General Principles of Head and Neck Pathology

Bruce M. Wenig

Jean-Marc Cohen

The surgical pathologist is an integral member of the clinical team that administers to the head and neck cancer patient. The pathologist’s role is multifactorial. In the simplest of terms, it is his/her job to render the correct diagnosis. However, that “final” goal is not an isolated achievement, nor is the diagnosis the sole responsibility placed on the surgical pathologist. There are numerous factors that go into the diagnosis of cancer, not the least important of which are what type of cancer is it, how invasive is the tumor, are the surgical margins free of involvement, is there metastatic disease, and are there any pathologic features that may allow for predicting the biologic behavior for a given tumor.

This chapter will be an overview of the pathologic issues relative to head and neck cancer. The chapter will be divided into two sections. Section I will be an overview of the general principles of the pathology of head and neck neoplasms. Section II will focus primarily on head and neck squamous cell carcinoma (HNSCC), including the parthologic findings of precursor lesions of HNSCC, invasive squamous cell carcinoma (SCC), and variants of SCC. Due to limitations of space, the pathology of salivary gland neoplasms, neuroendocrine neoplasms, thyroid and parathyroid lesions, and mesenchymal and hematolymphoid neoplasms will not be included in this chapter. The reader is referred to other chapters in this textbook discussing these subjects.

THE SURGICAL PATHOLOGY REPORT AND THE TISSUE SPECIMEN

The pathology report is the document that contains the pathologist’s diagnosis for a given surgical or cytologic specimen. The pathology report not only contains the diagnosis of the tumor but may also include the type, differentiation, and histologic grade of the tumor, the extent of disease, including whether the tumor is invasive (in situ vs. submucosal invasion), whether the surgical margins are involved by tumor, whether there is neural or lymphvascular space invasion, and whether nodal metastases and extranodal extension is present. In addition, the pathology report may contain the results of any adjunct studies that assist in establishing the diagnosis. Therefore, the pathology report includes information of prognostic and therapeutic import. Further, the pathology report is a legal document that becomes a part of the patient’s medical record. The College of American Pathologists (CAP) has established guidelines (referred to as checklists) for the reporting of human cancers. These guidelines include cancers of all body sites. The most recent guidelines for the reporting of cancers of the head and neck, including the thyroid gland, are detailed in Tables 1.1, 1.2, 1.3, 1.4, 1.5 and 1.6.

The final histologic diagnosis is not an isolated achievement or the sole responsibility of the pathologist. In addition to the final diagnosis, the pathology report contains the gross and microscopic description of the specimen. For small specimens such as a biopsy, the gross description is relatively simple and straightforward. For larger surgical resections, like those often required for the head and neck cancer patient, the surgical specimen may be large and complex in its details. The complexity of the surgical specimen necessitates that the pathologist has a good functional understanding of the surgical anatomy of the region. It is the responsibility of the pathologist to properly evaluate the gross specimen and to describe in detail the gross characteristics of the tumor to include its relationship to the surrounding structures. Equally important is the proper sectioning of the specimen. Improper sectioning will result in erroneous evaluation of the specimen. To this end, the surgeon and pathologist must work in unison, especially in appropriately orienting a large resection specimen and determining the key aspects of the specimen (e.g., surgical margins) that require special attention. The sections that are taken by the pathologist will ultimately indicate whether the tumor involves the surgical margins or whether the surgical margins are free of tumor. The issue of surgical margin involvement will impact on the necessity for additional surgical intervention and/or the utilization of adjuvant therapy. Therefore, the proper gross evaluation of the specimen, including the sectioning for histologic evaluation, is a critical component in the overall management of the head and neck cancer patient.

It should be obvious that the pathologist’s role as a member of the clinical team goes beyond the histologic evaluation of a tumor and the assigning of a name (i.e., a diagnosis). Certainly, the diagnosis of the tumor is important, but there are multiple additional factors that are equally important, perhaps even more important to the overall management and prognosis of the head and neck cancer patient. These issues will be discussed in detail later in this chapter.

The pathologist is entirely dependent on the tissue sampling that is received from the surgeon.

Without the appropriate material, a diagnosis cannot be rendered. This is true for neoplastic, as well as nonneoplastic lesions. In general, necrotic or ulcerated tissue should be avoided as the diagnostic yield from this material, at best, is low. The viable tissue surrounding or deep to the ulcerated or necrotic tissue should be sampled. The most common types of neoplastic proliferations
of the upper aerodigestive tract (UADT) originate from the surface epithelium. A critical parameter utilized by the pathologist in differentiating a reactive or benign surface epithelial lesion from a malignant neoplasm is the presence or absence of stromal invasion. Adequate sampling should therefore include the depth of the tissue so that the pathologist can evaluate the epithelial-tostromal interface, and an assessment for the presence or absence of stromal invasion can be made. Without an adequate epithelialto-stromal interface, a diagnosis cannot be made, resulting in frustration for the pathologist, surgeon, and, most importantly, the patient. The deficiency of proper sampling leads to diagnostic and therapeutic delays. Further, tissue sampling of any anatomic site results in secondary pathologic changes that may cause diagnostic dilemmas for the pathologist.

