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Diagnosing Melanocytic Lesions: Integrating Morphologic, Immunohistochemical
and Molecular Features: an Approach to Diagnosis and Reporting
Session number:1000
Victor G. Prieto, MD, PhD Chair, Professor of Pathology Michael T. Tetzlaff , MD, PhD Associate Professor of Pathology Jonathan L. Curry, MD Associate Professor of Pathology University of Texas-MD Anderson Cancer Center Houston, Texas
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SESSION NUMBER:1000 SEGMENT 3 Pathology report of the morphologic parameters: - impact staging - fulfill laboratory accreditation (Dr. Curry)
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Speaker Disclosure In the past 12 months, I have not had a significant
financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be discussed in my presentation.
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Outline 1. Cancer protocol template 2. Major histologic types of melanoma 3. Primary parameters that impact staging 4. Other histologic parameters 5. Lymph node status and satellitosis 6. Distant metastasis
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Invasive Cutaneous Melanoma
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Pathology Report
• Pathology reports have become more comprehensive – Diagnosis – Prognostic factors – Mutation information
• Include cancer protocol templates • Impact clinical decisions and treatment
modalities
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Cancer Templates
• Attempt to better standardize pathology
• To avoid omission of critical information
• Required for accreditation – Laboratory
• College of American Pathologists – Cancer center
• National Cancer Institute
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Histopathologic Parameters of Melanoma
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15 Histopathologic Parameters
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Histopathologic Parameters of Melanoma
15
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Histopathologic Parameters of Melanoma
* * *
*
*
* *
* CAP required elements *
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Histopathologic Parameters of Melanoma
* * *
*
*
* *
* CAP required elements * Elements for AJCC
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Why Report all 15 Histopathologic Parameters?
• Provide complete pathology report • Glean important information from non-required
elements – Clark level (e.g. Breslow thickness and/or mitotic rate not
available) • Fragmented tissue (e.g. curettage specimens) • Maloriented specimens
• Perineural invasion – Included in Breslow thickness – May upstage T classification (e.g. change T1 to T2)
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Why Report all 15 Histopathologic Parameters?
• Regression – Depth of regression measured in mm may impact overall survival
• Associated nevus – Aid in examination of excision specimens and/or sentinel lymph
nodes
• Cell phenotype – Aid in examination of excision specimens and/or sentinel lymph
nodes • Spindle • Nevoid
– Insight into BRAF mutation status • Spindle less likely to harbor BRAF V600E mutation than epithelioid
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Reporting Histopathologic Parameters of Melanoma
• Provide all 15 histopathologic parameters from biopsy specimen
• Excision specimen include – Clark level – Breslow thickness – Other parameters that differ or add information – Surgical margins
• Cancer Template – Incorporates histopathologic parameters seen in biopsy and
excision specimens – “The CAP and pTNM information provided in this report is a
compilation of both this current and the prior MDACC S- #”
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Melanoma Pathology Report
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Cancer Template
Primary tumor
Lymph node
TNM
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Outline 1. Cancer protocol template 2. Major histologic types of melanoma 3. Primary parameters that impact staging 4. Other histologic parameters 5. Lymph node status and satellitosis 6. Distant metastasis
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Histologic Types of Melanoma
• 4 major histologic types – Superficial spreading melanoma – Lentigo maligna melanoma – Nodular melanoma – Acral lentiginous/mucosal melanoma
• Many morphologic variants
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Melanoma Variants
Weedon
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Superficial Spreading Type
