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• Local MDT
– 31
• Proforma – 75
• Non-proforma – 4 central (6%) – 22 local (71%)
Lab Cases
1 25
2 8
3 19
4 4
5 26
6 11
7 8
Results - Melanoma
• All cases– Macroscopic description skin ellipse– Macroscopic description lesion– Excision margins
Results - Melanoma
Critical results
• Breslow 1 (1/0)
• Clark’s 6 (5/1)
• Ulceration 7 (7/0)
• 12 cases do not include vital data
• All destined for review
Results - Melanoma
• LVI 5 (5/0)
• PNI 11 (11/0)
• Microsat 52 (22/30)
• Subtype 13 (12/1)
• Growth phase 9 (9/0)
• Stage 21 (18/3)
Results - Melanoma
• Mitotic rate 2 (2/0)
• Regression 17 (15/2)
• TiL 14 (14/0)
• All data items provided 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
• 126 cases• Local MDT
– 52 (41%)
• Proforma – 63 (all central)
• Non-proforma – 11 central (17%) – 52 local (82%)
Lab Cases
1 25
2 9
3 25
4 2
5 24
6 20
7 21
Results - SCC
• All cases– Macroscopic description skin ellipse– Macroscopic description lesion– Excision margins
Results - SCC
Critical results
• Grade 8 (8/0)
• Thickness 10 (10/0)
• Level 32 (30/2)
Results - SCC
• LVI 7 (7/0)
• PNI 22 (22/0)
• Subtype 47 (47/0)
• Risk 86 (54/32)
• Stage 65 (41/24)
Results - SCC
• Correct assessment of risk– Recorded in 40
• 3 incorrect• 2 insufficient data in report to assess
• All data items provided 25%• 32 cases (2/30)
BCC
• Established data set
• Is it really cancer?
• Multiple specimens common
Results - BCC
• 159 cases• Local MDT
– 86 (54%)
• Proforma – 65 (all central)
• Non-proforma – 8 central (17%) – 86 local (100%)
Lab Cases
1 25
2 21
3 25
4 25
5 23
6 22
7 18
Results - BCC
• All cases– Macroscopic description skin ellipse– Macroscopic description lesion
Results - BCC
Key results
• Growth pattern 1 (1/0)
• Level 57 (56/1)
• Margins 2 (1/1)
Results - BCC
• LVI 28 (27/1)• PNI 15 (14/1)
• Risk 85 (85/0)• Stage 92 (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
radiation, burn or chronic inflammation
Site: Specimen type: Curette / Shave / Punch / Incisional ExcisionalSize: Length Width to a depth of
Size of lesion: mm high risk if >20mm Marker & ink: o’clock inked margin-Description:
LLP SH BB Tips: 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 HighMDT discussion: No Yes (excisional, high risk and incomplete)
Comments:
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
Questions?
