Guidelines in Reporting Skin Cancer

Guidelines in Reporting Skin Cancer

• Current situation• 2nd Edition RCPath guidelines• Guidelines/standards• International guidelines

Current Guidelines in UK

RCPath 1st EditionSkin Cancer Datasets

Feb 2002

2002

Minimum dataset for histopathological reporting of common skin cancers

Basal cell carcinomaSquamous cell carcinomaMelanoma

Updated Guidelines are being prepared

Consultation with

• NCIN• RCPath Dermatopathology

Subcommittee• National Specialist EQA/

Dermatopathology EQA members

Updated draft will take into account

• AJCC Cancer Stage Manual 7th Edition• Improving Outcomes for People with

Skin Tumours including Melanoma, NIHCE

• Cancer Peer Review (CPR) Skin Measures• BAD Guidelines for management of skin

cancers

2nd Edition will include

• Core (essential)• Non core (discretionary/

desirable)

Core items will be NCIN set with margins, TNM score and SNOMed

NCIN also looking to capture clinical items on request form

RCPath moving from Guidelines to Standards

RCPath will issue 2nd draft for consultation to all fellows

Basal Cell CarcinomaRCPath Draft 2nd Edition

Growth Pattern• Superficial• Nodular• Infiltrating/morphoeic• Micronodular• Other

Basal Cell carcinomaRCPath 2nd Edition

• Core (only for patterns other than pure superficial

• Differentiation• Atypic squamous component • (ie basosquamous component) Yes/No• Invasion > Clark level (specify) Yes/No• Lymphovascular/perineural invasion

(specify) Yes/No

Basal Cell CarcinomaRCPath 2nd Edition Draft

Margins

• Peripheral Involved/Clear <1 mm >1 mm• Deep Involved/Clear <1 mm >1 mm

Basal Cell CarcinomaRCPath 2nd Edition Draft

TNM Staging (AJCC7)

pT1 Microscopic diameter < 2 cmpT2 Microscopic diameter > 2 cmpT3 Invasion into facial or cranial bonespT4 Perineural invasion of skull bone or

invasion of skeleton

Basal Cell CarcinomaRCPath 2nd Edition Draft

Pathological Risk Status

low risk / high risk

SNOMed

Basal Cell CarcinomaRCPath 2nd Edition Draft

Non Core/Discretionary itemsMarginsNumerical measurementsClear but <1 mm to nearest 0.1Clear but >1 mm to nearest mm

Basal Cell CarcinomaRCPath 2nd Edition Draft

Non Core/Discretionary Items

Margin on orientated specimens

Information on nearest peripheral and deep margins in relation to designated specimen orientation

Basal Cell CarcinomaRCPath 2nd Edition Draft

Non Core/Discretionary Items

Growth pattern at involved margin

Thickness of tumour (eg for photo-dynamic therapy) - mm

BCC Pathology High Risk Status

1. Growth pattern – infiltrating/morphoeic and/or micronodular

2. Differentiation – basosquamous carcinoma3. Clark level V and beyond4. Lymphovascular and/or perineural invasion

present5. pT2, pT3, pT4

High Risk Basal Cell Carcinomas

1. Decide whether treatment in primary or secondary care appropriate

2. Extent of desirable margin clearance3. Facilitated skin cancer MDT action and

decision making4. Decide follow-up – duration and primary or

secondary care

Clinical Core/NCIN

SiteRecurrenceImmune stateGenetic syndromeClinical risk high/low

Clinical High Risk for Skin Cancer MDT

Any one makes it high risk

• Anatomical location (central face, around eyes, nose, lips and ears

• Recurrent at site• Reduce immune status• Genetic (eg Gorlin’s)

Squamous Cell carcinomaRCPath Draft 2nd Edition

Core/Essential• Histological subtype• Classical/no special type• Keratoacanthomatous• Veruccous• Acantholytic (pseudoglandular adenoid)• Spindle cell• Desmoplastic• Other

