Skin SSG (Anglia East & Anglia West)

Transcription

1 Skin SSG (Anglia East & Anglia West) Author: Dr Jennifer Garioch, Consultant Dermatologist Dr Pamela Todd, Consultant Dermatologist Approved by: Anglia Cancer Network Skin NSSG Approved on: Reviewed and re-issued with no changes 11 th May 2011 Next review due: May 2013 Ref: AngCN-SSG-S3 Version 6.0

2 CONTENTS Introduction... 3 General Considerations... 3 Pathologists... 3 Melanoma... 3 Sampling of specimens... 3 Pathological reporting of Melanoma... 3 Squamous Cell Carcinoma... 4 Sampling of Lesions... 4 Pathological Reporting of Squamous Cell Carcinoma... 4 Basal Cell Carcinoma... 4 Pathological Reporting of Basal Cell Carcinoma... 4 Cutaneous T Cell Lymphoma (CTCL)... 5 Skin Biopsies for CTCL... 5 Pathological Reporting of CTCL... 5 AngCN Skin Cancer SMDT (East and West) Meetings:... 6 Pathological Aspects... 6 Skin Cancer SMDT (East)... 6 Skin Cancers... 6 Melanoma:... 6 Squamous cell carcinoma:...6 Basal cell carcinoma:... 7 Other cases:... 7 Skin lymphoma SMDT (East) meeting organisation... 7 Skin Cancer SMDT (West)... 8 Malignant Melanoma... 8 Squamous Cell Carcinoma... 9 Basal cell carcinomas Skin lymphoma SMDT (West) meeting organisation Referral to Addenbrooke s for SMDT review Evidence of Agreement Monitoring the Effectiveness of the Process Page 2 of 13

3 Introduction Systematic, standardised and accurate specimen preparation, histopathology examination and reporting are essential steps in the management of patients with skin cancer. High quality histopathology is critical in determining the diagnosis, prognosis and optimal therapy for skin cancers. Pathology databases are central to the ensuring that all new skin cancer cases can be identified and submitted for discussion to the relevant MDTs. General Considerations: Pathologists, Specimen Preparation, Sampling and Reporting Pathologists Pathologists examining skin cancers should be core members of the MDT and should participate in a general or skin EQA. Melanoma Sampling of specimens Excised tumours should be sampled in their entirety, unless very large, when sampling is at the pathologist s discretion Pathological reporting of Melanoma Pathological reports should contain the following minimum data set: Site Surgical procedure for example excision or re-excision, punch, or shave biopsy Macrosopic description including dimensions of the specimen Comment as to whether this is a primary lesion, a local recurrence or a metastatic lesion. Ulceration whether present or absent and its extent Breslow depth to the nearest 0.1mm The growth phase should be recorded i.e. whether purely radial growth phase or whether there is any evidence of vertical growth phase Mitotic rate per sq mm Presence of lymphovascular invasion Presence of perineural involvement Presence or absence of regression Histological type Completeness of excision and peripheral and deep margins recorded in mm Pathological staging Tumour infiltrating lymphocytes Page 3 of 13

4 Pre-existing naevus Squamous Cell Carcinoma Sampling of Lesions Excised lesions should be adequately sampled. Pathological Reporting of Squamous Cell Carcinoma Pathological reports should contain the following minimum data: Site Surgical procedure for example excision or re-excision, currettage punch, or shave biopsy Macrosopic description including dimensions of the specimen Thickness of lesion in mm, excluding surface layers of keratin. Degree of differentiation (Broder s grades if preferred) Presence of lymphovascular invasion Presence of perineural involvement Histological subtype if relevant for example whether desmoplastic, acantholytic, spindle cell or verrucous Clearance of peripheral and deep margins measured Basal Cell Carcinoma Pathological Reporting of Basal Cell Carcinoma Pathological reports should contain the following minimum data: Site Surgical procedure for example excision or re-excision, curettage, punch, or shave biopsy Macrosopic description including dimensions of the specimen Perineural involvement, if present Metatypical/basisquamous differentiation, if present Histological subtype for example whether nodular, superficial, infiltrative, micronodular etc Clearance of peripheral and deep margins measured Breslow depth to be reported on incisional/punch biopsies in order to determine feasibility of photodynamic therapy. Page 4 of 13

