Guidelines in Reporting Skin Cancer

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

Current Guidelines in UK RCPath 1 st Edition Skin Cancer Datasets Feb 2002

2002 Minimum dataset for histopathological reporting of common skin cancers Basal cell carcinoma Squamous cell carcinoma Melanoma

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 7 th Edition Improving Outcomes for People with Skin Tumours including Melanoma, NIHCE Cancer Peer Review (CPR) Skin Measures BAD Guidelines for management of skin cancers

2 nd 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 2 nd draft for consultation to all fellows

Basal Cell Carcinoma RCPath Draft 2 nd Edition Growth Pattern Superficial Nodular Infiltrating/morphoeic Micronodular Other

Basal Cell carcinoma RCPath 2 nd 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 Carcinoma RCPath 2 nd Edition Draft Margins PeripheralInvolved/Clear 1 mm DeepInvolved/Clear 1 mm

Basal Cell Carcinoma RCPath 2 nd Edition Draft TNM Staging (AJCC7) pT1Microscopic diameter < 2 cm pT2Microscopic diameter > 2 cm pT3Invasion into facial or cranial bones pT4Perineural invasion of skull bone or invasion of skeleton

Basal Cell Carcinoma RCPath 2 nd Edition Draft Pathological Risk Status low risk / high risk SNOMed

Basal Cell Carcinoma RCPath 2 nd Edition Draft Non Core/Discretionary items Margins Numerical measurements Clear but <1 mm to nearest 0.1 Clear but >1 mm to nearest mm

Basal Cell Carcinoma RCPath 2 nd 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 Carcinoma RCPath 2 nd 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 carcinoma 3.Clark level V and beyond 4.Lymphovascular and/or perineural invasion present 5.pT2, pT3, pT4

High Risk Basal Cell Carcinomas 1.Decide whether treatment in primary or secondary care appropriate 2.Extent of desirable margin clearance 3.Facilitated skin cancer MDT action and decision making 4.Decide follow-up – duration and primary or secondary care

Clinical Core/NCIN Site Recurrence Immune state Genetic syndrome Clinical 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 carcinoma RCPath Draft 2 nd Edition Core/Essential Histological subtype Classical/no special type Keratoacanthomatous Veruccous Acantholytic (pseudoglandular adenoid) Spindle cell Desmoplastic Other

Squamous Cell carcinoma RCPath Draft 2 nd 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 carcinoma RCPath Draft 2 nd Edition Core/Essential Margins PeripheralInvolved/Clear 1 mm DeepInvolved/Clear 1 mm

Squamous Cell carcinoma RCPath Draft 2 nd Edition Core/Essential TNM Stage (AJCC7) pT1Microscopic diameter <2 cm pT2Microscopic diameter >2 cm or pT1 and two risk factors pT3Invasion into facial or cranial bones pT4Perineural invasion of skull base or invasion of skeleton

Squamous Cell carcinoma RCPath Draft 2 nd Edition Pathological Risk Factor of MDT Low Risk / High Risk SNOMed code

Squamous Cell carcinoma RCPath Draft 2 nd Edition Non Core / Discretionary Margins measurements Clear but <1 mm to nearest 0.1 mm Clear but >1 mm to nearest 0. 1 mm Orientated specimen Peripheral and deep margins to designated specimen orientation

Squamous Cell Carcinoma Risk Factor High Risk 1.Type: spindle/acantholytic/desmoplastic, metaplastic/sarcomatoid 2.Grade – poorly differentiated 3.Perineural invasion 4.Lymphovascular invasion 5.Thickness >4 mm

6.Clark level V or more 7.Adjacent Bowen’s 8.Clinical site ear or hair bearing lip 9.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 Melanoma RCPath 2 nd Edition Draft Core /Essential Histopathological subtype Lentigo maligna Superficial spreading Acral lentiginous Other

In Situ Malignant Melanoma RCPath 2 nd Edition Draft Non-Core (Desirable) RegressionYes / No (depth mm) Background naevusYes / No (if yes, dysplastic naevusYes / No Margins: Peripheral- Involved/Clear 1 mm Deep - Involved/Clear 1 mm TNM pT1s SNOMed

Invasive Malignant Melanoma RCPath 2 nd Edition Draft Core/Essential Histopathological subtype Lentigo maligna Superficial spread Nodular Aral lentiginous Desmoplastic Neurotropic Spitzoid Other

Invasive Malignant Melanoma RCPath 2 nd 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 Melanoma RCPath 2 nd Edition Draft Non Core/Desirable Growth pattern: Radial/Vertical Regression Yes / No ___ mm Tumour lymphocytes Absent/Non brisk/Brisk Background naevus Yes / No/Ulceratin

Invasive Malignant Melanoma RCPath 2 nd Edition Draft Non Core/Desirable Margins: Peripheral:Involved/Clear 1 mm Deep:Involved/Clear 1 mm TNM stage SNOMed

TNM Staging Malignant Melanoma (AJCC 2009) ClassificationThicknessUlceration T1< 1.0 mma.without ulceration and mitosis <1/mm 2 b.with ulceration and mitosis 1/mm 2 T mma.without ulceration b.with ulceration T mma.without ulceration b.with ulceration T4>4 mma.without ulceration b.with ulceration

Malignant Melanoma TNM Stage (AJCC 2009) Nodes# NodesNodal Mass N0No lymph node disease N11 nodea.micrometastasis b.macrometastasis N22-3 nodesa.micrometastasis b.macrometastasis N34 or more nodes or matted nodes or intransit metastases/satellites

Malignant Melanoma TNM Stage (AJCC 2009) MStaging M0No evidence of metastasis to distant tissues or organs M1aDistant skin, subcutaneous or nodal metastasis, serum LDH normal M1bLung metastasis, serum LDH normal M1cAll other visceral or any distance metastases, normal or elevated LDH

Invasive Adnexal Carcinoma RCPath 2 nd Edition Draft Core/Essential Diagnosis Grade (if applicable) Well/moderately/poorly differentiated Thickness >2 mm Yes / No ___ mm Invasion > Clark Level V Yes / No Lymphovascular/Perineural invasion Yes / No

Invasive Adnexal Carcinoma RCPath 2 nd Edition Draft Margins: Peripheral – Involved/Clear 1 mm Deep – Involved/Clear 1 mm TNM SNOMed

TMN Staging Adnexal Carcinoma (AJCC7) pT1Microscopic diameter <2 cm pT2Microscopic diameter >2 cm or pT1 with two risk factors pT3Invasion of facial or cranial bones pT4Perineural 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 Carcinoma RCPath 2 nd Edition Draft Core/Essential Invasion:> Clarke level V Yes / No Lymphovascular invasion Yes / No

Merkel Cell Carcinoma RCPath 2 nd Edition Draft Non Core/Desirable Tumour thickness ___ mm Mitotic rage ___ sq mm Tumour growth at base: Nodular / Infiltrative / Mixed Tumour Infiltrating Lymphocytes: Absent / Present

Merkel Cell Carcinoma RCPath 2 nd Edition Draft Non Core/Desirable Margins: Peripheral – Involved/Clear 1 mm Deep – Involved/Clear 1 mm TNM Stage SNOMed

Merkel Cell Carcinoma TNM Stage (AJCC7) pT1Microscopic diameter <2 cm pT2Microscopic diameter >2-5 cm pT3Microscopic diameter >5 cm pT4Invasion 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