LIP_AND_ORAL_CAVTY
Description:
Stores single response data for College of American Pathologists (CAP) form 76029-LIP AND ORAL CAVITY: INCISIONAL BIOPSY, EXCISIONAL BIOPSY, RESECTION.

Primary Key
Column Name Ordinal Position
RESULT_ID 1

Column Information
Name Type Discontinued?
1 RESULT_ID VARCHAR No
The unique identifier for the result record.
2 NEOADJUVANT_THRPY_C_NAME VARCHAR No
CAP synoptic form item: Neoadjuvant Therapy.
May contain organization-specific values: Yes
Category Entries:
Yes
No
Indeterminate
3 NEOADJ_THRPY_TYPE VARCHAR No
CAP synoptic form item: Neoadjuvant Therapy Type.
4 TUMOR_SITE_SPECIFY VARCHAR No
CAP synoptic form item: Specify tumor site.
5 SPEC_RECEIVED_C_NAME VARCHAR No
CAP synoptic form item: Specimen Received.
May contain organization-specific values: Yes
Category Entries:
Fresh
In formalin
Other
6 SPEC_RECV_SPECIFY VARCHAR No
CAP synoptic form item: Specify Other Specimens Received.
7 CAP_COMMENTS VARCHAR No
CAP synoptic form item: General comments.
8 SPEC_INTEGRITY_C_NAME VARCHAR No
CAP synoptic form item: Specimen Integrity.
May contain organization-specific values: Yes
Category Entries:
Intact
Fragmented
Single intact specimen (margins can be evaluated)
Multiple designated specimens (e.g., main excision and identified margins)
Fragmented (margins cannot be evaluated with certainty)
Morcellated hysterectomy specimen
Intact hysterectomy specimen
Disrupted
Indeterminate
Other
Not specified
9 SIZE_LARGST_POS_LYM NUMERIC No
CAP synoptic form item: Size (greatest dimension, in cm) of the Largest Positive Lymph Node.
10 SPEC_PROC_SPECIFY VARCHAR No
CAP synoptic form item: Specify the Specimen Procedure.
11 SPEC_SIZE_GREATEST NUMERIC No
CAP synoptic form item: Specimen Greatest Size.
12 SPEC_SIZE_ADDL NUMERIC No
CAP synoptic form item: Specimen size additional dimension (length).
13 SPEC_SIZE_ADDL2 NUMERIC No
CAP synoptic form item: Specimen size additional dimension (width).
14 SPEC_ADDL_GREATEST NUMERIC No
CAP synoptic form item: Additional specimen greatest size.
15 SPEC_ADDL_LENGTH NUMERIC No
CAP synoptic form item: Additional specimen size additional dimension (length).
16 SPEC_ADDL_WIDTH NUMERIC No
CAP synoptic form item: Additional specimen size additional dimension (width).
17 TUMOR_SIZE_GREAT NUMERIC No
CAP synoptic form item: Tumor Greatest Size.
18 TUMOR_SIZE_ADDL NUMERIC No
CAP synoptic form item: Tumor Size (length).
19 TUMOR_SIZE_ADDL2 NUMERIC No
CAP synoptic form item: Tumor Size (width).
20 TUMOR_SIZE_SPECIFY VARCHAR No
CAP synoptic form item: Specify Tumor Size.
21 MICRO_TMR_EXT_SPFY VARCHAR No
CAP synoptic form item: Specify Microscopic Tumor Extension.
22 MRG_CANNOT_ASSES_YN VARCHAR No
CAP synoptic form item: Margins Cannot Be Assessed.
May contain organization-specific values: No
Category Entries:
No
Yes
23 MARGIN_UNITS_C_NAME VARCHAR No
CAP synoptic form item: Margin Units.
May contain organization-specific values: Yes
Category Entries:
mm
cm
24 TREATMENT_EFFECT_C_NAME VARCHAR No
CAP synoptic form item: Treatment Effect.
May contain organization-specific values: Yes
Category Entries:
Not identified
No prior treatment
Not applicable
Present
No definite response identified (grade 3, poor/no response; extensive residual tumor)
No definite response identified (grade 3, poor or no response)
Greater than 10% residual viable tumor
Less than 10% residual viable tumor
Greater than 50% residual viable tumor
Less than 50% residual viable tumor
No definite or minimal response identified (poor or no response)
Marked response (minimal residual cancer)
No known presurgical therapy
No definite response to presurgical therapy
Probable or definite response to presurgical therapy
Cannot be determined
Indeterminate
Not known
25 TREAT_EFF_SPECIFY VARCHAR No
CAP synoptic form item: Specify treatment effect.