5 Cutaneous T Cell Lymphoma (CTCL) Skin Biopsies for CTCL Repeat skin biopsies from lesional skin are often required to confirm a diagnosis of CTCL Histology, immunophenotypic and preferably TCR gene analysis should be performed on all tissue samples. Fresh tissue should ideally be available for molecular studies, Pathological Reporting of CTCL The following should be noted; The presence or absence of epidermotropism Depth of the infiltrate Morphology or cytology of atypical cells and the presence of large cell transformation Folliculotropism, syringotropism, granuloma formation, angiocentricity and subcutaneous infiltration Immunophenotype markers should be performed on paraffin embedded tissue and include T cell markers (CD2 CD3 CD4 CD8) B Cell markers (CD20) and the activation marker CD30. Additional markers such as p53 may have prognostic significance in mycosis fungoides. In CTCL variants, markers of cytotoxic function such as TIA-1, the monocyte/macrophage marker CD68 and the NK cell marker CD56 may be useful. Ideally all the pathology should be reviewed by a central panel (usually within cancer centres0 The histology (after correlation with the clinical feature should be classified according to an integration of the WHO and EORTC classification (Grade A/level 3) Page 5 of 13

6 AngCN Skin Cancer SMDT (East and West) Meetings: Pathological Aspects Skin Cancer SMDT (East) The skin cancer SMDT for the eastern part of the network is based at the Norfolk and Norwich University Hospital Skin Cancers Monday (weekly), starting at 8:00 Pathology core MDT members: Drs Tim Barker, Urszula Carr, Joe Murphy, Pathology extended MDT members: Drs Laszlo Igali, Jamie Sington and Geoff Waters. Cases discussed: Melanoma: The following cases are included in the MDT meeting: new melanoma, metastatic and recurrent melanoma positive sentinel lymph node biopsies positive lymph nodes following lymph node clearance dysplastic naevi if there is a concern about the possibility of melanoma melanomas excised or biopsied in primary care All melanomas with a Breslow thickness of 0.75mm and greater are discussed at the MDT. Selected cases with histopathological points of interest or difficulty are also discussed. Melanomas with a Breslow thickness of less than 0.75mm which have been adequately excised and with no further clinical, histological or management issues are noted but not discussed. Squamous cell carcinoma: The following cases are discussed at the MDT meeting: tumours 6mm thick or more pt2 or above incompletely or narrowly excised tumours (<1mm margins) perineural or vascular invasion poorly differentiated tumours recurrent or metastatic tumours tumours from special or high risk sites (ear, lip, perineum, eyelid/canthus, sole of foot) Page 6 of 13

7 specific histological subtypes (clear cell, desmoplastic, verrucous, carcinosarcoma, and adenosquamous) those associated with immunosuppression including transplant tumours associated with burns, albinism, xeroderma, post-irradiation squamous cell carcinomas excised or biopsied in primary care All other cases are listed but not discussed unless there is a particular issue. Basal cell carcinoma: basal cell carcinomas incompletely or narrowly excised (< 1mm margin) tumours with perineural invasion tumours for consideration of Mohs surgery basal cell carcinomas (except superficial BCCs) excised in primary care Other cases: The following cases are also discussed at the MDT meeting: sarcoma atypical fibroxanthoma, dermatofibrosarcoma protuberans, leiomyosarcoma, sarcomas superficial to the deep fascia, sarcomas biopsied or excised in primary care rare skin tumours as listed in the NICE IOG guidance The list of patients to be discussed is generated by searching the NNUHFT histopathology database. Cases from other Trusts James Paget, Queen Elizabeth Hospital and Ipswich - are submitted by faxing or ing the MDT proforma. Other cases to be discussed can be added by ing or phoning Lorraine Nelhams, the MDT co-ordinator for NNUHFT or Rachel Stevenson, the Patient Pathway Co-ordinator for NNUHFT. Cases to be added - via proforma - by to Lorraine Nelhams (coordinator), by midday preceding Thursday. Cases collected and reviewed by pathologist, all cases discussed at the MDT. Decisions and discussion recorded onto the proforma during the meeting, further investigations are initiated, completed and the relevant information recorded on the subsequent meeting. If necessary, supplementary report issued. Pathology processing and reporting: According to the RCPath Standards and Minimum Datasets. The pathology report contains the necessary elements according to the above document, in case of the malignant melanoma, in a form of a template-based report. Skin lymphoma SMDT (East) meeting organisation Page 7 of 13

