Protocol for the Examination of Specimens from Patients With Carcinomas
of the Skin (Excluding Eyelid, Vulva, and Penis. Excludes malignant melanoma,
sarcoma, and hematopoietic malignancy.)
A Basis for Checklists
Protocol for the Examination of Specimens from Patients With Carcinomas
of the Skin (Excluding Eyelid, Vulva, and Penis. Excludes malignant melanoma,
sarcoma, and hematopoietic malignancy)
Procedures-
A. CLINICAL
INFORMATION
1. Patient
identification
a. Name
b. Identification number
c. Age (birth date)
d. Gender
e. Skin type (e.g., 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 (e.g., hard, tender, non-tender, etc.)
(6) fixation to deeper
tissues on palpation
5.Clinical
diagnosis
6. Procedure (eg, punch biopsy, incisional
biopsy; excisional biopsy, etc.)
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 (e.g.,
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, etc.)
C. MICROSCOPIC
EVALUATION
1. Tumor
a. Histological type (Note
A)
b. Histologic grade(if applicable) (Note B)
c. Depth of invasion, if appropriate
(Note C)
(1) measurement in mm
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 evaluable (eg, pushing; infiltrative)* (Note D)
* (Applies principally
to basal cell carcinomas)
**(Applies only
to Merkel cell carcinomas)
2. Associated
skin lesions
a. Actinic keratosis
b. Bowen's 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
A. CLINICAL
INFORMATION
1. Patient
identification
a. Name
b. Identification number
c. Age
d. Gender
e. Skin type (e.g., 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
(7) lesion number and
distribution
(8) nature of advancing
borders of lesion
(9) nature of
pigmentation if any
(10) ulceration
(11) palpable qualities
of lesion (e.g., hard, tender, non-tender, etc.)
(12) fixation to deeper
tissues on palpation
c. Clinical diagnosis
d. Procedure (eg, punch biopsy,
incisional biopsy; excisional biopsy, etc.)
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 (e.g.,
ellipse, punch core, shave fragments, currettings)
f. Dimensions
g. Results of intraoperative
consultation, if any
2. Tumor
a. Location
b. Configuration
c. Pigmentation (nature and extent)
d. Dimensions (three)
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, etc.)
C. MICROSCOPIC
EVALUATION
1. Tumor
a. Histological type (Note
A)
b. Histologic grade(if applicable) (Note B)
c. Depth of invasion (Note
C)
(1) measurement in mm
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 extent of regression, if present** (Note D)
h. Mitotic count per 10 HPF** (Note D)
* (Applies
principally to basal cell carcinomas)
**(Applies only
to Merkel cell carcinomas)
2. Margins (Note E)
3. Additional
pathologic findings, if present
a. Actinic keratosis
b. Bowen's 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
EXPLANATORY NOTES
The WHO
classification of carcinomas of the skin are 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 (1)
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 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
Post-traumatic (e.g., "Marjolin's
ulcer")
Metaplastic ("carcinosarcomatous")
SCC
Paget’s disease
Mammary Paget’s disease
Extramammary Paget’s 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.
Histologic
grading is appropriate only for squamous cell carcinomas and adnexal
carcinomas. Suggested histologic grades are as follows:
Grade 1 Well differentiated
Grade 2 Moderately differentiated
Grade 3 Poorly differentiated
Grade 4 Undifferentiated
The TNM Staging
System of the AJCC/UICC is recommended by this protocol.(2,3)
Primary Tumor (T)
TX Primary tumor cannot be
assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor 2 cm or less in
greatest dimension
T1a Limited
to dermis or 2 mm or less in thickness*
T1b Limited to dermis and more than 2 mm in
thickness but not more than 6 mm in thickness*
T1c Invading
the subcutis and/or more than 6 mm in thickness*
T2 Tumor more than 2 cm but not
more than 5 cm in greatest dimension
T2a Limited
to dermis or 2 mm or less in thickness*
T2b Limited to dermis and more than 2 mm in
thickness but not more than 6 mm in thickness*
T2c Invading
the subcutis and/or more than 6 mm in thickness*
T3 Tumor more than 5 cm in
greatest dimension
T3a Limited
to dermis or 2 mm or less in thickness*
T3b Limited to dermis and more than 2 mm in
thickness but not more than 6 mm in thickness*
T3c - invading the subcutis and/or
more than 6 mm in thickness*
T4 Tumor invades the deep extradermal
tissue (eg, bone, cartilage, muscle)
T4a - 6 mm or less in thickness*
T4b - more than 6 mm in thickness*
* Optional
expansions suggested by the TNM Supplement.(4)
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
definitive therapy (e.g., surgical resection for cure) is categorized by a
system known as 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" (e.g., ypT1). Thus, yTNM
indicates the post-treatment 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" (e.g., rpT1) is used to indicate the recurrent
status of the tumor.
Important
adverse prognostic factors for cutaneous malignancies are as follows:
Basal cell
carcinoma:
Infiltrative,
morpheaform, or micronodular histological 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 histological subtypes
Post-traumatic
clinicopathological subtype
Extensive
perineural or lymphatic or vascular invasion
Invasion into
subcutis
Positivity of
surgical margins
Acantholytic
subtype
Merkel cell
carcinoma
Gross size over
2 cm
Mitotic activity
(10 division figures per 10 high power (X400) microscopic fields
Extensive
lymphatic or vascular invasion
Presence of
associated Bowen’s disease
Divergent
squamous differentiation in invasive tumor
Positivity of
surgical 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.
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
AJCC-UICC stage of the tumor.
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Authors: Mark R.
Wick, MD; Carolyn Compton, MD, PhD
For members of
the Cancer Committee, College of American Pathologists
Contributing
Reviewers: Lyn Duncan, MD; Harley A. Haynes, MD; Gregg M. Menaker, MD; Nicholas
E. O’Connor; MD
Originally
published in the Archives of Pathology
& Laboratory Medicine, September 2001.