TABLE 1.1 College of American Pathologists (CAP) Check Lists for Cancers of the Larynx

Surgical Pathology Cancer Case Summary (Checklist)
Protocol web posting date: June 2012
LARYNX (SUPRAGLOTTIS, GLOTTIS, SUBGLOTTIS): Incisional and Excisional Biopsy, Resection Select a single response unless otherwise indicated.
Specimen (select all that apply)
	Larynx, supraglottis
	Larynx, glottis
	Larynx, subglottis
	Other (specify): _______________
	Not specified
Received
___ Fresh
___ In formalin
___ Other (specify): _______________
Procedure (select all that apply)
___ Incisional biopsy
___ Excisional biopsy
___ Resection
	___ Endolaryngeal excision
	___ Transoral laser excision (glottis)
___ Supraglottic laryngectomy
___ Supracricoid laryngectomy
___ Vertical hemilaryngectomy (specify side): __________
___ Partial laryngectomy (specify type): __________
___ Total laryngectomy
___ Neck (lymph node) dissection (specify): _______________
___ Other (specify): _______________
___ Not specified
*^Specimen Integrity**
^*___ Intact
^*___ Fragmented
Laryngectomy (required only if applicable)
___ Open
___ Unopened
Specimen Size
Greatest dimensions: ___ × ___ × ___ cm
^*Additional dimensions (if more than one part): ___ × ___ × ___ cm
Tumor Laterality (select all that apply)
___ Right
___ Left
___ Bilateral
___ Midline
___ Not specified
Tumor Site (select all that apply)
___ Larynx, supraglottis
	___ Epiglottis
		___ Lingual aspect
		___ Laryngeal aspect
		___ Aryepiglottic folds
	___ Arytenoid(s)
	___ False vocal cord
	___ Ventricle
___ Larynx, glottis
	___ True vocal cord
	___ Anterior commissure
	___ Posterior commissure
___ Larynx, subglottis
___ Other (specify): __________________
___ Not specified
Transglottic
___ Yes
___ No
Tumor Focality
___ Single focus
___ Bilateral
___ Multifocal (specify): __________
Tumor Size
Greatest dimension: ___ cm
^*Additional dimensions: ___ × ___ cm
___ Cannot be determined (see Comment)
^*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)
___ 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 (nonnasopharyngeal)
Neuroendocrine Carcinoma
___ Typical carcinoid tumor (well-differentiated neuroendocrine carcinoma)
___ Atypical carcinoid tumor (moderately differentiated neuroendocrine carcinoma)
___ Small cell carcinoma, neuroendocrine type (poorly differentiated neuroendocrine carcinoma)
___ Combined (or composite) small cell carcinoma, neuroendocrine type
___ Mucosal malignant melanoma
Carcinomas of Minor Salivary Glands
___ Adenoid cystic carcinoma
___ Mucoepidermoid carcinoma
	___ Low grade
	___ Intermediate grade
	___ High grade
___ Other (specify): _______________
___ Other carcinoma (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 (select all that apply)
___ Cannot be assessed
___ Margins uninvolved by invasive carcinoma
	Distance from closest margin: ___ mm or ___ cm
	Specify margin(s), per orientation, if possible: __________
___ Margins involved by invasive carcinoma
	Specify margin(s), per orientation, if possible: __________
___ Margins uninvolved by carcinoma in situ (includes moderate and severe dysplasia^#)
	Distance from closest margin: ___ mm or ___ cm
	Specify margin(s), per orientation, if possible: __________
___ Margins involved by carcinoma in situ (includes moderate and severe dysplasia^#)
	Specify margin(s), per orientation, if possible: __________
___ Not applicable
*^#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
___ Not identified
___ Present
___ Indeterminate
Lymph Nodes, Extranodal Extension
___ Not identified
___ Present
___ Indeterminate
Pathologic Staging (pTNM)
Note: The phrases in italics include clinical findings required for AJCC staging. This clinical information may not be available to the pathologist. However, if known, these findings should be incorporated into the pathologic staging.
TNM Descriptors (required only if applicable) (select all that apply)
___ m (multiple primary tumors)
___ r (recurrent)
___ y (posttreatment)
Primary Tumor (pT)
___ pTX: Cannot be assessed
___ pT0: No evidence of primary tumor
___ pTis: Carcinoma in situ
For All Carcinomas Excluding Mucosal Malignant Melanoma
Primary Tumor (pT): Supraglottis
___ pT1: Tumor limited to one subsite of supraglottis with normal vocal cord mobility
___ pT2: Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis (e.g., mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx
___ pT3: Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, preepiglottic space, paraglottic space, and/or inner cortex of thyroid cartilage
___ pT4a: Moderately advanced local disease. Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft tissues of neck including deep extrinsic muscle of tongue, strap muscles, thyroid, or esophagus)
___ pT4b: Very advanced local disease. Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures
Primary Tumor (pT): Glottis
___ pT1: Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal mobility
___ pT1a: Tumor limited to one vocal cord
___ pT1b: Tumor involves both vocal cords
___ pT2: Tumor extends to supraglottis and/or subglottis and/or with impaired vocal cord mobility
___ pT3: Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space and/or minor thyroid cartilage erosion (eg, inner cortex) (Note H)
___ pT4a: Moderately advanced local disease. Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus) (Note H)
___ pT4b: Very advanced local disease. Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures
___ Primary Tumor (pT): Subglottis
___ pT1: Tumor limited to subglottis
___ pT2: Tumor extends to vocal cord(s) with normal or impaired mobility
___ pT3: Tumor limited to larynx with vocal cord fixation
___ pT4a: Moderately advanced local disease. Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft tissues of neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus)
___ pT4b: Very advanced local disease. Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures
Regional Lymph Nodes (pN)^#
___ 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
___ pN2: Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension, or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension, or in bilateral or contralateral lymph nodes, none more than 6 cm 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: ___
___ Number cannot be determined (explain): __________
	^* Size (greatest dimension) of the largest positive lymph node: ___
^#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: _______________
	^* Source of pathologic metastatic specimen (specify): __________
For Mucosal Malignant Melanoma
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: _______________
^* Source of pathologic metastatic specimen (specify): __________
^* Additional Pathologic Findings (select all that apply)
^*___ None identified
^*___ Keratinizing dysplasia (Note M)
	^*___ Mild
	^*___ Moderate
	^___ Severe (carcinoma in situ*)
^* Nonkeratinizing dysplasia (Note M)
	^*___ Mild
	^*___ Moderate
	^___ Severe (carcinoma in situ*)
^*___ Inflammation (specify type): _______________
^*___ Squamous metaplasia
^*___ Epithelial hyperplasia
^*___ Colonization
	^*___ Fungal
	^*___ Bacterial
^*___ Other (specify): _______________
^* Ancillary Studies (Note N)
^* Specify type(s): _______________
^* Specify result(s): _______________
*^ Clinical History (select all that apply)**
^*___ Neoadjuvant therapy
	^*___ Yes (specify type): _______________
	^*___ No
	^*___ Indeterminate
^*___ Other (specify): _______________
^*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.

