

Specify margin(s), per orientation, if possible: ____________________________

___ Margins uninvolved by carcinoma in situ (includes moderate and severe dysplasia#) (Note E)

Distance from closest margin:

Specify distance: ____ mm

___ Cannot be determined

Specify location of closest margin, per orientation, if possible: ____________________________

___ Margins involved by carcinoma in situ (includes moderate and severe dysplasia#) (Note E)

Specify margin(s), per orientation, if possible: ____________________________


# Applicable only to squamous cell carcinoma and histologic variants.




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


+ ___ Not identified

+ ___ Present (specify): ____________________________

+ ___ Indeterminate

Lymph-Vascular Invasion


___ Not identified

___ Present

___ Indeterminate

Perineural Invasion (Note G)


___ Not identified

___ Present


___ Indeterminate




Lymph Nodes, Extranodal Extension (Note H)


___ Not identified

___ Present

___ Indeterminate

Pathologic Staging (pTNM) (Note I)




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


___ m (multiple primary tumors)

___ r (recurrent)

___ y (posttreatment)
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 J 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): ____________________________


Extracapsular Extension (Note G)

___ Not identified

___ Present

+ Distance from lymph node capsule: _____ mm

___ Indeterminate
# 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: ____________________________


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


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)

___ Not applicable

___ pM1: Distant metastasis present

+ Specify site(s), if known: ____________________________



+ 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


+ ___Indeterminate

+ ___ Other (specify): ____________________________



+ Comment(s)



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.

  1. 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.
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 mandible from the level of the posterior surface of the last molar tooth and the apex superiorly, adjacent to the tuberosity of the maxilla.
Floor of the Mouth. This is a semilunar space over the myelohyoid and hypoglossus muscles, extending from the inner surface of the lower alveolar ridge to the undersurface of the tongue. Its posterior boundary is the base of the anterior pillar of the tonsil. It is divided into two sides of the submaxillary and sublingual salivary glands.
Hard Palate. This is the semilunar area between the upper alveolar ridge and the mucous membrane covering the palatine process of the maxillary palatine bones. It extends from the inner surface of the superior alveolar ridge to the posterior edge of the palatine bone.
Anterior Two-Thirds of the Tongue (Oral Tongue). This is the freely mobile portion of the tongue that extends anteriorly from the line of circumvallate papillae to the undersurface of the tongue at the junction of the floor of the mouth. It is composed of four areas: the tip, the lateral borders, the dorsum, and the undersurface (nonvillous ventral surface of the tongue). The undersurface of the tongue is considered a separate category by the World Health Organization (WHO).




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