Squamous Cell carcinomaRCPath Draft 2nd Edition

Core/Essential

• Grade – well/moderately/poorly differentiated• Thickness >2 mm No / Yes – mm (whole

integer)• Invasion > Clark IV N / Yes (specify)• Lymphovascular/perineural invasion Yes / No

(specify)• Adjacent Bowen’s disease Yes / No

Squamous Cell carcinomaRCPath Draft 2nd Edition

Core/Essential

Margins

• Peripheral Involved/Clear <1 mm; >1 mm• Deep Involved/Clear <1 mm; >1 mm

Squamous Cell carcinomaRCPath Draft 2nd Edition

Core/EssentialTNM Stage (AJCC7)pT1 Microscopic diameter <2 cmpT2 Microscopic diameter >2 cm or pT1 and

two risk factorspT3 Invasion into facial or cranial bonespT4 Perineural invasion of skull base or

invasion of skeleton

Squamous Cell carcinomaRCPath Draft 2nd Edition

Pathological Risk Factor of MDT

Low Risk / High Risk

SNOMed code

Squamous Cell carcinomaRCPath Draft 2nd Edition

Non Core / DiscretionaryMargins measurementsClear but <1 mm to nearest 0.1 mmClear but >1 mm to nearest 0. 1 mmOrientated specimenPeripheral and deep margins to

designated specimen orientation

Squamous Cell CarcinomaRisk Factor

High Risk1.Type: spindle/acantholytic/desmoplastic,

metaplastic/sarcomatoid2.Grade – poorly differentiated3.Perineural invasion4.Lymphovascular invasion5.Thickness >4 mm

6. Clark level V or more7. Adjacent Bowen’s8. Clinical site ear or hair bearing lip9. pT2, 3, 4

Squamous Cell Carcinoma

Risk Factors

Any one of these factors is high risk

Squamous Cell Carcinoma NCIN

Clinical Core/ Essential

Site

Recurrent at site

Immune status

Genetic syndrome

Squamous Cell Carcinoma

Also high risk clinically

• Areas of radiation• Thermal injury• Chronic sinuses• Chronic ulcer• Chronic inflammation

In Situ Malignant MelanomaRCPath 2nd Edition Draft

Core /Essential

• Histopathological subtype• Lentigo maligna• Superficial spreading• Acral lentiginous• Other

In Situ Malignant MelanomaRCPath 2nd Edition Draft

Non-Core (Desirable)

Regression Yes / No (depth mm)Background naevus Yes / No (if yes, dysplastic naevus

Yes / NoMargins:Peripheral - Involved/Clear <1 mm/Clear >1 mmDeep - Involved/Clear <1 mm/Clear >1 mmTNM pT1s

SNOMed

Invasive Malignant MelanomaRCPath 2nd Edition Draft

Core/Essential

• Histopathological subtype

• Lentigo maligna• Superficial spread• Nodular• Aral lentiginous

• Desmoplastic• Neurotropic• Spitzoid• Other

Invasive Malignant MelanomaRCPath 2nd Edition Draft

Core/Essential

Breslow’s thickness ___ mm (nearest decimal point

Ulceration Yes / No ___ mm

Mitotic Rate – per square mm

Lymphovascular/Perineural invasion Yes / No (specify)

Microsatellite/Intransit metastasis Yes / No (specify)

Clark level IV/V

Invasive Malignant MelanomaRCPath 2nd Edition Draft

Non Core/Desirable

Growth pattern: Radial/VerticalRegression Yes / No ___ mmTumour lymphocytes Absent/Non brisk/BriskBackground naevus Yes / No/Ulceratin

Invasive Malignant MelanomaRCPath 2nd Edition Draft

Non Core/Desirable

Margins:Peripheral:Involved/Clear <1 mm/Clear >1 mmDeep: Involved/Clear <1 mm/Clear >1 mmTNM stageSNOMed

TNM StagingMalignant Melanoma (AJCC 2009)