8 The skin lymphoma MDT for the eastern part of the network is based at the Norfolk and Norwich University Hospital and is held bimonthly on Wednesdays at Pathology lead - Dr James Sington Other core skin lymphoma MDT pathology members: Drs Laszlo Igali and Tim Barker Cases discussed: all skin lymphoproliferative diseases, suggested for discussion by the pathologists and dermatologists. Cases to be added - by midday preceding Thursday. Cases collected and reviewed by pathologist, all cases discussed at the MDT. Pathology processing and reporting: According to the RCPath Standards and Minimum Datasets. General comments: Skin malignancies reported by all pathologists, difficult/unusual cases are referred to a core team of pathologist with special interest in dermatopathology. This core team includes: Dr T Barker, Dr J Murphy, Dr G Waters, Dr J Sington, Dr Urszula Carr and Dr L Igali. The malignant melanocytic lesions are double reported at the discretion of the reporting pathologists. Skin cancer cases requiring a further opinion are sent to individual national experts. Skin Cancer SMDT (West) The SMDT (West) is based at Cambridge University Hospital Trust (Addenbrooke s). The West Suffolk Hospital, Peterborough District Hospital, Bedford Hospital and Hinchingbrooke Hospital participate in the SMDT via a video teleconferencing link Pathology leads Dr Ed Rytina, Dr Vicky Bardsley and Dr Rebecca Brais (core members) Weekly (Monday) at 11-15am The cases discussed fall into 4 main groups, namely Melanomas, squamous cell carcinomas, basal cell carcinomas and cutaneous lymphomas. Malignant Melanoma Pathological Case Identification List of patients from Addenbrooke s generated by the histopathology department (Anne Coghill) on the Wednesday before the meeting using Meditech search: PMEL (searches the SNOMED diagnosis field for melanoma, lentigo maligna, Hutchinson s, Spitz, spitzoid and dysplastic naevus ). Page 8 of 13

9 Meditech generated list reviewed and revised by pathologist. Included in the meeting are all new melanoma metastatic melanoma,, lymph node biopsies, FNAs and excisions, dysplastic naevi where there was clinical concern about melanoma. Exclusions dysplastic naevi in which there was no clinical concern about melanoma. Lesions with a benign clinical diagnosis and a benign histological diagnosis are not reviewed. Revised list sent to MDT coordinator (Claire Herbert). A comprehensive list of all patients to be discussed is then compiled by the MDT coordinator and circulated to SMDT members Additions by pathologists, clinicians or melanoma nurse specialist by or phone to MDT coordinator. Selected relevant slides from all cases reviewed by pathologist by rapid review only, with rapid assessment of histological parameters. The cases discussed in detail at the MDT meeting are according to Skin SSG guidelines for the melanoma MDT, which includes all cases of stage 2b and above selected cases with histopathological points of interest or difficulty. Excised melanomas which have been managed according to the ACN guidelines with no further clinical, histological or management issues are noted but not discussed in detail, providing there is adequate documentation that management has been completely in accordance with ACN guidelines Decisions and discussions recorded on a JCIS proforma by the lead clinician at the meeting which is subsequently sent to the relevant clinician responsible for the care of the patient and the general practitioner. Squamous Cell Carcinoma Pathological Case Identification A list of patients from Addenbrooke s generated by the histopathology department (Anne Coghill) on the Wednesday before the meeting using Meditech search: PSCC (searches the SNOMED diagnosis field for Squamous cell carcinoma Meditech generated list reviewed and revised by the pathologist. Included in the meeting are all invasive SCCs. Those for histological review (as agreed by the Skin SSG) are: incision/punch biopsies, Page 9 of 13

10 tumours over 6mm depth, Clark s level 5, pt2 or above, incompletely excised or close (under 1mm) margins, poorly differentiated, vascular or perineural invasion, recurrent tumours metastases, tumours from special or high risk sites (ear, lip, perineum, eyelid/canthus, sole of foot), specific histological subtypes (clear cell, desmoplastic, verrucous, carcinoma, adenosquamous) those associated with immunosuppression (including transplant), xeroderma, albinism, burns, LS et A, post-irradiation or other pre-existing dermatoses. All other cases (i.e. thin, fully excised tumours) are listed but not discussed (unless there is a particular clinical issue); the histology is NOT reviewed before the meeting. In situ disease is not included in the meeting. Decisions and discussions recorded on a JCIS proforma by the lead clinician at the meeting which is subsequently sent to the relevant clinician responsible for the care of the patient. Post MDT investigations initiated and any additional information or alterations in diagnosis included in an addendum to the original report. Basal cell carcinomas Weekly Monday 11-15am Pathology lead - Dr Ed Rytina Pathological Case identification List of patients from Addenbrooke s generated by the histopathology department (Anne Coghill) on the Wednesday before the meeting using Meditech search: A list of all Basal cell carcinomas is obtained and noted by the MDT. The cases discussed are as follows: Basal cell carcinomas with involved or close margins. Basal cell carcinomas requiring Mohs microsurgery Revised lists in which patients to be noted and those to be discussed are highlighted and sent to MDT coordinator (Claire Herbert). Additions by pathologists or clinicians by or phone to MDT Coordinator. Selected relevant slides from all cases reviewed by pathologist by rapid review only, with rapid assessment of histological parameters. Page 10 of 13