TABLE 1.2 College of American Pathologists (CAP) Check Lists for Cancers of the Lip and Oral Cavity

Surgical Pathology Cancer Case Summary (Checklist)
Protocol web posting date: June 2012
Lip and Oral Cavity: Incisional Biopsy, Excisional Biopsy, Resection
Select a single response unless otherwise indicated.
Specimen (select all that apply)
___ 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)
___ 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 1 part): ___ × ___ × ___ cm
Specimen Laterality
___ Right
___ Left
___ Bilateral
___ Midline
___ Not specified
Tumor Site (select all that apply)
___ 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: ___ × ___ cm
___ Cannot be determined (see Comment)
*^ Tumor Thickness (pT1 and pT2 tumors)**
^* 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)
___ 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 (nonnasopharyngeal)
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
^* Specify: _______________
Margins (select all that apply)
___ Cannot be assessed
___ Margins uninvolved by invasive carcinoma
	Distance from closest margin: ___ mm or ___ cm
		Specify margin(s), per orientation, if possible: __________
___ 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: ___ mm or ___ cm
		Specify margin(s), per orientation, if possible: __________
___ Margins involved by carcinoma in situ (includes moderate and severe dysplasia^#) (Note E)
		Specify margin(s), per orientation, if possible: __________
___ Not applicable
*^#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
___ 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 (posttreatment)
For All Carcinomas Excluding Mucosal Malignant 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, i.e., chin or nose
Oral cavity: Tumor invades adjacent structures only (e.g., 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: ____
___ Number cannot be determined (explain): __________
	^* Size (greatest dimension) of the largest positive lymph node: ___
^#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: ____________________
	^* Source of pathologic metastatic specimen (specify): __________
For Mucosal Malignant Melanoma
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: ____________________
		^* Source of pathologic metastatic specimen (specify): __________
^* 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
^* Specify type(s): ____________________
^* Specify result(s): __________________
*^ Clinical History (select all that apply)**
^*___ Neoadjuvant therapy
	^*___ Yes (specify type): ____________________
	^*___ No
	^*___ Indeterminate
^*___ Other (specify): ____________________
^*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.

TABLE 1.3 College of American Pathologists (CAP) Check Lists for Cancers of the Nasal Cavity and Paranasal Sinuses

