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 101 cases MDT –31 vrs 70 Specialist Proforma –75 vrs 26 Non-proforma –22 Local 71% –4 Specialist 6% LabCases

Results - Melanoma All cases –Macroscopic description skin ellipse –Macroscopic description lesion –Excision margins

Results - Melanoma Critical results Breslow1(1/0) Clark’s6(5/1) Ulceration7(7/0) Free text/proforma 12 cases do not include vital data All destined for review

Results - Melanoma LVI 5 (5/0) PNI11(11/0) Microsat52(22/30) Subtype13(12/1) Growth phase 9 (9/0) Stage21(18/3)

Results - Melanoma Mitotic rate 2 (2/0) Regression17(15/2) TiL14(14/0) All data items provided47 (46%)

SCC Significant change around risk status Complexity with pT2 –Any two of Poor differentiation Into subcutaneous tissue >2mm Into reticular dermis

Results - SCC MDT –52 vrs 74 (59%) Proforma –63 vrs 63 –all central Non-proforma –52 Local 100% –11 Special 17% One lab sent SqCC coded LabCases

Results - SCC All cases –Macroscopic description skin ellipse –Macroscopic description lesion –Excision margins

Results - SCC Critical results Grade 8 (8/0) Thickness10(10/0) Level32(30/2)

Results - SCC LVI 7 (7/0) PNI22(22/0) Subtype47 (47/0) Risk 86(54/32) Stage65(41/24)

Results - SCC Correct assessment of risk –Recorded in 40 3 incorrect 2 insufficient data in report to assess All data items provided25% 32 cases (2/30)

BCC Established data set Is it really cancer? Multiple specimens common

Results - BCC MDT –86 vrs 73 (46%) Proforma –65 vrs 94 –all central Non-proforma –86 Local 100% –8 Special 17% LabCases

Results - BCC All cases –Macroscopic description skin ellipse –Macroscopic description lesion

Results - BCC Key results Growth pattern 1 (1/0) Level57(56/1) Margins 2 (1/1)

Results - BCC LVI28 (27/1) PNI15(14/1) Risk 85(85/0) Stage92(68/24) All data items provided26% 41 cases Combination risk and/or stage absent

Recommendations Data often could be derived Melanoma review centrally Confirms value in reporting by proforma –One RCPath KPIs Ensure proforma contains all core items Re-audit or audit locally

Clinical  imunosuppression  radiation, burn or chronic inflammation Site: Specimen type:  Curette / Shave / Punch / Incisional  Excisional Size: Length Width to a depth of Size of lesion: mm  high risk if >20mm Marker & ink: o’clock inked margin- Description: LLP SH BBTips: Transverse: SqCC Subtype:  Classic  KA-like  Verrucous  Acantholytic  Spindle cell Other: Grade:  Well  Moderate  Poor Thickness: mm  >4mm Stage may increase if >2mm Adj Bowen’s dis:  No  Yes BCC Subtype:  Superficial  Nodular  Infiltrative  Micronodular Atypical Sq D:  No  Yes Level of invasion:  confined to epidermis  into papillary dermis  fills papillary dermis  into reticular dermis*  into subcutaneous fat *possible stage increase for SqCCa LVI:  No  Yes PNI:  No  Yes Margins peripheral :  involved  clear <1mm  clear 1-5mm  clear 5mm+at unspecified margin/ o’clock deep:  involved  clear <1mm  clear 1-5mm  clear 5mm+ T stage: SCC only  pT1 <=20mm  pT2  pT3+ pT2 if 2 of poor diffn, PNI, lip/ear site, into reticular dermis, >2mm thick Risk status:  Low  High MDT discussion:  No  Yes (excisional, high risk and incomplete) Comments:

Questions?