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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