Surgical Pathology Cancer Case Summary (Checklist)
Protocol web posting date: June 2012
Nasal Cavity and Paranasal Sinuses: Incisional Biopsy, Excisional Biopsy, Resection
Select a single response unless otherwise indicated.
Specimen (select all that apply)
___ Nasal cavity
	___ Septum
	___ Floor
	___ Lateral wall
	___ Vestibule
___ Paranasal sinus(es), maxillary
___ Paranasal sinus(es), ethmoid
___ Paranasal sinus(es), frontal
___ Paranasal sinus(es), sphenoid
___ Other (specify): ____________________
___ Not specified
Received
___ Fresh
___ In formalin
___ Other (specify): ____________________
Procedure (select all that apply)
___ Incisional Biopsy
___ Excisional Biopsy
___ Resection (specify type)
	___ Partial maxillectomy
	___ Radical maxillectomy
___ 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 (select all that apply)
___ Right
___ Left
___ Bilateral
___ Midline
___ Not specified
Tumor Site (select all that apply)
___ Nasal cavity
	___ Septum
	___ Floor
	___ Lateral wall
	___ Vestibule
___ Paranasal sinus(es), maxillary
___ Paranasal sinus(es), ethmoid
___ Paranasal sinus(es), frontal
___ Paranasal sinus(es), sphenoid
___ Other (specify): ____________________
___ Not specified
Tumor Focality (select all that apply)
___ Single focus
___ Bilateral
___ Multifocal (specify): _______________
Tumor Size
Greatest dimension: ___ cm
^* Additional dimensions: ___ × ___ cm
___ Cannot be determined (see Comment)
*^ 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)
Carcinomas of the Nasal Cavity and Paranasal Sinuses
___ Squamous cell carcinoma, conventional
	___ Keratinizing
	___ Nonkeratinizing (formerly cylindrical cell, transitional cell)
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 (nonnasopharyngeal)
___ Sinonasal undifferentiated carcinoma (SNUC)
Adenocarcinoma, Non-Salivary Gland Type
___ Intestinal type
	___ Papillary type
	___ Colonic type
	___ Solid type
	___ Mucinous type
	___ Mixed type
___ Nonintestinal type
	___ Low grade
	___ Intermediate grade
	___ High grade
Carcinomas of Minor Salivary Glands
___ Acinic cell carcinoma
___ Adenoid cystic carcinoma
___ Adenocarcinoma, not otherwise specified (NOS)
	___ Low grade
	___ Intermediate grade
	___ High grade
___ Carcinoma ex pleomorphic adenoma (malignant mixed tumor)
___ Clear cell adenocarcinoma
___ Epithelial-myoepithelial carcinoma
___ Mucoepidermoid carcinoma
	___ Low grade
	___ Intermediate grade
	___ High grade
___ Myoepithelial carcinoma (malignant myoepithelioma)
___ Oncocytic carcinoma
___ Polymorphous low-grade adenocarcinoma
___ Salivary duct carcinoma
___ 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
___ Mucosal malignant melanoma
___ 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 (select all that apply)
___ Cannot be assessed
___ Margins uninvolved by invasive carcinoma
	Distance from closest margin: ___ mm or ___ cm
		Specify margin(s), per orientation, if possible: __________
___ 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: ___ mm or ___ cm
	Specify margin(s), per orientation, if possible: __________
___ Margins involved by carcinoma in situ (includes moderate and severe dysplasia^#) (Note D)
	Specify margin(s), per orientation, if possible: __________
___ Not applicable
*^#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 F)
___ Not identified
___ Present
___ Indeterminate
Lymph Nodes, Extranodal Extension (Note G)
___ Not identified
___ Present
___ Indeterminate
Pathologic Staging (pTNM)
TNM Descriptors (required only if applicable) (select all that apply)
___ m (multiple primary tumors)
___ r (recurrent)
___ y (posttreatment)
Primary Tumor (pT)
___ pTX: Cannot be assessed
___ pT0: No evidence of primary tumor
___ pTis: Carcinoma in situ
For All Carcinomas Excluding Mucosal Malignant Melanoma
Primary Tumor (pT): Maxillary Sinus
___ pT1: Tumor limited to maxillary sinus mucosa with no erosion or destruction of bone
___ pT2: Tumor causing bone erosion or destruction including extension into the hard palate and/or middle nasal meatus, except extension to posterior wall of maxillary sinus and pterygoid plates
___ pT3: Tumor invades any of the following: bone of the posterior wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa, ethmoid sinuses
___ pT4a: Moderately advanced local disease. Tumor invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses
___ pT4b: Very advanced local disease. Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V₂), nasopharynx, or clivus
Primary Tumor (pT): Nasal Cavity and Ethmoid Sinus
___ pT1: Tumor restricted to any one subsite, with our without bone invasion
___ pT2: Tumor invading two subsites in a single region or extending to involve an adjacent region within the nasoethmoidal complex, with our without bone invasion
___ pT3: Tumor extends to invade the medial wall or floor of the orbit, maxillary sinus, palate, or cribriform plate
___ pT4a: Moderately advanced local disease Tumor invades any of the following: anterior orbital contents, skin of nose or cheek, minimal extension to anterior cranial fossa, pterygoid plates, sphenoid or frontal sinuses
___ pT4b: Very advanced local disease. Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V₂), nasopharynx, or clivus
Regional Lymph Nodes (pN)^#
___ 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
___ pN2: Metastasis in a single ipsilateral lymph node, more than 3cm but not more than 6 cm in greatest dimension, or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension, or in bilateral or contralateral nodes, none more than 6 cm 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 Positive Lymph Nodes
Specify: _____
___ Number cannot be determined (explain): _______________
	^* Size of the largest positive lymph node: ________
	^* Size of the associated metastatic focus: ________
	^* Position of the involved node (level): ________
^#Metastases at level VII are considered regional lymph node metastases. Midline nodes are considered ipsilateral nodes.
Distant Metastasis (pM)
___ Not applicable
___ pM1: Distant metastasis
	^* Specify site(s) if known: ____________________
	^* Source of pathologic metastatic specimen (specify): __________
For Mucosal Malignant Melanoma
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: ____________________
^* Source of pathologic metastatic specimen (specify): __________
*^ Additional Pathologic Findings (select all that apply)**
^*___ None identified
^___ Carcinoma in situ* (Note M)
^*___ Epithelial dysplasia (Note M)
	^* Specify: ____________________
^*___ Inflammation (specify type): ____________________
^*___ Squamous metaplasia
^*___ Epithelial hyperplasia
^*___ Colonization
	^*___ Fungal
	^*___ Bacterial
^*___ Other (specify): ____________________
*^ Ancillary Studies (Note N)**
^* Specify type(s): ____________________
^* Specify result(s): __________________
*^ Clinical History (select all that apply)**
^*___ Neoadjuvant therapy
	^*___ Yes (specify type): ____________________
	^*___ No
	^*___ Indeterminate
^*___ Other (specify): ____________________
^*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

TABLE 1.4 College of American Pathologists (CAP) Check Lists for Cancers of the Pharynx