26 TUMOR_DESC_SPECIFY VARCHAR No
CAP synoptic form item: Specify tumor description.
27 PERINEURAL_INVASN_C_NAME VARCHAR No
CAP synoptic form item: Perineural Invasion.
May contain organization-specific values: Yes
Category Entries:
Cannot be assessed
Not identified
Absent
Present
Indeterminate
Portal vein invasion present
Hepatic vein invasion present
Present within tumor nodules
Present in vessels of parenchyma outside of tumor nodules
Cannot be determined
28 LYM_ND_EXNDL_EXT_C_NAME VARCHAR No
CAP synoptic form item: Lymph Nodes, Extranodal Extension.
The category values for this column were already listed for column: PERINEURAL_INVASN_C_NAME
29 SPECIMEN_OTHER_SPFY VARCHAR No
CAP synoptic form item: Specify other specimen.
30 REGIONL_LYMPH_ND_C_NAME VARCHAR No
CAP synoptic form item: Regional Lymph Nodes (pN).
May contain organization-specific values: Yes
Category Entries:
pNX: Cannot be assessed
pN0: No regional lymph node metastasis
pN1: Regional lymph node metastasis
pN1: Metastasis in perirectal lymph nodes
pN1: Metastasis in 1 to 3 regional lymph nodes
pN1a: Metastasis in 1 regional lymph node
pN1b: Metastasis in 2 to 3 regional lymph nodes
pN1c: Tumor deposit(s) in the subserosa, or non-peritonealized pericolic or perirecta
pN1 (IIIC1): Regional lymph node metastasis to pelvic lymph nodes
pN1: Regional lymph node metastasis involving 1 to 2 nodes
pN1 (IIIC): Regional lymph node metastasis
pN1: Metastases to nodes along the cystic duct, common bile duct, hepatic artery
pN1: Metastasis in single ipsilateral lymph node, 3 cm or less in greatest dimension
pN1: Metastasis in ipsilateral peribronchial and / or ipsilateral hilar lymph nodes,
pN1: Metastases in the ipsilateral bronchopulmonary or hilar lymph nodes
pN1a: Clinically occult (microscopic) metastasis
pN1b: Clinically apparent (macroscopic) metastasis
pN1: Unilateral metastasis in lymph node(s), 6 cm or less in greatest dimension
pN1: Metastasis in a single regional lymph node, 2 cm or less in greatest dimension
pN1: Metastasis in 1 to 2 perigastric lymph nodes
pN1: Metastasis with a lymph node mass less than 2 cm in greatest dimension,
pN1a: Nodal metastases to Level VI lymph nodes
pN1b: Metastases to unilateral, bilateral or contralateral cervical
pN1: Single regional lymph node metastasis in the true pelvis
pN1 (IVB): Pelvic or inguinal lymph node metastasis
pN1: Metastasis in regional lymph node or nodes
pN1: Regional lymph node involvement (preauricular, cervical, submandibular)
pN2: Metastasis in unilateral internal iliac and / or inguinal lymph node(s)
pN2: Metastasis in 4 or more regional lymph nodes
pN2: Metastasis to periaortic/pericaval/super. mesentery artery/celiac artery lym nd
pN2a: Metastasis in 4 to 6 regional lymph nodes
pN2b: Metastasis in 7 or more regional lymph nodes
pN2 (IIIC2): Regional lymph node metastasis to para-aortic lymph nodes, with or witho
pN2: 3 to 6 nodes involved
pN2: Metastases to periaortic,pericaval,super. mesenteric artery, celiac artery lym n
pN2: Metastasis in a single ipsilateral lymph node, more than 3 cm
pN2a: Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than
pN2b: Metastasis in a single ipsilateral lymph nodes, none >6cm in greatest dimension
pN2b: Metastasis in multiple ipsilateral lymph nodes, none >6cm in greatest dimension
pN2c: Metastasis in bilateral/contralateral lymph nodes, none >6cm in greatest dimen.
