Skin SSG (Anglia East & Anglia West)

Transcription

1 Guidelines for Referrals between Skin LMDT and SMDT 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 on 11 th May 2011 Next review due: May 2013 Ref: AngCN-SSG-S7 Version 1.0

2 CONTENTS Introduction...3 List of MDTs...3 Patients to be referred to the LSMDT...4 Patients to be referred to the SSMDT...4 Combined NNUHFT and Addenbrookes SMDT meetings...5 Appendices...6 Appendix 1: Rare skin tumours...6 Appendix 2: Levels of Care for Skin...7 Appendix 3: Indications for referral for Sentinel lymph node biopsy...8 Appendix 4: Indications for referral for Mohs surgery...9 Evidence of Agreement...10 Monitoring the Effectiveness of the Process...10 Page 2 of 10

3 Introduction The Anglia Cancer Network (AngCN) Skin Multidisciplinary Teams (MDTs) have been developed to deliver cancer services in accordance with the NICE Improving Outcomes Guidance for People with Skin Tumours including Melanoma (NICE 2006). The Anglia Cancer Network has: 8 Local Multidisciplinary Teams (LMDTs) These cover the secondary care of patients who are classed as care levels 2, 3 and 4 (please refer to appendix 2 for details of care levels for skin, as determined by NICE - Appendix 2: Levels of Care for Skin) 2 Specialist Multidisciplinary Teams (SMDTs) These cover the tertiary care of patients who are classed as care level 5. The two SMDTs make referrals to the Supra-Network MDT at St Thomas Hospital in London, and this supra-network MDT covers patients who are classed as care level 6 cutaneous lymphoma. In addition the two SMDTs combine as required to make joint care decisions for patients with rare skin cancers (Appendix 2). List of MDTs East LMDT (Secondary Care) Ipswich Hospital NHS Trust LMDT James Paget University Hospitals NHS Foundation Trust LMDT Queen Elizabeth Hospital NHS Trust, Kings Lynn, LMDT Norfolk and Norwich University Hospital NHS Foundation Trust LMDT SMDT (Tertiary Care) Norfolk and Norwich University Hospital NHS Foundation Trust SMDT West LMDT (Secondary Care) Addenbrooke s Hospital AND Hinchingbrooke Health Care NHS Trust (Joint) LMDT Bedford Hospital NHS Trust LMDT Peterborough & Stamford Hospitals NHS Foundation Trust LMDT West Suffolk Hospitals NHS Trust LMDT SMDT (Tertiary Care) Addenbrooke s Hospital SMDT Lead Clinician Sam Gibbs Robert Graham Gillian Dootson Jennifer Garioch Lead Clinician Jennifer Garioch Lead Clinician Pamela Todd (Melanoma) & Tom Ha (SCC) Katya Burova Richard (Dick) Mallett Sue Handfield-Jones Lead Clinician Pamela Todd Page 3 of 10

4 Joint Supra-Network MDT (Tertiary Care cutaneous lymphoma) St Thomas Hospital Lead Clinicians Sean Whittaker & Julia Scarisbrick Patients to be referred to the LSMDT All patients requiring level 3 or 4 care must be referred to a LSMDT (or to an SSMDT where it is acting as a local LSMDT). The following patients should be referred to the LSMDT. Low risk BCC incompletely or narrowly (< 1mm) excised, perineural invasion Low risk BCCs excised by non accredited GPs in the community High Risk BCC incompletely or narrowly ( < 1mm) excised, perineural invasion High risk BCCs excised by GPs in the community SCCs excised by GPs in the community SCC incompletely or narrowly excised (<1mm), perineural or lymphovascular invasion, thickness 6mm or more, pt2 or above, poorly differentiated tumours, specific histological subtypes (clear cell, desmoplastic, verrucous, carcinosarcoma, adenosquamous) SCCs from special or high risk sites (ear, lip, eyelid/canthus) Malignant melanoma new, single primary, adult, non-metastatic, not for approved trial entry, up to and incuding stage IIa Melanomas excised or biopsied in primary care Radiotherapy if attendance by clinical oncologist at LSMDT Lesion where diagnosis is uncertain but may be malignant Incompatible clinical and histological findings Patients to be referred to the SSMDT All patients requiring level 5 care should be referred to the SSMDT. In general, referral of cases will be made directly to the SSMDT. In certain circumstances, for example if the disease staging is upgraded, or if more specialist treatment such as Mohs microsurgery is deemed necessary, patients previously discussed at a LSMDT will then be referred on from the LSMDT to the SSMDT Those requiring level 5 care fall into a number of different skin tumour and patient groups. These are summarised below. Selected BCCs and SCCs needing plastic/reconstructive surgery by SMDT core member (as per network clinical guidelines) Radiotherapy (as per network clinical guidelines). If not discussed and treated by LMDT clinical oncology core team member Metastatic SCC on presentation or newly metastatic or recurrent. SCCs from special or high risk sites (perineum, sole of foot) MM stage Ib or more, or < 19 years or metastatic on presentation or newly Page 4 of 10

