Skin SSG (Anglia East & Anglia West)

Transcription

1 Guidelines for the Management of Skin Cancer in Specific Anatomical Sites 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 May 2011 Next review due: May 2013 Ref: AngCN-SSG-S9 Version 1.0

2 CONTENTS Introduction...3 Skin and Head and Neck MDTs...4 Norfolk & Norwich University Hospital...4 Addenbrooke s Hospital, Cambridge University Hospitals...5 Skin and Colorectal MDTs...6 Norfolk & Norwich University Hospital...6 Addenbrooke s Hospital, Cambridge University Hospitals...6 Skin and Gynaecology MDTs...8 Norfolk & Norwich University Hospital...8 Addenbrooke s Hospital, Cambridge University Hospitals...8 Skin and Urology MDTs...10 Norfolk & Norwich University Hospital...10 Addenbrooke s Hospital, Cambridge University Hospitals...10 Skin and Haemato-oncology MDTs...12 Norfolk & Norwich University Hospital...13 Addenbrooke s Hospital, Cambridge University Hospitals...13 Skin and Sarcoma MDTs...15 Norfolk & Norwich University Hospital...15 Addenbrooke s Hospital, Cambridge University Hospitals...16 Evidence of Agreement...18 Monitoring the Effectiveness of the Process...18 Page 2 of 18

3 Introduction There are several circumstances in which patients with skin cancer who are initially managed by skin MDT members and discussed in the skin cancer MDT are subsequently found to require referral to other cancer site MDTs for their specific expertise. The purpose of this guideline is to clarify both the circumstances which would necessitate a referral to a different MDT and the mechanisms for such referrals These guidelines are intended to ensure that patients with skin cancer at unusual sites have timely access to the expertise of the appropriate site specific MDTs. Page 3 of 18

4 Skin and Head and Neck MDTs 08-1A-212j There are several instances where tumours arising in the skin of the head and neck require the expertise of the head and neck SMDT. The following cancers should also be discussed at the H&N SMDT: - tumours of the lacrimal glands, including lymphoma, or Meibomian glands (with oculoplastic surgical input) - tumours involving the orbit (+/- oculoplastic surgical input) - Tumours involving reconstructive surgical input - Tumours involving the lateral or anterior skull base (who are likely to be referred to a centre of surgical expertise) - periocular melanomas requiring enucleation or exenteration of the orbit - malignant tumours of the lip (except T1 tumours excised with clear margins) - malignant tumours of the external and internal auditory meati - Squamous cell cancer of the skin metastasized to neck nodes (melanomas or BCCs with neck nodes are managed within the skin MDT) - Conjunctival melanoma - Nasal mucosal melanoma The skin SMDT includes dermatology, plastic surgery, oncology, oculoplastic surgery, pathology. The following cases affecting the skin of the head and neck will be discussed in the Skin SMDT: - all new patients with malignant melanoma affecting the skin including periorbital skin (primary, recurrent, metastatic melanoma) - conjunctival melanoma - nasal mucosal melanoma - high risk squamous cell carcinomas affecting the skin including periorbital skin - squamous cell carcinomas of the skin which have been incompletely excised or which are recurrent - basal cell carcinomas which have been incompletely excised or which are recurrent or which are metastatic - patients with skin lesions of uncertain but possible malignant nature - patients with rare skin tumours including all superficial sarcomas - patients suitable for Moh s surgery - patients with skin tumours for whom there is a discrepancy between the clinical diagnosis and the histopathology report - patients who may benefit from radiotherapy to the primary tumour - patients who may benefit for entry into clinical trials - patients who require adjuvant treatment (where this is shown to be beneficial) - adnexal tumours including peri-orbital adnexal tumours Norfolk & Norwich University Hospital The team includes ENT, OFMS, plastic surgery, oncology and rehabilitation expertise and meets weekly on a Wednesday from ALL new cases of primary upper aerodigestive tract or salivary gland cancer are discussed there. Page 4 of 18