pN2: Metastasis in ipsilateral mediastinal and / or subcarinal lymph node(s)
pN2: Metastases in the subcarinal or the ipsilateral mediastinal lymph nodes
pN2a: Clinically occult (microscopic) metastasis
pN2b: Clinically apparent (macroscopic) metastasis
pN2c: Satellite or in-transit metastasis without nodal metastasis
pN2: Bilateral metastasis in lymph node(s), 6 cm or less in greatest dimension
pN2: Metastasis in a single regional lymph node, more than 2 cm but not more than
pN2: Metastasis in 3 to 6 perigastric lymph nodes
pN2: Metastasis with a lymph node mass greater than 2 cm but not more than 5 cm
pN2: Multiple regional lymph node metastasis in the true pelvis
pN2: Distant lymph node involvement
pN3: Metastasis in perirectal and inguinal lymph nodes and / or bilateral internal il
pN3: 7 or more nodes involved
pN3: Metastasis in a lymph node more than 6 cm in greatest dimension
pN3: Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or
pN3: Metastases in the contralateral mediastinal, contralateral internal mammary,
pN3: Metastasis in 4 or more regional lymph nodes, or matted metastatic nodes, or
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
pN3: Metastasis in a regional lymph node more than 5 cm in greatest dimension
pN3: Metastasis in 7 or more perigastric lymph nodes
pN3a: Metastasis in 7 to 15 perigastric lymph nodes
pN3b: Metastasis in 16 or more perigastric lymph nodes
pN3: Metastasis with a lymph node mass greater than 5 cm in greatest dimension
pN3: Lymph node metastasis to the common iliac lymph nodes
pN1: One or two regional lymph nodes with the following features
pN2 (FIGO IIIB): Regional lymph node metastasis with the following features
pN3 (FIGO IVA): Fixed or ulcerated regional lymph node metastasis
31 REG_LN_NUM_EXM NUMERIC No
CAP synoptic form item: Regional Lymph Nodes Number Examined.
32 REG_LN_NUM_INV NUMERIC No
CAP synoptic form item: Regional Lymph Nodes Number Involved.
33 SRC_PATH_METAS_SPEC VARCHAR No
CAP synoptic form item: Source of Pathologic Metastatic Specimen Specify.
34 DISTNT_METASTASIS_C_NAME VARCHAR No
CAP synoptic form item: Distant Metastasis.
May contain organization-specific values: Yes
Category Entries:
Not applicable
cM0 (i+): No clinical or radiographic evidence of distant metastasis
pM0: No distant metastasis
pM1: Distant metastasis
pM1a: Intraperitoneal metastasis beyond the right lower quadrant, including pseudomyx
pM1b: Nonperitoneal metastasis
pM1: Distant detectable metastasis as determined by classic clinical
pM1 (IVB): Distant metastasis
pM1a: Separate tumor nodule(s) in contralateral lung; tumor with pleural nodules or
pM1b: Distant metastases outside the lung / pleura
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
pM1a: Nonregional lymph node(s)
pM1b: Bone(s)
pM1c: Other site(s) with or without bone disease
pM1: Metastasis to sites other than CNS
pM1a: Single lesion
pM1b: Multiple lesions
pM1c: CNS metastasis
pM1d: Discrete mass(es) without leptomeningeal and / or CSF involvement
pM1e: Leptomeningeal and / or CSF involvement
pM1a: Non-regional lymph nodes or pulmonary metastasis
pM1b: Distant metastasis other than to nonregional lymph nodes and lungs
pM1a (III): Tumor extends to the lungs with or without genital tract involvement
pM1b (IV): Tumor involves other metastatic sites
pM1a: Largest diameter of the largest metastasis 3 cm or less
pM1b: Largest diameter of the largest metastasis 3.1-8.0 cm
pM1c: Largest diameter of the largest metastasis 8 cm or more
pM1a: Lung
pM1b: Metastasis involving distant sites other than lung (including skip metastases)
Distant Metastasis present (includes metastasis to lymph nodes)
35 DSTNT_METASTATIS_ST VARCHAR No
CAP synoptic form item: Distant Metastasis Sites.
36 ADDL_PATH_FIND_SPFY VARCHAR No
CAP synoptic form item: Specify additional pathologic findings.
37 CLINICAL_HIST_SPFY VARCHAR No
CAP synoptic form item: Specify clinical history.