Surgical Pathology Cancer Case Summary (Checklist)
Protocol web posting date: June 2012
Pharynx (Oropharynx, Hypopharynx, Nasopharynx): Incisional Biopsy, Excisional Biopsy, Resection
Select a single response unless otherwise indicated.
Specimen (select all that apply)
___ Oropharynx
___ Nasopharynx
___ Hypopharynx
___ Other (specify): ____________________
___ Not specified
Received
___ Fresh
___ In formalin
___ Other (specify): ____________________
Procedure (select all that apply)
___ Incisional biopsy
___ Excisional biopsy
___ Resection
	___ Tonsillectomy
	___ Laryngopharyngectomy
	___ Other (specify): ____________________
___ 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 (select all that apply)
___ Left
___ Right
___ Bilateral
___ Midline
___ Not specified
Tumor Site (select all that apply)
___ Oropharynx
	___ Palatine tonsil
	___ Base of tongue, including lingual tonsil
	___ Soft palate
	___ Uvula
	___ Pharyngeal wall (posterior)
	___ Other
___ Nasopharynx
	___ Nasopharyngeal tonsils (adenoids)
___ Hypopharynx
	___ Piriform sinus
	___ Postcricoid
	___ Pharyngeal wall (posterior and/or lateral)
	___ Other
___ Other (specify): ____________________
___ Not specified
Tumor Laterality (select all that apply)
___ Left
___ Right
___ Bilateral
___ Midline
___ Not specified
Tumor Focality
___ Single focus
___ Bilateral
___ Multifocal (specify): _______________
Tumor Size
Greatest dimension: ___ cm
^* Additional dimensions: ___ × ___ cm
___ Cannot be determined (see Comment)
^* 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)
Carcinomas of the Oropharynx and Hypopharynx
___ 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 carcinoma
___ Verrucous carcinoma
___ Lymphoepithelial carcinoma (nonnasopharyngeal)
Carcinomas of the Nasopharynx
___ Keratinizing squamous cell carcinoma (formerly WHO-1)
___ Nonkeratinizing carcinoma
	___ Differentiated carcinoma (formerly WHO-2; transitional carcinoma)
	___ Undifferentiated carcinoma (formerly WHO-3; lymphoepithelioma)
___ Basaloid squamous cell carcinoma
Adenocarcinomas (Non-Salivary Gland Type)
___ Nasopharyngeal papillary adenocarcinoma
___ Adenocarcinoma, not otherwise specified (NOS)
	___ Low grade
	___ Intermediate grade
	___ High grade
___ Other (specify): ____________________
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)
___ Carcinoma, type cannot be determined
___ 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): ____________________
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
___ Mucosal malignant melanoma
___ Other carcinoma (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 (select all that apply)
___ Cannot be assessed
___ Margins uninvolved by invasive carcinoma
	Distance from closest margin: ___ mm or ___ cm
		Specify margin(s), per orientation, if possible: __________
___ 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: ___ mm or ___ cm
		Specify margin(s), per orientation, if possible: __________
___ Margins involved by carcinoma in situ (includes moderate and severe dysplasia^#) (Note D)
	Specify margin(s), per orientation, if possible: __________
___ Not applicable
^#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
___ Not identified
___ Present
___ Indeterminate
Lymph Nodes, Extranodal Extension
___ Not identified
___ Present
___ Indeterminate
Pathologic Staging (pTNM)
Note: The phrases in italics include clinical findings required for AJCC staging. This clinical information may not be available to the pathologist. However, if known, these findings should be incorporated into the pathologic staging.
TNM Descriptors (required only if applicable) (select all that apply)
___ m (multiple primary tumors)
___ r (recurrent)
___ y (posttreatment)
Primary Tumor (pT)
___ pTX: Cannot be assessed
___ pT0: No evidence of primary tumor
___ pTis: Carcinoma in situ
For All Carcinomas Excluding Mucosal Malignant Melanoma
Primary Tumor (pT): Oropharynx
___ pT1: Tumor 2 cm or less in greatest dimension
___ pT2: Tumor more than 2 cm but not more than 4 cm in greatest dimension without fixation ofhemilarynx
___ pT3: Tumor more than 4 cm in greatest dimension or with fixation of hemilarynx or extension to lingual surface of epiglottis
___ pT4a: Moderately advanced local disease. Tumor invades larynx, deep/extrinsic muscle of tongue, medial pterygoid muscles, hard palate, or mandible^#
___ pT4b: Very advanced local disease. Tumor invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, or skull base, or encases carotid artery
^#Note: Mucosal extension to lingual surface of epiglottis from primary tumors of the base of the tongue and vallecula does not constitute invasion of larynx.
Primary Tumor (pT): Nasopharynx
___ pT1: Tumor confined to nasopharynx, or tumor extends to oropharynx and/or nasal cavity without parapharyngeal extension^#
___ pT2: Tumor with parapharyngeal extension^#
___ pT3: Tumor invades bony structures of skull base and/or paranasal sinuses
___ pT4: Tumor with intracranial extension and/or involvement of cranial nerves, hypopharynx, orbit, or with extension to the infratemporal fossa/masticator space
^#Parapharyngeal extension denotes posterolateral infiltration of tumor.
Primary Tumor (pT): Hypopharynx
___ pT1: Tumor limited to one subsite of hypopharynx and/or 2 cm or less in greatest dimension
___ pT2: Tumor invades more than one subsite of hypopharynx or an adjacent site, or measures more than 2 cm but not more than 4 cm in greatest dimension without fixation of hemilarynx
___ pT3: Tumor measures more than 4 cm in greatest dimension orwith fixation of hemilarynx or extension to esophagus
___ pT4a: Moderately advanced local disease. Tumor invades thyroid/cricoid cartilage, hyoid bone, thyroid gland, or central compartment soft tissue^#
___ pT4b: Very advanced local disease. Tumor invades prevertebral fascia, encases carotid artery, or involves mediastinal structures
^#Note: Central compartment soft tissue includes prelarnygeal strap muscles and subcutaneous fat.
Regional Lymph Nodes (pN)
___ pNX: Cannot be assessed
___ pN0: No regional lymph node metastasis
Regional Lymph Nodes (pN): Oropharynx and Hypopharynx^#
___ pN1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
___ pN2: Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension, or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension, or in bilateral or contralateral lymph nodes, none more than 6 cm 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: ___
___ Number cannot be determined (explain): _______________
	^* Size (greatest dimension) of the largest positive lymph node: ___
^#Note: Metastases at level VII are considered regional lymph node metastases. Midline nodes are considered ipsilateral nodes.
Regional Lymph Nodes (pN): Nasopharynx^#
___ pN1: Unilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the supraclavicular fossa^##
___ pN2: Bilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the supraclavicular fossa^##
___ pN3: Metastasis in a lymph node greater than 6 cm and/or to supraclavicular fossa^##
___ pN3a: Greater than 6 cm in dimension
___ pN3b: Extension to the supraclavicular fossa^##
___ No nodes submitted or found
Number of Lymph Nodes Examined
Specify: _____
___ Number cannot be determined (explain): _______________
Number of Lymph Nodes Involved
Specify: _____
___ Number cannot be determined (explain): _______________
	^* Size (greatest dimension) of the largest positive lymph node: _____
^#Metastases at level VII are considered regional lymph node metastases. Midline nodes are considered ipsilateral nodes.
^##Supraclavicular zone or fossa is relevant to the staging of nasopharyngeal carcinoma and is the triangular region defined by three points: (1) the superior margin of the sternal end of the clavicle, (2) the superior margin of the lateral end of the clavicle, (3) the point where the neck meets the shoulder (see Figure 1-3, no. 2). Note that this would include caudal portions of Levels IV and VB. All cases with lymph nodes (whole or part) in the fossa are considered N3b.
Distant Metastasis (pM)
___ Not applicable
___ pM1: Distant metastasis
	^* Specify site(s), if known: ____________________
^* Source of pathologic metastatic specimen (specify): __________
For Mucosal Malignant Melanoma
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: ____________________
	^* Source of pathologic metastatic specimen (specify): __________
^* Additional Pathologic Findings (select all that apply)
^*___ None identified
^*___ Keratinizing dysplasia
	^*___ Mild
	^*___ Moderate
	^___ Severe (carcinoma in situ*)
^*___ Nonkeratinizing dysplasia
	^*___ Mild
	^*___ Moderate
	^___ Severe (carcinoma in situ)*
^*___ Inflammation (specify type): ____________________
^*___ Squamous metaplasia
^*___ Epithelial hyperplasia
^*___ Colonization
	^*___ Fungal
	^*___ Bacterial
^*___ Other (specify): ____________________
Ancillary Studies (required only for oropharynx [p16, HPV] and nasopharynx [EBV] if available at time of report completion) (select all that apply) (Notes M and 0)
___ p16
	___ Positive
	___ Negative
___ Human papillomavirus (HPV), in situ hybridization (ISH)
	Type (specify): ____________________
	___ Positive
		Pattern
		___ Punctate
		___ Diffuse
		___ Mixed
	___ Negative
	___ Indeterminate (explain): _______________
___ HPV, polymerase chain reaction (PCR)
	Type (specify): _______________
	___ Positive
	___ Negative
___ Epstein-Barr virus (Epstein-Barr virus-encoded RNA [EBER], other)
	___ Positive
	___ Negative
___ Other (specify): ____________________
___ Not specified
*^ Clinical History (select all that apply)**
^*___ Neoadjuvant therapy
	^*___ Yes (specify type): ____________________
	^*___ No
	^*___ Indeterminate
^*___ Other (specify): ____________________
^*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.

