Audit of plastic surgeons understanding of pathology reports of skin neoplasia

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1 The British Association of Plastic Surgeons (2004) 57, Audit of plastic surgeons understanding of pathology reports of skin neoplasia Y.S. Lau a, S.K. Suvarna b, *, L. Kangesu a, A. Mosahebi a a St Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Court Road, Chelmsford CM1 7ET, UK b Department of Histopathology, Northern General Hospital NHS Trust, Herries Road, Sheffield S5 7AU, UK Received 21 March 2003; accepted 28 November 2003 KEYWORDS Skin neoplasia; Histopathology; Pathology; Minimum dataset Summary This audit was set up to investigate Plastic Surgeons perception of minimum standards of reporting of skin neoplasia at the time of publication of the Royal College of Pathologists guidelines. Eight histopathology case reports of skin neoplasia were formulated; four had the minimum information required and four had vital information omitted. Surgeons were asked to evaluate and suggest management. Marks were allocated for awareness of substandard reporting and for patient management. Fortythree out of 60 questionnaires were returned. Consultants had a significantly higher total score compared to the other grades ðp, 0:05Þ: A high knowledge score was correlated with a high management score. However, awareness of minimum data was relatively poor across all grades. The majority of participants themselves were unaware of the new guidelines (38/43). Awareness of the guidelines and increased understanding of basic pathology should correct these weaknesses. Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. In the last decade, Plastic Surgeons have seen an increasing number of patients with skin neoplasia, due to an increase in incidence and greater public awareness. 1 Ideal patient management requires sound knowledge of the pathology in question in order to guide treatment options. Prognostic indicators 2 4 are well recognised within the literature both by Plastic Surgeons and Pathologists. The Royal College of Pathologists has produced evidence-based guidelines defining the minimum standards of reporting common skin cancers to prevent the proliferation of numerous diverse and *Corresponding author. Tel.: þ ; fax: þ address: s.k.suvarna@sheffield.ac.uk possibly conflicting local guidelines. 5 These proposals should be implemented for the following reasons: To achieve consistency in histopathology reporting with regards to terminology and content, in order to facilitate liaison at the multidisciplinary team level and collaboration between cancer centres and units. To aid patient management and treatment by providing minimum histopathological information necessary to assist decision-making. To provide accurate prognostic information. To create a common database for clinical audit, which will provide feedback to clinicians regarding their quality of treatment. S /$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi: /j.bjps

2 Audit of plastic surgeons understanding of pathology reports of skin neoplasia 135 To create a common database for research and entry into clinical trials. To create a common database for epidemiological monitoring and detection of changing patterns of disease. Plastic Surgeons historically have had a good understanding of pathology reports. This audit was set up to assess the level of knowledge at the time of the publication of the minimum data standards, and to find out whether, they were aware of the new published guidelines. Methods Eight histopathology reports of common skin neoplasia were formulated by a single Consultant Histopathologist, such that four reports were considered to have the minimum information required for planning further management, and the other four reports had the minimum information omitted (Appendix 1). The pathology reports in the format of a questionnaire were distributed to a group comprising Plastic Surgeons and trainees. The questionnaire contained eight case reports. Each surgeon was asked to state whether, each report was satisfactory or deficient, to highlight the deficiency if it existed and to suggest appropriate management for the patient in question. Each case report carried a maximum of four points; two points were given for correctly deciding if the report contained sufficient information, and a score of 0 2 points were given for management. The scores were tabulated under the headings knowledge and management, respectively. The answers were marked against the standard answer provided by two of the authors (S.K.S./A.M.) (Appendix 2). Other Pathologists commentary is also given alongside the answers. Results A total of 60 questionnaires were distributed, of which 43 were returned, giving a responder rate of 72%. Eight participants completed the questionnaire just before formal publication of the guidelines; the remaining 35 participants completed the questionnaire just after guideline publication. The participants and nonresponders were divided into four groups according to grade, as shown in Tables 1a and b. Thirty-five participants stated they were unaware of the guidelines. Table 1a Grade Scores ranged from 6 to 26 out of a total of 32. The Consultant participants obtained a mean total score of 19.7 out of 32 (made up of knowledge score of 10.9 and management score of 8.8). Specialist Registrars in years 4 6 obtained a mean total score of 15.9 (knowledge score of 9.5 and management score 6.4). Specialist Registrars in years 1 3 obtained a mean total score of 13.6 (knowledge score of 9.0 and management score of 4.6). Senior House Officers obtained a mean total score of 13.9 (knowledge score 8.6 and management score 5.3). These results are tabulated in Table 2. Table 3 shows the performance of participants against each pathology report. Statistical analysis of the results using the Mann Whitney U-test shows a significantly higher total score in the Consultant group ðp, 0:05Þ compared to the other grades. There was no significant difference between the other groups. Discussion Distribution of grades of participants Consultant 10 Specialist Registrar (years 4 6) 15 Specialist Registrar (years 1 3) 14 Senior House Officer 4 The nature of modern cancer therapy demands considerable familiarity with the pathological basis of malignancy. A good knowledge of basic pathology is essential for making decisions regarding further management of all types of malignancies. Our results confirm this fact, showing that a high knowledge score correlated with a high management score. Consultants achieved a significantly higher total score than the other grades. However, we demonstrated disappointingly poor scores across all the grades. Although the sample size is small, we feel that it is sufficient to be representative. The performance of a large proportion of Table 1b Grade Distribution of grades of nonresponders Consultant 2 Specialist Registrar 6 Senior House Officer 9 n n

