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%

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) Free text/proforma

• 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

• MDT– 52 vrs 74 (59%)

• Proforma – 63 vrs 63 – all central

• Non-proforma – 52 Local 100%– 11 Special 17%

One lab sent SqCC coded

Lab Cases

1 25

2 9

3 25

4 2

5 24

6 20

7 21

126

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

• MDT– 86 vrs 73 (46%)

• Proforma – 65 vrs 94– all central

• Non-proforma – 86 Local 100%– 8 Special 17%

Lab Cases

1 25

2 21

3 25

4 25

5 23

6 22

7 18

159

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 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 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?