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Protocol revision date: January 2005 Based on AJCC/UICC TNM, 6th edition Procedures • Biopsy (No Accompanying Checklist) • Excision • Re-excision Authors Carolyn Compton, MD, PhD Department of Pathology, McGill University, Montreal, Quebec, Canada Raymond Barnhill, MD Department of Pathology, George Washington University Medical Center, Washington, DC Mark R. Wick, MD Department of Pathology, University of Virginia Health System, Charlottesville, Virginia Charles Balch, MD American Society of Clinical Oncology, Alexandria, Virginia For the Members of the Cancer Committee, College of American Pathologists © 2005. College of American Pathologists. 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 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 (Checklist)” 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 checklist 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 the document. 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. Summary of Changes to Checklist(s) Protocol revision date: January 2005 No changes have been made to the data elements of the checklist(s) since the January 2004 protocol revision. Surgical Pathology Cancer Case Summary Protocol revision date: January 2005 Applies to invasive melanoma only Based on AJCC/UICC TNM, 6th edition MELANOMA OF THE SKIN: Excision, Re-Excision Patient name: Surgical pathology number: Note: Check 1 response unless otherwise indicated. MACROSCOPIC Specimen Type ___ Excision, ellipse ___ Excision, wide ___ Excision, other (specify): ____________________________ ___ Re-excision, ellipse ___ Re-excision, wide ___ Re-excision, other (specify): ____________________________ ___ Lymphadenectomy, sentinel node(s) ___ Lymphadenectomy, regional nodes (specify): ____________________________ ___ Other (specify): ____________________________ ___ Not specified Macroscopic Tumor ___ Present ___ Absent ___ Indeterminate Tumor Site Specify (if known): ____________________________ ___ Not specified Lesion Size Greatest dimension: ___ cm *Additional dimensions: ___ x ___ cm ___ Cannot be determined (see Comment) Satellite Nodule(s) ___ Absent ___ Present (specify): ____________________________ ___ Cannot be determined *Pigmentation *___ Absent *___ Present, diffuse *___ Present, patchy/focal *___ Indeterminate *___ Cannot be determined MICROSCOPIC Histologic Type ___ Superficial spreading melanoma ___ Lentigo maligna melanoma ___ Nodular melanoma ___ Acral lentiginous melanoma ___ Mucosal-lentiginous melanoma ___ Desmoplastic (spindle desmoplastic; neuroid) melanoma ___ Neurotropic melanoma ___ Malignant blue nevus ___ Melanoma in congenital melanocytic nevi ___ Minimal deviation (nevoid) melanoma ___ Other (specify): ____________________________ ___ Melanoma, type cannot be determined Ulceration ___ Present ___ Absent Depth of Invasion Specify: ___ mm ___ Cannot be determined (see Comment) Pathologic Staging (pTNM) Primary Tumor (pT) ___ pTX: Primary tumor cannot be assessed (see Comment) ___ pT0: No evidence of primary tumor ___ pTis: Melanoma in situ (ie, not an invasive tumor: level I) pT1: Melanoma 1.0 mm or less in thickness, with or without ulceration ___ pT1a: Melanoma 1.0 mm or less in thickness and level II or III, no ulceration ___ pT1b: Melanoma 1.0 mm or less in thickness and level IV or V or with ulceration pT2: Melanoma 1.01 to 2mm in thickness, with or without ulceration ___ pT2a: Melanoma 1.01 to 2.0 mm in thickness, no ulceration ___ pT2b: Melanoma 1.01 to 2.0 mm in thickness, with ulceration pT3: Melanoma 2.01 to 4.0 mm in thickness, with or without ulceration ___ pT3a: Melanoma 2.01 to 4.0 mm in thickness, no ulceration ___ pT3b: Melanoma 2.01 to 4.0 mm in thickness, with ulceration pT4: Melanoma greater than 4.0 mm in thickness, with or without ulceration ___ pT4a Melanoma greater than 4.0 mm in thickness, no ulceration ___ pT4b Melanoma greater than 4.0 mm in thickness, with ulceration Regional Lymph Nodes (pN) ___ pNX: Regional lymph nodes cannot be assessed ___ pN0: No regional lymph node metastasis pN1: Metastasis in 1 regional lymph node ___ pN1a: Clinically occult (microscopic) metastasis ___ pN1b: Clinically apparent (macroscopic) metastasis pN2: Metastasis in 2 to 3 regional nodes or intra-lymphatic regional metastasis without nodal metastasis ___ pN2a: Clinically occult (microscopic) metastasis ___ pN2b: Clinically apparent (macroscopic) metastasis ___ pN2c: Satellite or in-transit metastasis without nodal metastasis ___ pN3: Metastasis in 4 or more regional lymph nodes, or matted metastatic nodes, or in-transit metastasis or satellites(s) with metastasis in regional node(s) Number identified: ____ Number containing metastases identified macroscopically: ____ Number containing metastases identified microscopically: ____ Matted nodes: ___ Present ___ Absent Distant Metastasis (pM) ___ pMX: Presence of distant metastasis cannot be assessed ___ pM1: Distant metastasis (documented in this specimen) *___ pM1a: Metastasis in skin, subcutaneous tissues, or distant lymph nodes *___ pM1b: Metastasis to lung *___ pM1c: Metastasis to all other visceral sites or distant metastasis at any site associated with an elevated serum lactic dehydrogenase (LDH) *(Other site, specify: ____________________________) Margins (check all that apply) Lateral Margins ___ Cannot be assessed ___ Uninvolved by invasive melanoma Distance of invasive melanoma from closest lateral margin: ___ mm Specify location(s), if possible: ____________________________ ___ Involved by invasive melanoma Specify location(s), if possible: ____________________________ ___ Uninvolved by melanoma in situ Distance of melanoma in situ from closest margin: ___ mm Specify location(s), if possible: ____________________________ ___ Involved by melanoma in situ Specify location(s), if possible: ____________________________ Deep Margin ___ Cannot be assessed ___ Uninvolved by invasive melanoma Distance of invasive melanoma from margin: ___ mm Specify location(s), if possible: ____________________________ ___ Involved by invasive melanoma Specify location(s), if possible: ____________________________ *Venous (Large Vessel) Invasion (V) *___ Absent *___ Present *___ Indeterminate *Perineural Invasion *___ Absent *___ Present *___ Indeterminate *Tumor-Infiltrating Lymphocytes *___ Absent *___ Nonbrisk *___ Brisk *Tumor Regression *___ Absent *___ Present involving less than 75% *___ Present involving 75% or more of lesion *Mitotic Index *___ Less than 1 mitotic figure per mm2 *___ 1 or more mitotic figure per mm2 *Additional Pathologic Findings (check all that apply) *___ Nevus remnant *___ Actinic keratosis *___ Other (specify): ____________________________ *Comment(s) Melanoma of the Skin • Skin CAP Approved CAP Approved Skin • Melanoma of the Skin PAGE 2 PAGE 3 PAGE 8 * Data elements with asterisks are not required for accreditation purposes for the Commission on Cancer. These elements may be clinically important, but are not yet validated or regularly used in patient management. Alternatively, the necessary data may not be available to the pathologist at the time of pathologic assessment of this specimen. PAGE 7 * Data elements with asterisks are not required for accreditation purposes for the Commission on Cancer. These elements may be clinically important, but are not yet validated or regularly used in patient management. Alternatively, the necessary data may not be available to the pathologist at the time of pathologic assessment of this specimen. 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