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Nodular Type
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Acral Lentiginous Melanoma
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Desmoplastic Melanoma • Morphologic feature-seen with any of the
major histologic type of melanoma
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Desmoplastic Melanoma
Not DMM-Cellular and spindle DMM=Hypocellular
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Pure Desmoplastic Melanoma • Defined as >90 % of
tumor with uniform desmoplastic stroma and hypocellular proliferation of spindle cells
• Pure DM with 2.2 % positive SLN
• Mixed DM with 15.8% positive SLN
• Non-DM with 17.5% positive SLN
Pawlik, Ross, Prieto, et. al. Cancer, 2005
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Outline 1. Cancer protocol template 2. Major histologic types of melanoma 3. Primary parameters that impact staging 4. Other histologic parameters 5. Lymph node status and satellitosis 6. Distant metastasis
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TNM • T = Primary tumor
(Stage I and II) – Breslow (Tumor)
thickness – Mitotic rate – Ulceration
• N = Regional
metastasis (Stage III) – Lymph node
• Microscopic • Macroscopic
– Skin/subcutaneous tissue (Intransit metastasis/satellites)
• M = Distant metastasis (Stage IV) – Lymph node – Skin/subcutaneous
tissue – Visceral metastasis
• Pulmonary • Non-pulmonary
– Serum LDH
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Impact on T Stage • T = Primary tumor (Stage I and II)
– Breslow (Tumor) thickness – Mitotic rate – Ulceration
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Breslow (Tumor) Thickness • Powerful predictor of survival • T category for thickness
– Defined in even integers: 1.0, 2.0, and 4.0 mm • 10 year survival
T1 (≤ 1.0 mm): 92% T2 (1.01-2.0 mm): 80% T3 (2.01-4.0 mm: 63% T4 (> 4.0 mm): 50%
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Breslow Thickness
Fills and expands papillary dermis
Extend into papillary dermis
Epidermis
Papillary dermis
Reticular dermis
Subcutaneous fat
Intra-epidermal
Reticular dermis
Subcutaneous fat
I
II
III
IV V
Breslow thickness Clark level
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Tumor Thickness Measured From Center of Follicle
Breslow thickness
Tumor thickness
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Microanatomic Compartment
Papillary dermis
Reticular dermis
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Breslow thickness
Clark level
Breslow Thickness and Clark Level
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Pitfalls in Measurement of Breslow Thickness (BT)
• Follicle/adnexal structures • Satellite lesion • Tangential sections • Combine BT from two separate biopsies • Nevus cells • Artifact spaces or tears in tissue • We do include Breslow thickness
measurement to area of perineural invasion
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Pitfalls in the Measurement of Breslow Thickness
Adnexal structure
Breslow thickness
Overestimate Breslow thickness
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Pitfalls in the Measurement of Breslow Thickness
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Breslow Thickness
Breslow thickness
Satellite lesion
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Tangential Section
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Pitfalls in the Measurement of Breslow Thickness
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Specimen 1
Specimen 2
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Breslow Thickness Are Not Additive
BT1 BT2 BT3
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Breslow thickness
Breslow Thickness in Melanoma with Associated Nevus
Do not include nevus cells in Breslow thickness
Do not report Breslow thickness at least, since nevus cells at the base of shave
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Breslow Thickness Reported “At Least”
Breslow thickness, at least, base transected
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Breslow thickness
Do include Breslow thickness to area of perineural invasion (PNI)
PNI
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Perineural Invasion • Seen more frequently
in LMM and ALM with desmoplastic features
• Presence of PNI may be indicator for further adjuvant therapy with XRT
• Include area of PNI in Breslow thickness measurement
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Impact on T Stage • T = Primary tumor (Stage I and II) • Breslow (Tumor) thickness • Mitotic rate • Ulceration
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T= Primary Tumor