38 HISTOLOGIC_GRADE_C_NAME VARCHAR No
CAP synoptic form item: Histologic Grade.
May contain organization-specific values: Yes
Category Entries:
Not applicable
GX: Cannot be assessed
G1: Well differentiated
G2: Moderately differentiated
G3: Poorly differentiated
G4: Undifferentiated
G4: Undifferentiated / anaplastic
WHO grade not assigned
Low-grade (well-differentiated to moderately differentiated)
High-grade (poorly differentiated to undifferentiated)
FIGO Grade 1
FIGO Grade 2
FIGO Grade 3
Favorable (purely epithelial, fetal subtype, mitotically inactive with <=2 mitoses in
Less favorable (all subtypes other than those designated "Favorable" or "Unfavorable"
Unfavorable (small cell undifferentiated or rhabdoid as the predominant or sole histo
Gleason Pattern
Ungraded sarcoma
pGX: Grade cannot be assessed
pG1: Spindle cell melanoma
pG2: Mixed cell melanoma
pG3: Epithelioid cell melanoma
WHO Grade I
WHO Grade II
WHO Grade III
WHO Grade IV
pG1: Well differentiated
pG2: Moderately differentiated
pG3: Poorly differentiated
pG4: Undifferentiated
FNCLCC Grade 1
FNCLCC Grade 2
FNCLCC Grade 3
Grade 1
Grade 2
Grade 3
Cannot be determined
Other
39 HISTOLGC_GRADE_SPFY VARCHAR No
CAP synoptic form item: Specify histologic grade.
40 MRG_INV_CARCINOMA_C_NAME VARCHAR No
CAP synoptic form item: Margin Invasive Carcinoma.
May contain organization-specific values: Yes
Category Entries:
Cannot be assessed
Benign glands at surgical margin
No tumor at margins
Tumor present at surgical margin of optic nerve
Extrascleral extension (for enucleation specimens)
No melanoma at margins
Margins uninvolved by tumor
Margins involved by tumor
Margins negative for tumor
Margin involvement by tumor not identified
Margins uninvolved by invasive carcinoma
Margins involved by invasive carcinoma
Margins uninvolved by carcinoma
Margins involved by carcinoma
Margins uninvolved by sarcoma
Margins involved by sarcoma
Margins positive for sarcoma
Sarcoma involvement of margins not identified
Margins negative for sarcoma
Margins uninvolved by DCIS (DCIS present)
Margins positive for DCIS
Margins negative for mesothelioma
Margins involved by mesothelioma
Margins uninvolved by malignant tumor
Margins involved by malignant tumor
Margins uninvolved by carcinoma in situ
Margins involved by carcinoma in situ
Indeterminate
Cannot be determined
Other Margins Involved
Not applicable
41 MARGIN_UNITS_2_C_NAME VARCHAR No
CAP synoptic form item: Margin Units (second measurement).
The category values for this column were already listed for column: MARGIN_UNITS_C_NAME
42 MACRO_EXTENT_SPFY VARCHAR No
CAP synoptic form item: Specify Macroscopic Extent.
43 NECK_DISSECTN_SPFY VARCHAR No
CAP synoptic form item: Specify Neck (Lymph Node) Dissection.
44 MUCOEPIDRMD_CARC_C_NAME VARCHAR No
CAP synoptic form item: Mucoepidermoid carcinoma.
May contain organization-specific values: Yes
Category Entries:
Low grade
Intermediate grade
High grade
45 PATHOLOGIC_STAGE_C_NAME VARCHAR No
CAP synoptic form item: Pathologic Staging.
May contain organization-specific values: Yes
Category Entries:
For All Carcinomas Excluding Mucosal Malignant Melanoma
For Mucosal Malignant Melanoma
46 KERAT_DYSPLS_C_NAME VARCHAR No
CAP synoptic form item: Keratinizing dysplasia.
May contain organization-specific values: Yes
Category Entries:
Mild
Moderate
Severe (carcinoma in situ)
47 NON_KERAT_DYSPLS_C_NAME VARCHAR No
CAP synoptic form item: Non-keratinizing dysplasia.
The category values for this column were already listed for column: KERAT_DYSPLS_C_NAME
48 PROC_GLOSSECTOMY VARCHAR No
CAP synoptic form item: Procedure - Specify Glossectomy.
49 PROC_MANDIBULECTOMY VARCHAR No
CAP synoptic form item: Procedure - Specify Mandibulectomy.