3 136 Y.S. Lau et al. Table 2 Mean scores obtained according to grade Grade Knowledge score (16) Management score (16) Total score (32) Consultant Specialist Registrar (year 4 6) Specialist Registrar (year 1 3) Senior House Officer participants fell short of the recommended standards. Out of the eight cases presented, only two were correctly managed by more than 50% of participants. The results of this audit might be argued to show that Plastic Surgeons had a poor knowledge base with regard to skin cancer reporting. However, it should be remembered that the audit was set up to deliberately enforce binary scoring (satisfactory/ unsatisfactory report) and therefore the results are not necessarily surprising. Certainly, many of the surgeons who were involved in the audit commented that they would have made contact with the Pathology Department upon receipt of such reports in order to clarify matters/seek further information directly with the Pathologist in question, indicative of good practice. No opportunity to record this was made available in the answer sheet, again forcing the surgeon to declare a polar view. The possibility of personal bias with regard to the production of the histopathology reports needs to be considered, since only one Pathologist was involved with the construction of the questionnaire. Since the audit, this questionnaire has been circulated amongst five other Consultant Histopathologists, two of whom have a particular interest in dermatological disease. Their comments and criticisms are indicated by italicised script alongside the standard answers. Conclusion Perfection in reporting standards and style is the aspiration of all good Histopathologists in the UK. Hitherto with variable training in different centres and with the individual needs of different clinical groups even within a single hospital it has been difficult to achieve standard reporting style and content. The introduction of the Royal College of Pathologists guidelines for skin cancer reporting, and indeed other neoplasia, have found considerable clarification with regard to the needs of clinicians today and those involved in strategic planning of healthcare resources for the future. Drawn up to promote good standards of care across the whole country, the guidelines are intended to promote the integration of care between medical specialties for the benefit of the patient. It was clear from initial analysis of the questionnaires that some Plastic Surgeons felt this was an unfair exercise given that it was done at the time of publication of the guidelines, and that no similar assay had been previously performed against Histopathologists. Although formal publication occurred in February 2002, hard copies reached the Pathology departments nationwide around April 2002, the guidelines had been widely discussed in the Royal College of Dermatologists and Plastic Table 3 Distribution of correct responses for each pathology report Pathology report Participants with the correct response for Deciding if report contained minimum information, n (%) Management, n (%) 1 28 (65) 19 (44) 2 27 (63) 29 (67) 3 43 (100) 20 (47) 4 24 (56) 14 (33) 5 27 (63) 15 (35) 6 19 (44) 10 (23) 7 17 (40) 22 (51) 8 26 (60) 15 (35)