2001 2010
Mitotic rate (MR)
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Mitotic Rate • Important predictor of survival • 5 year survival rate non-ulcerated T1
melanoma – Mitosis: < 1=98%; 1-2=95%; 3-5=87%; 6-
10=78%; 11-19 =70%; >20=59% • T1 > 0.76 mm with at least 1 mitosis
– 10% risk of occult metastasis • 78% of ulcerated T1 melanomas were
associated with mitotic rate of at least 1/mm2
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Mitotic Rate
Dermal mitosis Junctional mitosis
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Mitotic Rate • Do’s
– Try to find highest mitosis per mm2
– Examine all sections and levels for mitosis or “hot spot”
– Search for mitosis in invasive melanoma
– Look for mitosis by morphology
• Don’ts – Average mitotic count in
more than one mm2 area (1/2mm2 = 0.5/mm2)
– Cut additional sections only to evaluate for mitosis
– Junctional mitosis – Report Ki-67 positive cells
as mitotic rate
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Pitfalls in Identification of Mitotic Figure
• Report mitotic figure of inflammatory cell or endothelial cell as positive
• Resolve with IHC studies
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Impact on T Stage • T = Primary tumor (Stage I and II) • Breslow (Tumor) thickness • Mitotic rate • Ulceration
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T= Primary Tumor
2001 2010
Ulceration
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Ulceration
• Defined as absence of intact epidermis overlying primary invasive melanoma
• Based on microscopic examination
• Distinguish from artifactual or traumatic disruption of epidermis
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Ulceration
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Pitfalls in the Assessment of Ulceration
• Transepidermal elimination of tumor • Incomplete sections • Prior trauma or biopsy site • Detached epidermis
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Not ulcerated
Detached epidermis
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Not ulcerated
In tact epithelium
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Not ulcerated from melanoma
Ulcerated Basal cell
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Not ulcerated
Ulcer from trauma Absence of melanoma beneath ulcer
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Pitfalls of Ulceration
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Outline 1. Cancer protocol template 2. Major histologic types of melanoma 3. Parameters that impact staging 4. Other histologic parameters 5. Lymph node status and satellitosis 6. Distant metastasis
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Histopathologic Parameters of Melanoma
* * * * * * *
*
* CAP required elements
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Vascular Invasion
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Detection of Vascular Invasion in Primary Melanoma with D2-40
• (+) LVI with D2-40 – 67% positive SLN
• (-) LVI with D2-40 – 19% positive SLN
• Patients with LVI – Decreased
disease specific survival
Petersson et. al. J Cutan Pathol. 2009
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Detection of Vascular Invasion
D2-40
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Histopathologic Parameters of Melanoma
* * *
*
*
* *
* CAP required elements * Elements for AJCC
not required elements in cancer checklist
RADIAL (NON-TUMORIGENIC) GROWTH PHASE, PRESENT VERTICAL (TUMORIGENIC) GROWTH PHASE, PRESENT
REGRESSION, NOT IDENTIFIED
TUMOR-INFILTRATING LYMPHOCYTES, NON-BRISK
PREDOMINANT CYTOLOGY, EPITHELIOIOD ASSOCIATED MELANOCYTIC NEVUS, NOT IDENTIFIED
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Radial and Vertical Growth Phase • Radial growth phase (RGP)
– Expansion of tumor parallel to the epidermis • invasive tumor cells are not proliferative • in situ and/or invasive components
• Vertical growth phase (VGP) – Expansion of tumor perpendicular to the
epidermis • invasive tumor cells are proliferative • mitogenic-presence of dermal mitosis • tumorigenic-dermal nest lager than junctional nests
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Radial Growth Phase (RGP)
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Vertical Growth Phase (VGP)
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Regression • Defined as replacement of melanoma cells in
the dermis with fibrosis, vascular proliferation, lymphocytic infiltrate, and melanophages
• Changes of epidermis with loss of rete ridges • Regression reported as focal or extensive
(>50% or >75%) • Nagarajan et. al.
