Skin cancer path

[deleted1111261]

How do your pathologists report out squamous cell cancer, particularly from head and neck?

We get:

1) the fact that it is squamous

2) margins negative or positive

Nothing else - no size, no PNI, no grade, no LVSI, no DOI. And, this is not the first place that does this. I have been at least 3 centers that report it out this way.

What do your pathologists do?

The CAP for squamous cell of the head and neck says all this should be reported out.

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[DrZap]

How do your pathologists report out squamous cell cancer, particularly from head and neck?

We get:

1) the fact that it is squamous

2) margins negative or positive

Nothing else - no size, no PNI, no grade, no LVSI, no DOI. And, this is not the first place that does this. I have been at least 3 centers that report it out this way.

What do your pathologists do?

The CAP for squamous cell of the head and neck says all this should be reported out.

We get PNI LVI (DOI if oral cavity)

 

[OTN]

We get PNI and LVSI if it's an ENT case, but if it's Mohs, we usually get detailed description of PNI from the Mohs team along with DOI info, but usually not LVSI info.

 

[TheWallnerus]

How do your pathologists report out squamous cell cancer, particularly from head and neck?

We get:

1) the fact that it is squamous

2) margins negative or positive

Nothing else - no size, no PNI, no grade, no LVSI, no DOI. And, this is not the first place that does this. I have been at least 3 centers that report it out this way.

What do your pathologists do?

The CAP for squamous cell of the head and neck says all this should be reported out.

Surprised you haven’t already spoken to the pathologist(s) on the phone. If the path is coming from derms… good luck!

 

[medgator]

How do your pathologists report out squamous cell cancer, particularly from head and neck?

We get:

1) the fact that it is squamous

2) margins negative or positive

Nothing else - no size, no PNI, no grade, no LVSI, no DOI. And, this is not the first place that does this. I have been at least 3 centers that report it out this way.

What do your pathologists do?

The CAP for squamous cell of the head and neck says all this should be reported out.

No p16/hpv status? Can't really stage it properly in that case

Edit: nvm saw that your thread title is regarding skin, not mucosal h&n scc. Agree that seems skimpy. Pni lvi etc usually mentioned in our reports

 

[taserlaser]

Totally depends on If it’s from mohs, WLE, whatnot. Have done some education to local paths asking to please quantify extent and multifocality of PNI, nerve calibre, etc. Usually can get margins, size, etc too

Our skin tumor board is well attended by the mohs surgeons and dermpath so any outstanding questions I can usually hound them for if it will sway a recommendation

 

[metallica81788]

How do your pathologists report out squamous cell cancer, particularly from head and neck?

We get:

1) the fact that it is squamous

2) margins negative or positive

Nothing else - no size, no PNI, no grade, no LVSI, no DOI. And, this is not the first place that does this. I have been at least 3 centers that report it out this way.

What do your pathologists do?

The CAP for squamous cell of the head and neck says all this should be reported out.

For larger resections done at the hospital we will get size, margins, PNI/LVI

For Mohs I don't get anything besides judging how big their wound/scar is and the fact the Mohs surgeon sent them to me

 

[Palex80]

We get squamous or not (plus subtypes of squamous sometimes), margins (including mm), size, PNI, grade, LVSI, DOI.
I am still trying to persuade them to give us a TNM, but they dont want to. I do not know why.

Once a new pathologist started working and he missed several of these points. I called him and described what I expect from a pathology report and failure to do so may lead to me under- or overtreating patients. That troubled him a lot.

I find that the pathologists are really happy to hear that their reports actually make a difference in management and I believe that radiation oncologists are among those physicians that read the report with all the details and not just the summary. Feedback is something pathologists often appreciate if they can see that their work has a clinical impact.

 

[Skindoc83]

As a mohs surgeon I document PNI and degree of differentiation. I generally document the presence of certain characteristics and not usually the absence of things (I.e. I likely won’t mention a lack of PNI)

 

[Reaganite]

I get "at least squamous cell carcinoma in situ, cannot rule out invasion"

 

[medgator]

I get "at least squamous cell carcinoma in situ, cannot rule out invasion"

Sounds like the anal and esophagus path i get sometimes too

 

[Palex80]

I get "at least squamous cell carcinoma in situ, cannot rule out invasion"

Pathologist be like:

 

[evilbooyaa]

How do your pathologists report out squamous cell cancer, particularly from head and neck?

We get:

1) the fact that it is squamous

2) margins negative or positive

Nothing else - no size, no PNI, no grade, no LVSI, no DOI. And, this is not the first place that does this. I have been at least 3 centers that report it out this way.

