Protocol for the Examination of Specimens From Patients With Carcinomas of the Skin, Excluding Eyelid, Vulva, and Penis(*).
This protocol is intended to assist pathologists in providing clinically useful and relevant information as a result of the examination of surgical specimens. Use of this protocol is intended to be entirely voluntary. If equally valid protocols or similar documents are applicable, the pathologist is, of course, free to follow those authorities. Indeed, the ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of the individual circumstances presented by a specific patient or specimen.
It should be understood that adherence to this protocol will not guarantee a successful result. Nevertheless, pathologists are urged to familiarize themselves with the document. Should a physician choose to deviate from the protocol based on the circumstances of a particular patient or specimen, the physician is advised to make a contemporaneous written notation of the reason for the procedure followed.
The College recognizes that this document may be used by hospitals, attorneys, managed care organizations, insurance carriers, and other payers. However, the document was developed solely as a tool to assist pathologists in the diagnostic process by providing information that reflects the state of relevant medical knowledge at the time the protocol was first published. It was not developed for credentialing, litigation, or reimbursement purposes. The College cautions that any uses of the protocol for these purposes involve considerations that are beyond the scope of this document.
PROTOCOL FOR THE EXAMINATION OF SPECIMENS FROM PATIENTS WITH CARCINOMAS OF THE SKIN, EXCLUDING EYELID, VULVA, AND PENIS
I. Biopsy A. Clinical information 1. Patient identification a. Name b. Identification number c. Age (birth date) d. Gender e. Skin type (eg, Fitzpatrick type, other) 2. Responsible physician(s) 3. Date of procedure 4. Other clinical information a. Relevant history (1) Duration of lesion (2) Previous excision of present lesion (3) Previous similar lesions (4) Family history of similar lesions (5) Immunosuppression (6) Radiation exposure b. Relevant findings (1) Number of lesions and their distribution (2) Nature of advancing borders of lesion (3) Nature of pigmentation, if any (4) Ulceration (5) Palpable qualities of lesion (eg, hard, tender, nontender) (6) Fixation to deeper tissues on palpation 5. Clinical diagnosis 6. Procedure (eg, punch biopsy, incisional biopsy) a. Anatomic site of specimen(s) B. Macroscopic examination 1. Specimen a. Tissues received (specify nature and site) b. Unfixed/fixed (specify fixative) c. Number of pieces of tissue d. Shape/type of specimen (eg, ellipse, punch core, shave fragments) e. Dimensions f. Results of intraoperative consultation, if performed 2. Tumor, if discernible a. Location b. Descriptive features (1) Color (eg, pigmentation) (2) Consistency (3) Ulceration (4) Hemorrhage c. Dimensions d. Configuration 3. Tissue submitted for microscopic examination a. Submit all b. Frozen section tissue fragment(s) 4. Special studies (specify) (eg, histochemical stains, immunohistochemistry, electron microscopy, flow cytometry, cytogenetics) C. Microscopic evaluation 1. Tumor a. Histologic type (note A) b. Histologic grade, if applicable (note B) c. Depth of invasion, if appropriate (note C) (1) Measurement in millimeters for squamous carcinoma (note C) d. Perineural invasion (note D) e. Blood/lymphatic vessel invasion (note D) f. Nature of advancing margin of tumor, if able to be evaluated (eg, pushing, infiltrative)(*) (note D) (*) Applies principally to basal cell carcinomas. 