– Depth of regression measured in mm associated with worse prognosis
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Regression
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Tumor-infiltrating Lymphocytes (TIL) • Brisk:
lymphocytes infiltrate entire base of invasive melanoma
• Non-brisk: lymphocytes infiltrate focally
• Absent: lymphocytes not associated with tumor
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Predominant Cytology
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Surgical Margins
• “Present” • “Uninvolved” • Distance of residual tumor to margins in
excision specimens – Not required element in template – Measured distance from pathology specimens
may differ from distance of “clinical” surgical margins
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Primary Tumor Parameters • Initial histologic evaluation is critical in
diagnosis and T staging – Breslow thickness – Mitotic rate – Ulceration
• Clinically suspected melanoma – Excise entire lesion – Deep saucerization – Punch biopsy
• Superficial shave biopsy or curettings should be avoided
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Outline of Presentation
1. Cancer protocol template 2. Major histologic types of melanoma 3. Primary parameters that impact staging 4. Other histologic parameters 5. Lymph node status and satellitosis 6. Distant metastasis
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TNM • T = Primary tumor
(Stage I and II) – Breslow (Tumor)
thickness – Mitotic rate – Ulceration
• N = Regional
metastasis (Stage III) – Lymph node
• Microscopic • Macroscopic
– Skin/subcutaneous tissue (Intransit metastasis/satellites)
• M = Distant metastasis (Stage IV) – Lymph node – Skin/subcutaneous
tissue – Visceral metastasis
• Pulmonary • Non-pulmonary
– Serum LDH
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Regional Metastatic Melanoma
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Sentinel Lymph Node (SLN)
• Sentinel lymph nodes in melanoma – Positive in ∼20% of patients
• 15% > 1.0 mm • 5% < 1.0 mm • 16% detected on initial H&E • 4% detected with additional sections/IHC
– <5% with extracapsular extension • Frozen section of SLN not recommended
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SLN Isolated Melanoma Cell
• Criteria for positive lymph node – Any tumor deposit size – Isolated tumor cell on IHC acceptable – H&E confirmation no longer required – Positive for one melanocytic marker (HMB45,
Melan-A/Mart-1) – Cells have malignant morphology
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Detection of Micrometastasis
Metastatic melanoma
H&E Panmelanocytic cocktail (HMB-45, tyrosinase, Mart-1)
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Pitfall in Interpretation
Melan-A positive macrophages in SLN
H&E Melan A
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Pitfall in Interpretation
Sentinel lymph node
Melan A HMB-45
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Template for Lymph Nodes • Number of lymph nodes
(SLN and non-SLN) • Number containing
metastasis • Tumor location
– Subcapsular – Intraparenchymal
• Tumor size – Reported in mm – Measured gross exam or slide
• Extracapsular extension • Matted lymph node
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Extracapsular Extension
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In-transit Metastasis/Satellites (N2c)
• 2.0 cm distance • Arbitrary
measurements – >0.05 mm – 0.3 mm from primary
component • Deposit separated
by normal tissue
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Microscopic Satellitosis
Normal dermis
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Pitfalls in the Assessment of Microscopic Satellitosis
• Colonization of adnexal structures • Intravascular deposit • Lesion contiguous on deeper sections • Incidental nevus
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Colonization of ducts
Intravascular collection of tumor
Pitfalls of Satellitosis
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Satellitosis
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Outline 1. Cancer protocol template 2. Major histologic types of melanoma 3. Primary parameters that impact staging 4. Other histologic parameters 5. Lymph node status and satellitosis 6. Distant metastasis
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TNM • T = Primary tumor
(Stage I and II) – Breslow (Tumor)
thickness – Mitotic rate – Ulceration
• N = Regional
metastasis (Stage III) – Lymph node
• Microscopic • Macroscopic
– Skin/subcutaneous tissue (Intransit metastasis/satellites)
• M = Distant metastasis (Stage IV) – Lymph node – Skin/subcutaneous
tissue – Visceral metastasis
• Pulmonary • Non-pulmonary
– Serum LDH
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Distant Melanoma Metastasis (M)
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Template for Distant Metastasis
• pMX-removed from AJCC-TNM system • pM0 stage defined clinically • Pathologists should not report pMx or pM0 • pM1 reported only when metastases
documented by pathology examine • Report: pM Not applicable
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Therapy Related Tumor Regression
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TNM Descriptors
• Post-therapy state (y) pTNM • Retreatment classification (r) pTNM
– Recurrent tumor – Not change original stage
• Autopsy classification (a) pTNM – Disease only recognized post mortem
• R classification (residual tumor) – RX, R0, R1 (micro), R2 (macro)
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Summary of Melanoma Parameters • Elements for cancer template • Primary tumor characteristics that impact
AJCC-TNM staging • Breslow thickness
– Pitfalls in measurement – Include PNI in Breslow thickness
• Pitfalls in evaluation – Mitotic figures – Ulceration – Satellitosis – SLN
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THANK YOU
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