What do your pathologists do?

The CAP for squamous cell of the head and neck says all this should be reported out.

Only way to incite change is to provide feedback.

"Hey, Dr. Microscope, wanted to touch base with you about this skin cancer case. Was there a size of the tumor? PNI/LVSI? These are thing sthat may influence whether I recommend radiation or not. Yeah, if you can addend the report that'd be great. It'd be super helpful if you could make this a standard thing for any excised lesion you're seeing. Great, thanks. Have a good day!"

Not 100% sure why grade or DOI on a cutaneous squam could matter in terms of RT decisions. Really same with LVSI as well although I don't treat a lot of skin.

 

[taserlaser]

Grade is an important characteristic in cut SCC - high grade is one of the BWH risk factors, which outperforms ajcc 8

Accuracy of the AJCC Staging Manual 8th Edition vs the BWH Tumor Classification System for HNCSCC

This cohort study compares the performance of American Joint Committee on Cancer, 8th edition and the Brigham and Women’s Hospital tumor classification systems in patients diagnosed with head and neck cutaneous squamous cell carcinomas.

jamanetwork.com

I have one high grade on treatment that has recurred post Mohs within a few weeks and has doubled in size in the past week and half. Nasty nasty tumor.

Also relevant re path, both stolen from latest NCCN

 

[doctalaughs]

From a derm perspective—
The % of cutaneous SCC that ends up being referred to radiation oncology is minuscule. Usually they are cured by mohs, excision, ED&C (or topical in the case of SCCIS). 99%+ conservatively.

If they were referred over - it’s likely because they had some of these features, were not a good surgical candidate (or refused surgery) or it was not clearable, or multiply recurrent or met.

I suspect path doesn’t regularly report some of this stuff but the understanding between me and my pathologists (who I’ve worked with for 15 years and talk over the phone with all the time) is that it’s not there if they didn’t comment on it (ie they better report PNI if it’s there —as it changes my management too for the 10 SCC reports I get back per day which usually say “well differentiated invasive SCC, deep margin positive/negative” and that’s it. I also suspect they don’t report the TNM regularly as it’s a lot of extra work for things that are 99.9% T1N0M0)

Dermpath sub trained I trust more to report any high risk features (I only work with dermpaths) - but they still don’t say the pertinent negatives usually…. I wouldn’t be happy though if they don’t say it’s well differentiated and the margins at the least.

I do think anything high risk enough to be sent to you guys it would be reasonable for pathology to add all the pertinent negatives and staging etc.

 

[deleted1111261]

From a derm perspective—
The % of cutaneous SCC that ends up being referred to radiation oncology is minuscule. Usually they are cured by mohs, excision, ED&C (or topical in the case of SCCIS). 99%+ conservatively.

If they were referred over - it’s likely because they had some of these features, were not a good surgical candidate (or refused surgery) or it was not clearable, or multiply recurrent or met.

I suspect path doesn’t regularly report some of this stuff but the understanding between me and my pathologists (who I’ve worked with for 15 years and talk over the phone with all the time) is that it’s not there if they didn’t comment on it (ie they better report PNI if it’s there —as it changes my management too for the 10 SCC reports I get back per day which usually say “well differentiated invasive SCC, deep margin positive/negative” and that’s it. I also suspect they don’t report the TNM regularly as it’s a lot of extra work for things that are 99.9% T1N0M0)

Dermpath sub trained I trust more to report any high risk features (I only work with dermpaths) - but they still don’t say the pertinent negatives usually…. I wouldn’t be happy though if they don’t say it’s well differentiated and the margins at the least.

I do think anything high risk enough to be sent to you guys it would be reasonable for pathology to add all the pertinent negatives and staging etc.

I hear you

What I am being told is “we don’t look for it”

This is referring to grade, pni, size, quantifying the margin.

I’m seeing the recurrence, then finding out they actually had every risk factor - it just wasn’t looked for

 

[doctalaughs]

I hear you

What I am being told is “we don’t look for it”

This is referring to grade, pni, size, quantifying the margin.

I’m seeing the recurrence, then finding out they actually had every risk factor - it just wasn’t looked for

Yeah that’s just bad pathology then….

Hopefully aren’t seeing this from dermpath sub-trained people. If so (or either way) whoever decides should be sending their path elsewhere.

 

[deleted1111261]

They are receptive to change.

It’s just the 3rd hospital where this is occurring

I think maybe the CAP only recently updated too for skin cancer of head neck