2. Associated skin lesions a. Actinic keratosis b. Bowen disease 3. Additional pathologic findings, if present 4. Results of special studies (specify) 5. Comments a. Correlation with intraoperative consultations, if any b. Correlation with prior specimens, if any c. Correlation with clinical findings, as appropriate II. Excision A. Clinical information 1. Patient identification a. Name b. Identification number c. Age (birth date) d. Gender e. Skin type (eg, Fitzpatrick type, other) 2. Responsible physician(s) 3. Date of procedure 4. Other clinical information a. Relevant history (1) Duration of lesion (2) Previous excision of present lesion (3) Previous similar lesions (4) Family history of similar lesions (5) Immunosuppression (6) Radiation exposure b. Relevant findings (1) Lesion number and distribution (2) Nature of advancing borders of lesion (3) Nature of pigmentation, if any (4) Ulceration (5) Palpable qualities of lesion (eg, hard, tender, nontender) (6) Fixation to deeper tissues on palpation c. Clinical diagnosis d. Procedure e. Anatomic site of specimen(s) B. Macroscopic examination 1. Specimen a. Tissues received (specify type and site) b. Unfixed/fixed (specify fixative) c. Orientation of specimen, if indicated by surgeon d. Number of pieces of tissue e. Shape/type of specimen (eg, ellipse, punch core, shave fragments, curettings) f. Dimensions g. Results of intraoperative consultation, if any 2. Tumor a. Location b. Configuration c. Pigmentation (nature and extent) d. Dimensions (3) e. Descriptive characteristics (1) Color (2) Consistency (3) Ulceration (4) Fixation to other tissues (5) Necrosis (6) Hemorrhage f. Estimated depth of invasion from skin surface (specify compartment, eg, deep dermis, subcutis) 3. Margins (specify if involved or uninvolved by tumor, if appropriate to specimen) 4. Regional lymph nodes, if any a. Location (as specific as possible) b. Number c. Gross appearance (with measurement of macroscopically obvious tumor deposits within the nodes) 5. Additional pathologic findings, if present a. Actinic keratoses b. Melanocytic nevi c. Other 6. Tissue submitted for microscopic examination (specify location in specimen of each) 7. Special studies (specify) (eg, histochemical stains, immunohistochemistry, electron microscopy, flow cytometry, cytogenetics) C. Microscopic evaluation 1. Tumor a. Histologic type (note A) b. Histologic grade, if applicable (note B) c. Depth of invasion (note C) (1) Measurement in millimeters for squamous carcinoma (note C) d. Perineural invasion (with extent) (note D) e. Blood/lymphatic vessel invasion (with extent) (note D) f. Nature of advancing margin of tumor (eg, pushing, infiltrative) (note D) g. Presence and approximate percentage of extent of regression, if present(*) (note D) h. Mitotic count per 10 high-power fields([dagger]) (note D) (*) Applies principally to basal cell carcinomas. ([dagger]) Applies only to Merkel cell carcinomas. 2. Margins (note E) 3. Additional pathologic findings, if present a. Actinic keratosis b. Bowen disease 4. Regional lymph nodes (pN) (note F) a. Number b. Number containing metastases (1) Measurement of metastatic focus (2) Extranodal extension, if present 5. Metastases to other organs (pM) 6. Results of special studies (specify) 7. Comments a. Correlation with intraoperative consultations, if any b. Correlation with prior specimens, if any c. Correlation with clinical findings, as appropriate d. Comments on prognostic findings
A: Histologic Subtypes.--The World Health Organization (WHO) classification of carcinomas of the skin is shown below. Epidermal carcinomas Basal cell carcinoma (BCC) and variants listed below: Superficial BCC Nodular BCC (solid, adenoid cystic) Infiltrating BCC Sclerosing BCC (desmoplastic, morpheic) Fibroepithelial BCC BCC with adnexal differentiation Follicular BCC Eccrine BCC Basosquamous carcinoma Keratotic BCC Pigmented BCC BCC in basal cell nevus syndrome Micronodular BCC Squamous cell carcinoma (SCC) and variants listed below: Spindle cell (sarcomatoid) SCC Acantholytic SCC Verrucous SCC SCC with horn formation Lymphoepithelial SCC Variants not included in the WHO classification are as follows: Papillary SCC Clear cell SCC Small cell SCC Posttraumatic (eg, Marjolin ulcer) Metaplastic (carcinosarcomatous) SCC Paget disease Mammary Paget disease Extramammary Paget disease Adnexal carcinomas Eccrine carcinoma and variants listed below: Sclerosing sweat duct carcinoma (syringomatous carcinoma, microcystic adnexal carcinoma) Malignant mixed tumor of the skin (malignant chondroid syringoma) Porocarcinoma Malignant nodular hidradenoma Malignant eccrine spiradenoma Mucinous eccrine carcinoma Adenoid cystic eccrine carcinoma Aggressive digital papillary adenoma/adenocarcinoma Apocrine carcinoma Sebaceous carcinoma Tricholemmocarcinoma and its variant listed below: Malignant pilomatricoma (matrical carcinoma) Note.