50 PROC_MAXILLECTOMY VARCHAR No
CAP synoptic form item: Procedure - Specify Maxillectomy.
51 CARC_EX_PLEOM_C_NAME VARCHAR No
CAP synoptic form item: Carcinoma ex pleomorphic adenoma (malignant mixed tumor).
May contain organization-specific values: Yes
Category Entries:
Low-grade
High-grade
Invasive
Intracapsular (noninvasive)
52 EX_PLEOM_INVASIVE_C_NAME VARCHAR No
CAP synoptic form item: Carcinoma ex pleomorphic adenoma Invasive.
May contain organization-specific values: Yes
Category Entries:
Minimally invasive
Invasive
53 MINOR_SALV_GLD_SPFY VARCHAR No
CAP synoptic form item: Specify Carcinomas of Minor Salivary Glands.
54 NON_SALV_ADENOC_C_NAME VARCHAR No
CAP synoptic form item: Non-Salivary Gland Adenocarcinoma, not otherwise specified (NOS).
The category values for this column were already listed for column: MUCOEPIDRMD_CARC_C_NAME
55 NON_SALIV_GLD_SPFY VARCHAR No
CAP synoptic form item: Non-Salivary Gland - Specify Adenocarcinoma.
56 NEUROEND_CARC_SPFY VARCHAR No
CAP synoptic form item: Specify Neuroendocrine Carcinoma.
57 PT1_OR_PT2_TUMOR_YN VARCHAR No
CAP synoptic form item: Tumor Thickness For pT1 or pT2 Tumors.
The category values for this column were already listed for column: MRG_CANNOT_ASSES_YN
58 TMR_THICK_MEASURE NUMERIC No
CAP synoptic form item: Tumor Thickness Measurement.
59 TMR_THICK_DESC_C_NAME VARCHAR No
CAP synoptic form item: Tumor Thickness Description.
May contain organization-specific values: Yes
Category Entries:
Intact surface mucosa
Ulcerated surface
60 MARGIN_IN_SITU_C_NAME VARCHAR No
CAP synoptic form item: Margin In Situ.
May contain organization-specific values: Yes
Category Entries:
Margins uninvolved by carcinoma in situ (includes moderate and severe dysplasia)
Margins uninvolved by carcinoma in situ
Margins involved by carcinoma in situ (includes moderate and severe dysplasia)
Margins involved by carcinoma in situ
Not applicable
61 PATH_INFLAM_SPFY VARCHAR No
CAP synoptic form item: Additional Pathological Findings - Specify Inflammation.
62 TMR_FOC_MUL_SPFY VARCHAR No
CAP synoptic form item: Tumor Focality - Specify Multifocal.
63 HIST_TYPE_ADE_NOS_C_NAME VARCHAR No
CAP synoptic form item: Histologic Type Adenocarcinomas, Not Otherwise Specified.
May contain organization-specific values: Yes
Category Entries:
Low grade
Intermediate grade
High grade
64 SPECIAL_STUDY_RESUL VARCHAR No
CAP synoptic form item: Special Studies - Specify Results.
65 MARGIN_INV_SPECIFY VARCHAR No
CAP synoptic form item: Margins Invasive Specify Margins Per Orientation.
66 MARG_INV_DIST_CLOSE NUMERIC No
CAP synoptic form item: Margins Invasive Distance of Invasive Carcinoma from Closest Margin.
67 PT_CARC_EX_MALIG_C_NAME VARCHAR No
CAP synoptic form item: Primary Tumor for All Carcinomas Excluding Mucosal Malignant Melanoma.
May contain organization-specific values: Yes
Category Entries:
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, in
pT4b: Very advanced local disease. Tumor invades masticator space, pterygoid plates,
pT1: Tumor confined to nasopharynx, or tumor extends to oropharynx and / or nasal cav
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, hypoph
pT1: Tumor limited to one subsite of hypopharynx and / or 2 cm or less in greatest di
pT2: Tumor invades more than one subsite of hypopharynx or an adjacent site, or measu
pT3: Tumor measures more than 4 cm in greatest dimension or with fixation of hemilary
pT4a: Moderately advanced local disease. Tumor invades thyroid / cricoid cartilage, h
pT4b: Very advanced local disease. Tumor invades prevertebral fascia, encases carotid