TABLE 1.5 College of American Pathologists (CAP) Check Lists for Cancers of the Salivary Glands

Surgical Pathology Cancer Case Summary (Checklist)
Protocol web posting date: June 2012
Major Salivary Glands: Incisional Biopsy, Excisional Biopsy, Resection
Select a single response unless otherwise indicated.
Specimen (select all that apply)
___ Parotid gland
	___ Superficial lobe only
	___ Deep lobe only
	___ Total parotid gland
___ Submandibular gland
___ Sublingual gland
___ Other (specify): ____________________
___ Not specified
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 (see Comment)
^* 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)
	___ Low grade
	___ High grade
	___ Invasive
		___ Minimally invasive
		___ Invasive
	___ Intracapsular (noninvasive)
___ 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 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 (Notes D and E)
___ 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)
Note: The phrases in italics include clinical findings required for AJCC staging. This clinical information may not be available to the pathologist. However, if known, these findings should be incorporated into the pathologic staging.
TNM Descriptors (required only if applicable) (select all that apply)
___ m (multiple primary tumors)
___ r (recurrent)
___ y (posttreatment)
Primary Tumor (pT)
___ pTX: Cannot be assessed
___ pT0: No evidence of primary tumor
___ pT1: Tumor 2 cm or less in greatest dimension without extraparenchymal extension
___ pT2: Tumor more than 2 cm but not more than 4 cm in greatest dimension without extraparenchymal extension (Note I)
___ pT3: Tumor more than 4 cm and/or tumor having extraparenchymal extension
___ pT4a: Moderately advanced disease. Tumor invades skin, mandible, ear canal, and/or facial nerve.
___ pT4b: Very advanced local disease. Tumor invades skull base and/or pterygoid plates and/or encases carotid artery
Note: There is no category of carcinoma in situ (pTis) relative to carcinomas of salivary glands (major, minor).
Regional Lymph Nodes (pN)^#
___ 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: _____
___ Number cannot be determined (explain): _______________
^* 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: ____________________
*^ 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 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.