--Merkel cell carcinoma is not included in the WHO classification of skin tumors. B: Histologic Grade.--Histologic grading is appropriate only for SCCs and adnexal carcinomas. Suggested histologic grades are as follows: Grade 1 Well differentiated Grade 2 Moderately differentiated Grade 3 Poorly differentiated Grade 4 Undifferentiated C: TNM and Stage Groupings.--The authors of this protocol recommend the TNM Staging System of the American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC).[1,2] Primary Tumor (T) TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ T1 Tumor [is less than or equal to] 2 cm in greatest dimension T1a Limited to dermis or [is less than] 2 mm in thickness(*) T1b Limited to dermis and [is greater than] 2 mm in thickness, but [is less than or equal to] 6 mm in thickness(*) T1c Invading the subcutis and/or [is greater than] 6 mm in thickness(*) T2 Tumor [is greater than] 2 cm but [is less than or equal to] 5cm in greatest dimension T2a Limited to dermis or [is less than] 2 mm in thickness(*) T2b Limited to dermis and [is greater than] 2 mm in thickness, but [is less than or equal to] 6 mm in thickness(*) T2c Invading the subcutis and/or [is greater than] 6 mm in thickness(*) T3 Tumor [is greater than] 5 cm in greatest dimension T3a Limited to dermis or [is less than] 2 mm in thickness(*) T3b Limited to dermis and [is greater than] 2 mm in thickness buy [is less than or equal to] 6 mm in thickness(*) T3c Invading the subcutis and/or [is greater than] 6 mm in thickness(*) T4 Tumor invades the deep extradermal tissue (eg, bone, cartilage, muscle) T4a [is less than or equal to] 6 mm in thickness(*) T4b [is greater than] 6 mm in thickness(*) (*) Optional expansions suggested by the TNM Supplement. Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis Distant Metastasis (M) MX Presence of distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis Stage Groupings Stage 0 Tis N0 M0 Stage 1 T1 N0 M0 Stage 2 T2 N0 M0 T3 N0 M0 Stage 3 T4 N0 M0 Any T N1 M0 Stage 4 Any T Any N M1
Important Note.--By AJCC/UICC convention, the designation "T" refers to a primary tumor that has not been previously treated. The symbol "p" refers to the pathologic classification of the TNM, as opposed to the clinical classification and is based on gross and microscopic examination. pT entails a resection of the primary tumor or biopsy adequate to evaluate the highest pT category, pN entails removal of nodes adequate to validate lymph node metastasis, and pM implies microscopic examination of distant lesions. Clinical classification (cTNM) is usually carried out by the referring physician before treatment during initial evaluation of the patient or when pathologic classification is not possible.
Tumor remaining in a patient after cancer-directed therapy (eg, surgical resection for cure) is categorized by a system known as the R classification, shown below.
RX Presence of residual tumor cannot be assessed R0 No residual tumor R1 Microscopic residual tumor R2 Macroscopic residual tumor
For the surgeon, the R classification may be useful to indicate the known or assumed status of the completeness of a surgical excision. For the pathologist, the R classification is relevant to the status of the margins of a surgical resection specimen; that is, tumor involving the resection margin on pathologic examination may be assumed to correspond to residual tumor in the patient and may be classified as macroscopic or microscopic according to the findings at the specimen margin(s).
