Reporting of Skin cancer using
RCPath Standards.
A regional perspective.
Paul Barrett
Aim
• Determine if RCPath standards have been
adopted
– Part of network clinical guidelines (Jul13)
– RCPath Oct12 (revised May14)
• Pathology can be critical in determining
cases to be discussed at MDT
– Excisional intent
– High risk
– Incompletely excised
• Planned high quality
cancer care to just
over 3 million people
in the North of
England
• 8 Foundation and 1
NHSTrusts
• 14 Primary Care
Trusts (PCTs)
• 5 localities
Method
• 25 reports requested from 2014
– Each cancer type
– Each centre reporting in North East
• Core items in RCPath guidelines assessed
• One centre failed to submit by deadline
• Not all cases suitable
• Not all sites had 25 cases
Melanoma
• Fairly established dataset
• No major changes
Results - Melanoma
•
•
Lab
Cases
1
25
2
8
3
19
Non-proforma
4
4
– 4 central (6%)
– 22 local (71%)
5
26
6
11
7
8
101 cases
Local MDT
– 31
• Proforma
– 75
•
Results - Melanoma
• All cases
– Macroscopic description skin ellipse
– Macroscopic description lesion
– Excision margins
Results - Melanoma
Critical results
• Breslow
1
• Clark’s
6
• Ulceration 7
(1/0)
(5/1)
(7/0)
• 12 cases do not include vital data
• All destined for review
Results - Melanoma
• LVI
• PNI
• Microsat
5
11
52
(5/0)
(11/0)
(22/30)
• Subtype
• Growth phase
• Stage
13
9
21
(12/1)
(9/0)
(18/3)
Results - Melanoma
• Mitotic rate
• Regression
• TiL
2
17
14
• All data items provided
(2/0)
(15/2)
(14/0)
47 (46%)
SCC
• Significant change around risk status
• Complexity with pT2
– Any two of
•
•
•
•
Poor differentiation
Into subcutaneous tissue
>2mm
Into reticular dermis
Results - SCC
•
•
Lab
Cases
1
25
2
9
3
25
Non-proforma
4
2
– 11 central (17%)
– 52 local
(82%)
5
24
6
20
7
21
126 cases
Local MDT
– 52 (41%)
• Proforma
– 63 (all central)
•
Results - SCC
• All cases
– Macroscopic description skin ellipse
– Macroscopic description lesion
– Excision margins
Results - SCC
Critical results
• Grade
8
• Thickness 10
• Level
32
(8/0)
(10/0)
(30/2)
Results - SCC
• LVI
• PNI
7
22
(7/0)
(22/0)
• Subtype
• Risk
• Stage
47
86
65
(47/0)
(54/32)
(41/24)
Results - SCC
• Correct assessment of risk
– Recorded in 40
• 3 incorrect
• 2 insufficient data in report to assess
• All data items provided
• 32 cases (2/30)
25%
BCC
• Established data set
• Is it really cancer?
• Multiple specimens common
Results - BCC
•
•
Lab
Cases
1
25
2
21
3
25
Non-proforma
4
25
– 8 central
– 86 local
5
23
6
22
7
18
159 cases
Local MDT
– 86 (54%)
• Proforma
– 65 (all central)
•
(17%)
(100%)
Results - BCC
• All cases
– Macroscopic description skin ellipse
– Macroscopic description lesion
Results - BCC
Key results
• Growth pattern
• Level
1
57
(1/0)
(56/1)
• Margins
2
(1/1)
Results - BCC
• LVI
• PNI
28
15
(27/1)
(14/1)
• Risk
• Stage
85
92
(85/0)
(68/24)
• All data items provided
26%
• 41 cases
• Combination risk and/or stage absent
Recommendations
• Data could be derived
• Melanoma review centrally
• Confirms value in reporting by proforma
– College KPI
• Ensure proforma contains all core items
• Re-audit or audit locally
Clinical
 imunosuppression
Site:
Specimen type:
Size:
Size of lesion:
Marker & ink:
Description:
 Curette / Shave / Punch / Incisional
Length
Width
o’clock
LLP SH BB
 Classic
 Acantholytic
Grade:  Well
Thickness:
mm
Adj Bowen’s dis:  No
SqCC
Subtype:
BCC
Subtype:
 Superficial
 Infiltrative
Atypical Sq D:  No
Level of invasion:
 radiation, burn or chronic
inflammation
 Excisional
to a depth of
mm  high risk if >20mm
inked margin-
Tips:
Transverse:
 KA-like
 Verrucous
Other:
 Spindle cell
 Moderate
 Poor
 >4mm Stage may increase if >2mm
 Yes
Adj Bowen’s dis:  No
 Micronodular
 Yes
BCC
T stage:
SCC only
Risk status:
MDT discussion:
Comments:
Subtype:
 into papillary
dermis
 into reticular
dermis*
 confined to epidermis
 Yes
 Superficial
 Nodular
 Infiltrative
 Micronodular
Atypical Sq D:  No
 into subcutaneous fat
*possible stage increase for SqCCa
 No
 Yes
 No
 Yes
 involved
 clear <1mm
 clear 1-5mm
 Yes
 confined to epidermis
 into papillary dermis
at unspecified margin/
 clear <1mm
o’clock
 clear 1-5mm
 fills papillary dermis
 into reticular dermis*
 pT2
 pT3+
pT2 if 2 of poor diffn, PNI, lip/ear site, into reticular dermis, >2mm thick
 into subcutaneous fat
 Low
 No
LVI:
 No
 Yes
PNI:
 No
 Yes
Level of invasion:
 clear 5mm+
 involved
 clear 5mm+
 pT1 <=20mm
deep:
Stage may increase if >2mm
 Nodular
 fills papillary dermis
LVI:
PNI:
Margins peripheral:
mm  >4mm
Thickness:
 High
 Yes (excisional, high risk and incomplete)
Margins peripheral:  involved
deep:
T stage:
SCC only
 clear <1mm
*possible stage increase for SqCCa
 clear 1-5mm
o’clock
 clear 5mm+
at unspecified margin/
 involved
 clear 5mm+
 clear <1mm
 clear 1-5mm
 pT1 <=20mm
 pT2
 pT3+
pT2 if 2 of poor diffn, PNI, lip/ear site, into reticular dermis, >2mm thick
Questions?