11 The cases discussed at the MDT meeting are according to Skin SSG guidelines for the BCC MDT, which includes selected cases with histopathological points of interest or difficulty. Adequately excised tumours with no further clinical, histological or management issues are noted but not discussed. Decisions and discussions recorded by the lead clinician at the meeting. Post MDT investigations initiated and any additional information or alterations in diagnosis included in an addendum to the original report. Skin lymphoma SMDT (West) meeting organisation The skin lymphoma MDT for the western part of the network is based at Addenbrooke s Hospital. Skin lymphoma cases are discussed in: Weekly Skin cancer SMDT (11-15 Monday am) when urgent assessment of cases and urgent management plans are required. Three times yearly SMDT where the cases are discussed in greater depth and the patients also attend for clinical assessment. (Usually 2-30 pm the 3rd Wednesday afternoon of the month) Pathology lead - Dr Rebecca Brais Other core skin lymphoma MDT pathology members: Drs Ed Rytina, Dr Vicky Bardsley Cases discussed: all skin lymphoproliferative diseases, referred for discussion by pathologist, clinical oncologists and dermatologists. Cases to be added - by midday preceding Thursday. Cases collected and reviewed by pathologist, all cases discussed at the MDT. Pathology processing and reporting: According to the RCPath Standards and Minimum Datasets. Referral to Addenbrooke s for SMDT review Cases from other trusts (WSH, PDH, Hinchingbrooke and Bedford) to be discussed fortnightly at the SMDT are submitted by faxed or ed by proforma by the preceding Thursday (mid-day). Standard cases are not sent for routine central histology review but where histopathology review is required, the slides and blocks are sent for review to Dr Rytina, Dr Bardsley or Dr Brais Cases can be referred for histopathological specialist review by local Pathologists if required, either for diagnosis before the SMDT, or after discussion at the SMDT following a decision for referral by the MDT. Request for specialist review can be made to the local pathologist by the patient s clinician. Pathology Referral pathways: Page 11 of 13

12 Skin malignancies reported by all pathologists, difficult/unusual cases are referred to a core team of pathologist with special interest in dermatopathology. This core team includes: Dr Ed Rytina, Dr Vicky Bardsley and Dr Rebecca Brais. The malignant melanocytic lesions are double reported at the discretion of the reporting pathologists Skin cancer cases necessary for secondary and tertiary referral to Addenbrooke s, St John s Institute of Dermatopathology or individual national experts. Page 12 of 13

13 Evidence of Agreement This Guideline has been agreed by: The Anglia Cancer Network Board Name: Carole Taylor-Brown Position: Chief Executive Suffolk PCT and Chair of the Anglia Cancer Network Board Date agreed: 9 th June 2010 The SSG Members This document was agreed to at the Joint Skin SSG Meeting on 12 th May Monitoring the Effectiveness of the Process a) Process for Monitoring compliance and Effectiveness - Review of compliance as determined by audit. Any non compliance to be presented by QA Manager to the AngCN Business Meeting on an annual basis the minutes of this meeting are retained for a minimum of five years. b) Standards/Key Performance Indicators This process forms part of a quality system working to, but not accredited to, International Standard BS EN ISO 9001:2008. The effectiveness of the process will be monitored in accordance with the methods given in the quality manual, AngCN-QM Equality and Diversity Statement This document complies with the Suffolk PCT Equality and Diversity statement an EqIA assessment is available on request to Anglia Cancer Network QA Manager, Gibson Centre, Exning Road, Newmarket, CB8 7JG. Disclaimer It is your responsibility to check against the electronic library that this printed out copy is the most recent issue of this document. Please notify any changes required to the Anglia Cancer Network Quality Assurance Manager Page 13 of 13