5 To refer a patient to the H&N SMDT, please contact: Tracey Church Tom Roques MDT coordinator H&N Lead Clinician Tracey.church@jpaget.nhs.uk tom.roques@nnuh.nhs.uk Lorraine Nelhams Jennifer Garioch Chair Skin SMDT lorraine.nelhams@nnuh.nhs.uk jennifer.garioch@nnuh.nhs.uk ext Fax Addenbrooke s Hospital, Cambridge University Hospitals The team includes ENT, OFMS, plastic surgery, clinical and medical oncology and rehabilitation expertise and meets weekly on a Wednesday at 8am. ALL new cases of primary upper aerodigestive tract and salivary gland cancer are discussed there. To refer a patient to the H&N SMDT, please contact: Pauline Fotheringham MDT coordinator pauline.fotheringham@addenbrookes.nhs.uk Richard Price Plastic surgery Head & Neck skin cancer lead Richard.price@addenbrookes.nhs.uk Richard Benson H&N Lead Clinician richard.benson@addenbrokes.nhs.uk Claire Herbert Claire.herbert@addenbrookes.nhs.uk Pamela Todd MDT lead clinician for melanoma pamela.todd@addenbrookes.nhs.uk Dr Tom Ha MDT Lead Clinician for Non- melanoma Skin Cancer thomas.ha@addenbrookes.nhs.uk Page 5 of 18

6 Skin and Colorectal MDTs 08-1A-213j Most tumours of the perianal skin and anal canal are squamous cell carcinomas and are dealt with exclusively by the colorectal/anal MDT. Melanomas of intestinal or perianal origin whether primary or secondary should be discussed at both the colorectal/anal MDT and the skin MDT. See below for specific detail: The following skin cancers should be discussed at the Colorectal/Anal SMDT: - Squamous cell carcinoma arising from perianal skin, anal canal or rectum - Melanoma arising from perianal skin, anal canal or intestinal mucosa - Secondary melanoma affecting any part of the colorectum or small bowel The following cases discussed at the colorectal/anal MDT should also be discussed in the Skin SMDT: - Melanoma arising from perianal skin, anal canal or intestinal mucosa - Secondary melanoma affecting any part of the colorectum or small bowel Norfolk & Norwich University Hospital The team meets weekly on a Wednesday from 08:00 to 09:00. To refer a patient to the Colorectal MDT please contact: Jane McCulloch Richard Wharton Colorectal MDT coordinator Colorectal MDT lead Jane.McCulloch@nnuh.nhs.uk Bleep 0017 Richard.wharton@nnuh.nhs.uk Lorraine Nelhams Jennifer Garioch Chair Skin SMDT lorraine.nelhams@nnuh.nhs.uk jennifer.garioch@nnuh.nhs.uk ext 4221/bl Fax Addenbrooke s Hospital, Cambridge University Hospitals The team meets weekly on a Monday at 1-00pm To refer a patient to the Colorectal MDT please contact: Ruth Andrews Colorectal MDT coordinator Ruth.andrews@addenbrokes.nhs.uk Mr Nigel Hall Colorectal MDT lead nigel.r.hall@addenbrookes.nhs.uk Page 6 of 18

7 Claire Herbert Pamela Todd MDT Lead clinician for melanoma Dr Tom Ha MDT Lead clinician for Non- melanoma Skin Cancer Page 7 of 18

8 Skin and Gynaecology MDTs 08-1A-214j There are several instances when skin cancer arising on the vulval skin require the expertise of the gynaecology SMDT. The following cancers arising on the vulval skin and genital mucosa should be discussed at the Gynaecology SMDT: - Squamous cell carcinoma - Squamous cell carcinoma which has metastasised to regional lymph nodes - Melanoma of the vulval skin - Melanoma arising from genital mucosa - Melanoma which has metastasised to the vulva or genital mucosa - Melanoma of the vulva which has metastasised to regional lymph node - Basal cell carcinoma The skin SMDT includes dermatology, plastic surgery, oncology, oculoplastic surgery, pathology and oncology.the following cases affecting the vulva and genital mucosa will be discussed in the Skin SMDT: - all new patients with melanoma affecting the vulva or genital mucosa - patients with vulval or genital melanoma which has metastasised to regional lymph nodes Norfolk & Norwich University Hospital The team meets weekly on a Thursday from 12:00-13:30 hours with videoconference link to JPH. To refer a patient to the Gynaecology MDT please contact: Mr Crocker s secretary Tel Mr Nieto s secretary Tel Simon Crocker MDT Lead Simon.crocker@nnuh.nhs.uk Joaquin.nieto@nnuh.nhs.uk Lorraine Nelhams Jennifer Garioch Chair Skin SMDT lorraine.nelhams@nnuh.nhs.uk jennifer.garioch@nnuh.nhs.uk ext 4221/bl Fax Addenbrooke s Hospital, Cambridge University Hospitals The team meets weekly on Tuesday from 1-00pm to 3-00pm Page 8 of 18