Classification Thickness Ulceration

T1 < 1.0 mm a. without ulceration and mitosis <1/mm2

b. with ulceration and mitosis 1/mm2

T2 1.01-2.0 mm a. without ulcerationb. with ulceration

T3 2.01-4 mm a. without ulcerationb. with ulceration

T4 >4 mm a. without ulcerationb. with ulceration

Malignant MelanomaTNM Stage (AJCC 2009)

Nodes # Nodes Nodal Mass

N0 No lymph node disease

N1 1 node a.micrometastasisb.macrometastasis

N2 2-3 nodes a. micrometastasisb. macrometastasis

N3 4 or more nodes or matted nodes or intransit metastases/satellites

Malignant MelanomaTNM Stage (AJCC 2009)

M StagingM0 No evidence of metastasis to distant

tissues or organsM1a Distant skin, subcutaneous or nodal

metastasis, serum LDH normalM1b Lung metastasis, serum LDH normalM1c All other visceral or any distance metastases, normal or elevated LDH

Invasive Adnexal CarcinomaRCPath 2nd Edition Draft

Core/Essential

DiagnosisGrade (if applicable)Well/moderately/poorly differentiatedThickness >2 mm Yes / No ___ mmInvasion > Clark Level V Yes / NoLymphovascular/Perineural invasion Yes / No

Invasive Adnexal CarcinomaRCPath 2nd Edition Draft

Margins:

Peripheral – Involved/Clear <1 mm/Clear >1 mmDeep – Involved/Clear <1 mm/Clear >1 mmTNMSNOMed

TMN StagingAdnexal Carcinoma (AJCC7)

pT1 Microscopic diameter <2 cmpT2 Microscopic diameter >2 cm or pT1

with two risk factorspT3 Invasion of facial or cranial bonespT4 Perineural invasion of skull base or

skeleton

Risk Factors in Adnexal Carcinoma

• Grade: poorly differentiated• Perineural invasion• Thickness >2 mm• Clark level > IV• Clinical ear or hair bearing lip

Merkel Cell CarcinomaRCPath 2nd Edition Draft

Core/Essential

Invasion: > Clarke level V Yes / No

Lymphovascular invasion Yes / No

Merkel Cell CarcinomaRCPath 2nd Edition Draft

Non Core/Desirable

Tumour thickness ___ mmMitotic rage ___ sq mmTumour growth at base: Nodular / Infiltrative / MixedTumour Infiltrating Lymphocytes: Absent / Present

Merkel Cell CarcinomaRCPath 2nd Edition Draft

Non Core/Desirable

Margins:Peripheral – Involved/Clear <1 mm/Clear >1 mmDeep – Involved/Clear <1 mm/Clear >1 mmTNM StageSNOMed

Merkel Cell CarcinomaTNM Stage (AJCC7)

pT1 Microscopic diameter <2 cmpT2 Microscopic diameter >2-5 cmpT3 Microscopic diameter >5 cmpT4 Invasion of deeper structures

including bone, muscle, fascia, cartilage

International Standard Guidelines

RCPath (UK)

CAP (USA)

CAP-ACP (Canada)

RCPA (Australia)

Canadian Association of Pathologists

College of American Pathologists

Core/Essential

Non core/Desirable

Primary Invasive Melanoma

Melanoma

• Core/Essential• Non core/Desirable

Core Elements

• Tumour site• Specimen laterality• Specimen type• Breslow thickness• In situ component: peripheral margin in mm• Invasive component: peripheral margin in mm

Core Elements

• Invasive component: deep margin in mm• Ulceration• Mitotic rate/mm• Lymphovascular invasion• Neurotropism• Satellites• Satellites – margin involved

Core Elements

• Desmoplastic component

Non Core

• Specimen orientation• Specimen dimensions• Macroscopic primary lesion dimensions• Macroscopic description of lesion• Other lesions• Macroscopic description of other lesions

Non Core

• Melanoma histological subtype• Extent of ulceration• Clark level• Tumour infiltrating lymphocytes • Tumour regression• Associated melanocytic lesions

Core Elements Lymph nodes

• Number of sentinel nodes• Number of sentinel nodes with

metastases• Total number of nodes