TABLE 1.6 College of American Pathologists (CAP) Check Lists for Cancers of the Thyroid Gland

Surgical Pathology Cancer Case Summary (Checklist)
Protocol web posting date: June 2012
Thyroid Gland: Resection
Select a single response unless otherwise indicated.
Procedure (select all that apply)
___ Thyroid lobectomy
	___ Right
	___ Left
___ Partial thyroidectomy (anything less than a lobectomy)
	___ Right
	___ Left
___ Hemithyroidectomy (lobe and part or all of isthmus)
	___ Right
	___ Left
___ Total thyroidectomy
___ Total thyroidectomy with central compartment dissection
___ Total thyroidectomy with right neck dissection
___ Total thyroidectomy with left neck dissection
___ Total thyroidectomy with bilateral neck dissection
___ Other (specify): ____________________
___ Not specified
^* Received
^*___ Fresh
^*___ In formalin
^*___ Other
Specimen Integrity
___ Intact
___ Fragmented
Specimen Size
Right lobe: ___ × ___ × ___ cm
Left lobe: ___ × ___ × ___ cm
Isthmus ± pyramidal lobe: ___ × ___ × ___ cm
Central compartment: ___ × ___ × ___ cm
Right neck dissection: ___ × ___ × ___ cm
Left neck dissection: ___ × ___ × ___ cm
^* Additional dimensions (specify): ___ × ___ × ___ cm
*^ Specimen Weight**
^* Specify: _____ g
Tumor Focality (select all that apply)
___ Unifocal
___ Multifocal (specify):
	___ Ipsilateral
	___ Bilateral
	___ Midline (isthmus)
Dominant Tumor
Tumor Laterality (select all that apply)
___ Right lobe
___ Left lobe
___ Isthmus
___ Not specified
Tumor Size
Greatest dimension: ___ cm
^* Additional dimensions: ___ × ___ cm
___ Cannot be determined
Histologic Type (select all that apply)
___ Papillary carcinoma
	Variant, specify
	___ Classical (usual)
	___ Clear cell variant
	___ Columnar cell variant
	___ Cribriform-morular variant
	___ Diffuse sclerosing variant
	___ Follicular variant
	___ Macrofollicular variant
	___ Microcarcinoma (occult, latent, small, papillary microtumor)
	___ Oncocytic or oxyphilic variant
	___ Solid variant
	___ Tall cell variant
	___ Warthin-like variant
	___ Other, specify: _______________
	Architecture
	___ Classical (papillary)
	___ Cribriform-morular
	___ Diffuse sclerosing
	___ Follicular
	___ Macrofollicular
	___ Solid
	___ Other, specify: _______________
	Cytomorphology
___ Classical
___ Clear cell
	___ Columnar cell
	___ Oncocytic or oxyphilic
	___ Tall cell
___ Follicular carcinoma
	Variant, specify
___ Clear cell
	___ Oncocytic (Hürthle cell)
	___ Other, specify: ____________________
___ Poorly differentiated thyroid carcinomas, including insular carcinoma
___ Medullary carcinoma
___ Undifferentiated (anaplastic) carcinoma
___ Other (specify): ____________________
___ Carcinoma, type cannot be determined
^* Histologic Grade
^*___ Not applicable
^*___ GX: Cannot be assessed
^*___ G1: Well differentiated
^*___ G2: Moderately differentiated
^*___ G3: Poorly differentiated
^*___ G4: Undifferentiated
^*___ Other (specify): ____________________
Margins
___ Cannot be assessed
___ Margins uninvolved by carcinoma
	^* Distance of invasive carcinoma to closest margin: ___ mm
___ Margin(s) involved by carcinoma
^* Site(s) of involvement: ____________________
Tumor Capsule
___ Cannot be assessed
___ Totally encapsulated
___ Partially encapsulated
___ None
Tumor Capsular Invasion (select all that apply)
___ Cannot be assessed
___ Not identified
___ Present
	Extent
	___ Minimal
	___ Widely invasive
___ Indeterminate
Lymph-Vascular Invasion (select all that apply)
___ Cannot be assessed
___ Not identified
___ Present
	Extent
	___ Focal (<4 vessels)
	___ Extensive (4 or more vessels)
___ Indeterminate
^* Perineural Invasion
^*___ Not identified
^*___ Present
^*___ Indeterminate
Extrathyroidal Extension (select all that apply)
___ Cannot be assessed
___ Not identified
___ Present
	Extent
	___ Minimal
	___ Extensive
Second Tumor (for multifocal tumors only)
Tumor Laterality (select all that apply)
___ Right lobe
___ Left lobe
___ Isthmus
___ Not specified
Tumor Size
Greatest dimension: ___ cm
^* Additional dimensions: ___ × ___ cm
___ Cannot be determined
Histologic Type (select all that apply)
___ Papillary carcinoma
	Variant, specify
		___ Classical (usual)
		___ Clear cell variant
		___ Columnar cell variant
		___ Cribriform-morular variant
		___ Diffuse sclerosing variant
		___ Follicular variant
		___ Macrofollicular variant
		___ Microcarcinoma (occult, latent, small, papillary microtumor)
		___ Oncocytic or oxyphilic variant
		___ Solid variant
		___ Tall cell variant
		___ Warthin-like variant
		___ Other, specify: _______________
	Architecture
		___ Classical (papillary)
		___ Cribriform-morular
		___ Diffuse sclerosing
		___ Follicular