4 Audit of plastic surgeons understanding of pathology reports of skin neoplasia 137 Surgeons before February It is stressed that this audit was simply a benchmark assessment of knowledge at the time of guideline publication, with the object to retest this knowledge base 2 years following guideline publication. Plastic Surgeons should familiarise themselves with the published standards in order to ensure a high quality of care for their patients. In addition, we recommend that more emphasis be drawn toward the education of trainees with regard to understanding basic pathology. With the implementation of these changes, a further monitoring will be undertaken to complete the audit cycle. 6 Appendix A Histopathology reports in questionnaire 1. This is a skin ellipse measuring 9 5 3mm 3, with a central 4 mm diameter papule. Histological examination confirms the presence of a 1.9 mm deep nodular basal cell carcinoma with a deep and peripheral margin clearance of 0.5 and 0.9 mm, respectively. 2. This is a skin ellipse measuring mm 2 with a depth of 6 mm. Centrally there is a brown macule measuring 9 mm diameter. All the tissue has been examined in serial pieces revealing an invasive superficial spreading malignant melanoma, composed of nonpigmented epithelioid cells, that penetrates the dermis to a Breslow depth of 0.7 mm, Clark s level III. There is a mild host lymphoid reaction locally. The melanoma shows a mitotic rate of four mitoses per square mm. No blood or lymphatic vessel invasion is seen. No pre-existing nevus, satellite focus or ulceration is identified. Local excision clearance is complete with a deep margin of 3.1 mm and a lateral clearance of 2.3 mm. 3. This is a polypoid piece of skin measuring 9 7 6mm 3. Focal ulceration is noted. Histological examination reveals a moderate grade nonkeratinising squamous cell carcinoma. There is a mild host lymphoid reaction. No blood or lymphatic vessel invasion is seen. 4. This is an ovoid piece of skin measuring mm 2 with a depth of 5 mm. Centrally there is an ulcerated grey tumour measuring 15 mm diameter maximum. The central tumour is an ulcerated Merkel cell carcinoma that shows positive staining with CK20 and dot positivity with cytokeratin 5.2. No blood or lymphatic vessel invasion is seen, but the tumour is noted to be present at the deep resection margin. The peripheral margin is clear of neoplasia. 5. This is a skin ellipse measuring 14 7mm 2 with a depth of 2 mm. All this tissue has been examined in serial pieces revealing a superficial basal cell carcinoma that is fully excised in the planes examined. 6. A strip of skin measuring 6 4 3mm 3. This incisional biopsy reveals part of a microcystic adnexal carcinoma. 7. This is a skin ellipse measuring 9 7mm 2 with a depth of 5 mm. Centrally there is a pink papule measuring 5 mm. Histological examination reveals a nodular cluster of lymphocytes within the dermal tissues, extending into the subcutis. Immunohistochemistry reveals both T and B-cell components with scattered CD21 cells and no staining for CD5 or CD10. Bcl-2 staining is equivocal. The appearances may represent lymphocytoma cutis, although this would require clinico-pathological correlation. 8. An ovoid piece of skin bearing tissue measuring mm 2 with a depth of 10 mm this seen with an ulcerated beige tumour measuring 15 mm in maximum dimension. The tumour is a high-grade leiomyosarcoma that shows marked pleomorphism and a mitotic count of five mitoses per square millimetre. The tumour is clear of the peripheral boundary by 6 mm. There is a mild host lymphoid reaction. No lymphatic invasion is seen. Appendix B Answers used in marking questionnaires 1. Satisfactory. No deficiencies. Allows decision making regarding treatment. 2. Satisfactory. No deficiencies. Allows consideration of whether to proceed to wider clearance or wait-and-watch. Since the publication of the guidelines, it is noted that the phrase vertical growth phase should be used together with a gradation with regard to the lymphoid infiltrate. 3. Unsatisfactory. No size of tumour or clearance margins (deep and lateral), or the subtype of squamous cell carcinoma. Insufficient information for clinical decision making. 4. Unsatisfactory. No peripheral clearance of tumour stated. Allows decision making with regard to an aggressive sub-type carcinoma. Need for wide excision and dermatology multidisciplinary team (MDT) referral.

5 138 Y.S. Lau et al. 5. Unsatisfactory. No macroscopic measurements. Insufficient histological measurements defined. Insufficient data for review or follow-up. 6. Satisfactory. Measurements may not be relevant as this is only an incisional biopsy. Sufficient data to indicate aggressive sub-type carcinoma with associated clearance problems. May need MDT referral. Some Pathologists would grade this type of carcinoma and specifically mention perineural invasion of lymphatics if present/absent. 7. Satisfactory. The pathologist is querying whether specimen is a benign lymphoid proliferation or nonhodgkin s lymphoma. Further discussion with pathologist and other clinicians is needed to resolve management (dermatology and/or lymphoma MDT). Staging investigations need to be considered. Some aspects of this biopsy report are inaccurate/confusing with regard to the subtype of lymphoma/lymphoid population. This was deliberately used as an example following a recent medico-legal case. 8. Unsatisfactory. No deep clearance given; vascular invasion not quoted. Insufficient data for decision making, but needs referral to sarcoma MDT. References 1. Ko CB, Walton S, Keczkes K, Bury HP, Nicholson C. The emerging epidemic of skin cancer. Br J Dermatol 1994;130: Masback A, Olsson H, Westerdahl J, Ingvar C, Jonsson N. Prognostic factors in invasive cutaneous malignant melanoma: a population-based study and review. Melanoma Res 2001;11: Cherpelis BS, Marcusen C, Lang PG. Prognostic factors for metastasis in squamous cell carcinoma of the skin. Dermatol Surg 2002;28: Motley R, Kersey P, Lawrence C. Multiprofessional guidelines for the management of the patient with primary cutaneous squamous cell carcinoma. Br J Dermatol 2002;146: Minimum dataset for the histopathological reporting of common skin cancers. Royal College of Pathologists Working Group on Cancer Services, 2002 (website 6. National Institute for Clinical Excellence, Principles for best practice in clinical audit. Oxford: Radcliffe Medical Press; 2002.