9 To refer a patient to the Gynaecology MDT please contact: Rachel Pyman MDT Co-ordinator Rachel.pyman@addenbrookes.nhs.uk Mr Robin Crawford Lead Clinician for Gynaecological Onclogy Robin.crawford@addenbrookes.nhs.uk Claire Herbert Claire.herbert@addenbrookes.nhs.uk Pamela Todd MDT lead clinician for melanoma pamela.todd@addenbrookes.nhs.uk Dr Tom Ha MDT Lead Clinician for Non- melanoma Skin Cancer thomas.ha@addenbrookes.nhs.uk Page 9 of 18

10 Skin and Urology MDTs 08-1A 215j There are several instances when skin cancer arising on the urogenital skin require the expertise of the urology SMDT. The following skin cancers arising on the urogenital skin and mucosa should be discussed at the Urology SMDT: - Squamous cell carcinoma (including carcinoma in situ, erythroplasia of Queyrat and Bowen s disease) - Squamous cell carcinoma which has metastasised to regional lymph nodes - Melanoma of the penile skin and scrotum - Melanoma arising from urogenital mucosa - Melanoma which has metastasised to the urogenital mucosa - Melanoma of the penile skin or urogenital mucosa which has metastasised to regional lymph nodes - Extra-mammary Paget s disease of the penile skin The skin SMDT includes dermatology, plastic surgery, oncology, oculoplastic surgery, pathology and oncology. The following cases affecting the penile skin or urogenital mucosa will be discussed in the Skin SMDT: - all new patients with melanoma affecting the urogenital skin or mucosa - patients with melanoma arising from the penile or scrotal skin or urogenital mucosa which has metastasised locally or to regional lymph nodes Extra-mammary Paget s of the penile skin Norfolk & Norwich University Hospital The team includes Urology, Oncology, Pathology and Radiology and meets weekly on Monday from 10:30 to 12:00. To refer a patient to the Urology MDT please contact: Sarah Patience Robert Mills Urology MDT coordinator Urology MDT lead Sarah.patience@nnuh.nhs.uk Robert.mills@nnuh.nhs.uk Fax Lorraine Nelhams Jennifer Garioch Chair Skin SMDT lorraine.nelhams@nnuh.nhs.uk jennifer.garioch@nnuh.nhs.uk ext 4221/bl Fax Addenbrooke s Hospital, Cambridge University Hospitals Page 10 of 18

11 Core team members include Urology, Oncology, Pathology and Radiology and meets weekly on Monday from 2-00pm (SMDT) and Wednesday 1-00pm (LMDT) To refer a patient to the Urology MDT please contact: Susan Foxwell Urology MDT coordinator Susan.foxwell@addenbrookes.nhs.uk Mr Bill Turner Urology MDT lead william.turner@addenbrookes.nhs.uk Claire Herbert Claire.herbert@addenbrookes.nhs.uk Pamela Todd MDT lead clinician for melanoma pamela.todd@addenbrookes.nhs.uk Dr Tom Ha MDT Lead Clinician for Non- melanoma Skin Cancer thomas.ha@addenbrookes.nhs.uk Page 11 of 18