In contrast, tumor remaining in a resection specimen from a patient who has undergone previous (neoadjuvant) treatment of any type (radiation therapy alone, chemotherapy therapy alone, or any combined modality treatment) is codified by the TNM using a prescript "y" (eg, ypT1). Thus, yTNM indicates the posttreatment status of the tumor. For many neoadjuvant therapies, the classification of residual disease may be a strong predictor of postoperative outcome. In addition, the ypTNM classification provides a standardized framework for the collection of data needed to accurately evaluate new neoadjuvant therapies.
In contrast to residual tumor, classification of a tumor as recurrent requires a documented disease-free interval after definitive therapy. Recurrent tumor may also be classified according to the TNM categories, but the prefix "r" (eg, rpT1) is used to indicate the recurrent status of the tumor.
D: Adverse Prognostic Factors.--Important adverse prognostic factors for cutaneous malignancies are as follows:
Basal cell carcinoma Infiltrative, morpheaform, or micronodular histologic subtype Invasion into deep subcutaneous fat, muscle, or cartilage Perineural invasion Positivity of surgical margins Presence of scar within the tumor Squamous cell carcinoma Adenoid, basaloid, small cell or spindle cell histologic subtypes Posttraumatic clinicopathologic subtype Extensive perineural, lymphatic, or vascular invasion Invasion into subcutis Positivity of surgical margins Acantholytic subtype Merkel cell carcinoma Gross size [is greater than] 2 cm Mitotic activity (10 division figures/10 high-power [x400] microscopic fields) Extensive lymphatic or vascular invasion Presence of associated Bowen disease Divergent squamous differentiation in invasive tumor Positivity of surgical margins
E: Margins.--If the specimen is oriented, the position of lateral margins involved by tumor should be indicated. A comment on margins is necessary only for excisional biopsies or formal resections. Measurements of distance from tumor to margins are generally not considered useful or helpful and need not be routinely reported. However, distance to margins may be reported in special circumstances and/or when requested by the treating physician.
F: Lymph Node Dissections.--Lymph node dissections are not routinely performed for any cutaneous malignancy. Therefore, a comment may be needed that documents the clinical nodal status (cN substage) instead of pathologic (pN substage) status in assembling the final stage grouping for the tumor.
Lyn Duncan, MD; Harley A. Haynes, MD; Gregg M. Menaker, MD; and Nicholas E. O'Connor, MD contributed to the development of this monograph.
[1.] Fleming ID, Cooper JS, Henson DE, et al. AJCC Manual for Staging of Cancer. 5th ed. Philadelphia, Pa: Lippincott Raven; 1997.
[2.] Sobin LH, Wittekind C, eds. TNM Classification of Malignant Tumours: International Union Against Cancer. 5th ed. New York, NY: Wiley; 1997.
[3.] Hermanek P, Henson DE, Hutter RVP, Sobin LH. TNM Supplement. New York, NY: Springer-Verlag; 1993.
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Elder DE, Guerry D IV, Epstein MN, et al. Invasive malignant melanomas lacking competence for metastasis. Am J Dermatopathol. 1983;6(suppl):55-61.
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Schwartz RA, ed. Skin Cancer Recognition and Management. New York, NY: Springer-Verlag; 1988.
Smith DE, Bielamowicz S, Kagan AR, Anderson PJ, Peddada AV. Cutaneous neuroendocrine (Merkel cell) carcinoma: a report of 35 cases. Am J Clin Oncol. 1995;18:199-203;
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Accepted for publication April 17, 2001.
From the Departments of Pathology, University of Virginia Health Sciences Center, Charlottesville, Va (Dr Wick); and McGill University, Montreal, Quebec (Dr Compton).
(*) The protocol excludes malignant melanoma, sarcoma, and hematopoietic malignancy
This protocol was developed by the Cancer Committee of the College of American Pathologists and submitted for editorial review and publication, it represents the views of the Cancer Committee and is not the official policy of the College of American Pathologists.
Reprints: See Archives of Pathology 8, Laboratory Medicine Web site at www.cap.org.
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|Author:||Wick, Mark R.; Compton, Carolyn|
|Publication:||Archives of Pathology & Laboratory Medicine|
|Date:||Sep 1, 2001|
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