5 metastatic or recurrent or for approved trial entry or +ve excision margins Patients for sentinel lymph node biopsy (See Appendix 3: Indications for referral for Sentinel lymph node biopsy) Positive sentinel lymph node biopsies Patients with positive lymph nodes following lymph node clearance Any cases for adjuvant therapy (as per network clinical guidelines) Histology opinion from SMDT core pathology team member Mohs surgery (See Appendix 4: Indications for referral for Mohs surgery) Skin cancer in immunocompromised patients including organ transplant recipients Skin cancer in genetically predisposed patients including Gorlin s Syndrome Tumours associated with burns, albinism, xeroderma, post-irradiation Rare skin tumours sebaceous carcinoma, malignant pilomatrixoma, neuroendocrine carcinoma Cutaneous sarcoma superficial to the deep fascia Cutaneous lymphoma * Details of the SSMDTs are available in the Skin Operational Policy documents for Addenbrooke s and NNUHFT. * There are two cutaneous lymphoma MDTs within the Anglia Cancer Network. Details of these MDTs - including frequency, how to refer etc - are available in the Operational Policy Documents for Addenbrooke s and NNUHFT. Combined NNUHFT and Addenbrookes SMDT meetings The following diagnoses necessitate a joint Addenbrooke s and NNUHFT SSMDT: Children and young people with skin cancer Rare skin tumours as listed in the NICE IOG - except sebaceous carcinoma, malignant pilomatrixoma, neuroendocrine carcinoma - (Appendix 1: Rare skin tumours) See operational policy documents for process of referring to a joint Addenbrooke s and NNUHFT SSMDT. Page 5 of 10

6 Appendices Appendix 1: Rare skin tumours Epidermal and appendage tumours Apocrine carcinoma. Hidradenocarcinoma. Eccrine porocarcinoma. Sebaceous carcinoma. Tumours associated with Muir Torre syndrome. Eccrine epithelioma (syringoid carcinoma). Microcystic adnexal carcinoma. Primary adenoid cystic carcinoma. Primary mucoepidermoid carcinoma. Primary mucinous carcinoma. Digital papillary adenocarcinoma. Malignant cylindroma. Malignant spiradenoma (spiradenocarcinoma). Malignant pilar tumour. Malignant pilomatrixoma. Neuroendocrine carcinoma (Merkel cell tumour/trabecular carcinoma). Dermal and subcutaneous tumours Atypical fibroxanthoma (AFX) (superficial malignant fibrous histiocytoma, superficial sarcoma not otherwise specified). Dermatofibrosarcoma protuberans (DFSP). Leiomyosarcoma. Angiosarcoma. Kaposi s sarcoma. Haemangioendothelioma. Epithelioid sarcoma. Primary cutaneous rhabdomyosarcoma. Cutaneous malignant nerve sheath tumours (including cutaneous neurofibrosarcoma and malignant Schwannoma). Page 6 of 10