		___ Macrofollicular
		___ Solid
		___ Other, specify: _______________
	Cytomorphology
___ Classical
___ Clear cell
	___ Columnar cell
	___ Oncocytic or oxyphilic
	___ Tall cell
___ Follicular carcinoma
	Variant, specify
___ Clear cell
	___ Oncocytic (Hürthle cell)
	___ Other, specify: _______________
___ Poorly differentiated thyroid carcinomas, including insular carcinoma
___ Medullary carcinoma
___ Undifferentiated (anaplastic) carcinoma
___ Other (specify): ____________________
___ Carcinoma, type cannot be determined
^* Histologic Grade
^*___ Not applicable
^*___ GX: Cannot be assessed
^*___ G1: Well differentiated
^*___ G2: Moderately differentiated
^*___ G3: Poorly differentiated
^*___ G4: Undifferentiated
^*___ Other (specify): ____________________
Margins
___ Cannot be assessed
___ Margins uninvolved by carcinoma
	^* Distance of invasive carcinoma to closest margin: ___ mm
___ Margin(s) involved by carcinoma
^* Site(s) of involvement: ____________________
Tumor Capsule
___ Cannot be assessed
___ Totally encapsulated
___ Partially encapsulated
___ None
Tumor Capsular Invasion (select all that apply)
___ Cannot be assessed
___ Not identified
___ Present
	Extent
	___ Minimal
	___ Widely invasive
___ Indeterminate
Lymph-Vascular Invasion (select all that apply)
___ Cannot be assessed
___ Not identified
___ Present
	Extent
	___ Focal (< 4 vessels)
	___ Extensive (4 or more vessels)
___ Indeterminate
^* Perineural Invasion
^*___ Not identified
^*___ Present
^*___ Indeterminate
Extrathyroidal Extension (select all that apply)
___ Cannot be assessed
___ Not identified
___ Present
	Extent
	___ Minimal
	___ Extensive
Pathologic Staging (pTNM)
TNM Descriptors (required only if applicable) (select all that apply)
___ m (multiple primary tumors)
___ r (recurrent)
___ y (posttreatment)
Primary Tumor (pT)
___ pTX: Cannot be assessed
___ pT0: No evidence of primary tumor
___ pT1: Tumor size 2 cm or less, limited to thyroid
___ pT1a: Tumor 1 cm or less in greatest dimension limited to the thyroid
___ pT1b: Tumor more than 1 cm but not more than 2 cm in greatest dimension, limited to the thyroid
___ pT2: Tumor more than 2 cm, but not more than 4 cm, limited to thyroid
___ pT3: Tumor more than 4 cm limited to thyroid or any tumor with minimal extrathyroid extension (e.g., extension to sternothyroid muscle or perithyroid soft tissues)
___ pT4a: Moderately advanced disease. Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus or recurrent laryngeal nerve
___ pT4b: Very advanced disease. Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels
Note: There is no category of carcinoma in situ (pTis) relative to carcinomas of thyroid gland.
Anaplastic Carcinoma
___ pT4a: Intrathyroidal anaplastic carcinoma
___ pT4b: Anaplastic carcinoma with gross extrathyroid extension
Regional Lymph Nodes (pN)^#
___ pNX: Regional lymph nodes cannot be assessed
___ pN0: No regional lymph node metastasis
___ pN1a: Metastasis to Level VI (pretracheal, paratracheal and prelaryngeal/Delphian) lymph nodes
___ pN1b: Metastasis to unilateral, bilateral or contralateral cervical (Levels I, II, III, IV, V) or retropharyngeal or superior mediastinal lymph nodes (Level VII)
Specify: Number examined: ___
	Number involved: ___
^#Superior mediastinal lymph nodes are considered regional lymph nodes (level VII).
Midline nodes are considered ipsilateral nodes.
^* Lymph Node, Extranodal Extension
^*___ Not identified
^*___ Present
^*___ Indeterminate
Distant Metastasis (pM)
___ Not applicable
___ pM1: Distant metastasis
	^* Specify site(s), if known: ____________________
	^* Source of pathologic metastatic specimen (specify): _______________
*^ Additional Pathologic Findings (select all that apply)**
^*___ Adenoma
^*___ Adenomatoid nodule(s) or Nodular follicular disease (eg, nodular hyperplasia, goitrous thyroid)
^*___ Diffuse hyperplasia (Graves’ disease)
^*___ Thyroiditis
	^*___ Advanced
	^*___ Focal (nonspecific)
	^*___ Palpation
	^*___ Other (specify): ____________________
^*___ Parathyroid gland(s)
	^*___ Within normal limits
	^*___ Hypercellular
	^*___ Other (specify): ____________________
^*___ C-cell hyperplasia
^*___ None identified
^*___ Other (specify): ____________________
*^ Ancillary Studies (Note 0)**
^* Specify type (e.g., histochemistry, immunohistochemistry, DNA analysis): ____________________
^* Specify results: ____________________
*^ Clinical History (select all that apply)**
^*___ Radiation exposure
	^*___ Yes (specify type): ____________________
	^*___ No
	^*___ Indeterminate
^*___ Family history
^*___ Other (specify): ____________________
^*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.