7 Appendix 2: Levels of Care for Skin Care Level Person or Team Case mix / Procedure 1 Any general practitioner in the community Benign lesions Actinic keratoses 2 General Practitioner with a Special Interest (GPwSIs) in Skin Cancer see Department of Health guidance i.e. model 1 in figure 2 3 LSMDT, hospital staff core team member (may be core member of SSMDT acting as local LSMDT). Without mandatory individual case review by MDT. 4 LSMDT, hospital staff core team member(s), with mandatory individual case review by LSMDT (may be the SSMDT and its core members acting as local LSMDT). 5 SSMDT hospital staff core team member(s) with mandatory individual case review by SSMDT. (May have been previously reviewed by LSMDT or rapidly referred without prior review). For some cases only one agreed SSMDT, if more than one in the network. Precancerous SCC, in situ/bowen s Low risk BCC High risk BCC SCC High risk BCC SCC Malignant melanoma new, single primary, adult, non-metastatic, not for approved trial entry, up to and incuding stage IIa (must fulfil all of these criteria) Radiotherapy if attendance by clinical oncologist at LSMDT Lesion where diagnosis is uncertain but may be malignant Incompatible clinical and histological findings Selected BCCs and SCCs needing plastic/reconstructive surgery by SMDT core member (as per network clinical guidelines) Radiotherapy (as per network clinical guidelines). If not discussed and treated by LMDT clinical oncology core team member Metastatic SCC on presentation or newly metastatic MM stage Ib or more, or < 19 years or metastatic on presentation or newly metastatic or recurrent or for approved trial entry or +ve excision margins Any cases for adjuvant therapy (as per network clinical guidelines) Histology opinion from SMDT core pathology team member Mohs surgery Skin cancer in immunocompromised patients including organ transplant recipients Skin cancer in genetically predisposed patients including Gorlin s Syndrome 6 Supranetwork team. Selected Networks only. Agreed with SCGs. Clinician responsible for named facilities for photopheresis (very small numbers of patients). Agreed with SCGs. Cases discussed in SSMDT for cutaneous lymphoma in host network. Cases to be dealt with by only one agreed SSMDT per Network, if more than one in the Network; Cutaneous lymphoma Kaposi s sarcoma Cutaneous sarcoma above superficial fascia. (Below fascia, refer to sarcoma MDT) in cancers Other rare skin cancers (see appendix 1 in the Skin Cancer IOG pg 128/129). T-cell Cutaneous Lymphoma: Total Body Surface Electron Beam Therapy. T-cell cutaneous lymphoma. Photopheresis. Page 7 of 10

8 Appendix 3: Indications for referral for Sentinel lymph node biopsy The following patients should be considered for sentinel lymph node biopsy: 1) All primary melanomas pt1b pt3b (a) All primary melanomas with Breslow thickness 1 to 4 mm. (b) Primary melanomas Breslow thickness mm. with any of the following: (i) (ii) (iii) Ulceration Mitotic rate >= 1 mitoses/mm² Age <40 years 2) All primary melanomas pt4+ (Breslow >4mm) AND age <=75 years 3) Melanomas of unknown Breslow thickness (usually curetted lesions) 4) Pigmented lesions of uncertain malignant potential 5) Merkel cell tumours The following patients would usually be excluded from sentinel lymph node biopsy: 1) Patients where the wider excision has already been performed 2) Recurrent or in transit disease 3) Patients assessed as unfit for a general anaesthetic 4) Patients with macroscopic stage III disease or evidence of stage IV disease Note: Patients older than 75 years of age should not be automatically referred for sentinel lymph node biopsy but should be discussed at the skin cancer multidisciplinary team meeting forum. Page 8 of 10

9 Appendix 4: Indications for referral for Mohs surgery Mohs surgery should be considered for patients with high risk basal cell carcinoma (BCC) - poorly defined BCC - incompletely excised BCC - histologically aggressive BCC (sclerosing or morphoeaform, infiltrating, perineural, perivascular, metatypical, keratinising, multicentric or those that involve deep tissue) - BCC at high risk sites: nose, periorbital area, ears - BCC arising in younger patients especially facial lesions - BCC arising from previously irradiated skin - BCC in immunocompromised patients - Where tissue sparing is important Other indications for Mohs surgery - Squamous cell carcinoma - Microcystic adnexal tumour - Sebaceous carcinoma - Atypical fibroxanthoma - Dermatofbrosarcoma protuberans Page 9 of 10

10 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 10 of 10