12 Skin and Haemato-oncology MDTs 08-1A-216j Cutaneous Lymphoma MDT The following cases should be referred to the Cutaneous Lymphoma MDT: PRIMARY SKIN LYMPHOMAS Mature T cell neoplasms / Cutanous T cell lymphomas* Patients with cutaneous T cell Lymphoma stage 1b or above Mycosis Fungoides - Follicular mycosis fungoides - Pagetoid reticulosis - Granulomatous slack skin Sezary Syndrome Subcutaneous panniculitis-like T cell lymphoma Primary cutaneous CD30 positive T-cell lymphoproliferative disorders - lymphomatoid papulosis - primary cutaneous anaplastic large cell lymphoma - primary cutaneous gamma delta T cell lymphoma Extranodal NK/T-cell lymphoma, nasal type Primary cutaneous CD8 positive aggressive epidermotropic cytotoxic T-cell lymphoma Primary cutaneous CD4 positive small/medium T-cell lymphoma Adult T-cell leukaemia / lymphoma Hydroa-vacciniform-like lymphoma Mature B cell neoplasms / Cutaneous B-cell lymphomas* All patients with cutaneous B cell lymphoma including: - Primary cutaneous follicle centre lymphoma - Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (Primary cutaneous marginal-zone B-cell lymphoma*) - Primary cutaneous diffuse large B-cell lymphoma, leg type - Primary cutaneous diffuse large B-cell lymphoma, other* - Intravascular large B-cell lymphoma* Acute Myeloid Leukaemia (AML) and related precursor neoplasms / Precursor haematologic neoplasm* Blastic plasmacytoid dendritic cell neoplasm (CD4/56+ haematodermic neoplasm*), previously known as blastic NK-cell lymphoma PSEUDOLYMPHOMAS (when diagnostic doubt only) MASTOCYTOSIS (when diagnostic or management doubt only) Mastocytosis in skin (all ages) Indolent systemic (and smouldering) Patients presenting with cutaneous metastases or involvement from primary systemic haemato-oncology Haemato-oncology MDT Page 12 of 18

13 The following patients should be referred to the haemato-oncology MDT: SYSTEMIC LYMPHOMA WITH SECONDARY SKIN INVOLVEMENT All SYSTEMIC MASTOCYTOSIS Associated haematological non-mast cell disease Aggressive systemic Mast cell leukaemia Supra Network MDT at St Thomas, London The following patients should be referred to the Supra network MDT at St Thomas s, London: Those cases of nodular mycosis fungoides (stage 2B or over) should be referred for discussion and consideration of Total Surface Electron Beam Therapy (TSEBT) Those cases of erythrodermic T-cell lymphoma, stages 3 and 4, having both skin involvement and circulating T-cell clonal cells, should be discussed with the clinician in charge of a named photopheresis facility for potential referral and treatment by photopheresis. Norfolk & Norwich University Hospital Skin lymphoma MDT co-ordinator: Lorraine Nelhams lorraine.nelhams@nnuh.nhs.uk; lnelhams@nhs.net tel , fax Skin lymphoma MDT lead: Dr Clive Grattan clive.grattan@nnuh.nhs.uk Secretary: Rachel Appleton; tel , fax Haemato-oncology MDT co-ordinator: sally.hardwick@nnuh.nhs.uk tel fax Lorraine Nelhams Jennifer Garioch Chair Skin SMDT lorraine.nelhams@nnuh.nhs.uk jennifer.garioch@nnuh.nhs.uk ext 4221/bl Fax Addenbrooke s Hospital, Cambridge University Hospitals To refer a patient to the Haemato-oncology MDT please contact Claire Herbert Haemato-oncology MDT coordinator Claire.herbert@addenbrookes.nhs.uk Dr George Fellowes Haemato-oncology (MDT lead) george.fellowes@addenbrookes.nhs.uk Page 13 of 18

14 To refer a patient for discussion at the skin SMDT contact: Claire Herbert Claire.herbert@addenbrookes.nhs.uk Pamela Todd MDT lead clinician for melanoma pamela.todd@addenbrookes.nhs.uk Dr Tom Ha MDT Lead Clinician for Non- melanoma Skin Cancer thomas.ha@addenbrookes.nhs.uk Page 14 of 18

15 Skin and Sarcoma MDTs 08-1A-217j There are several instances when Soft Tissue Tumours arising in the skin or subcutaneous tissue require the expertise of the Sarcoma MDT. The following list of sarcomas arising as a skin tumour should be discussed at the Sarcoma MDT 1. Sarcomas of skin origin - angiosarcoma - angioendothelioma - Kaposi s sarcoma - dermatofibrosarcoma protuberans (DFSP) - dermal leiomyosarcomas - epithelioid sarcomas 2. Sarcomas presenting as subcutaneous lumps - Liposarcoma - Fibroblastic/myofibroblastic sarcoma of the skin - Leiomyosarcoma subcutaneous tissue - Other superficial sarcomas of skin The skin SMDT includes dermatology, plastic surgery, oncology, oculoplastic surgery, pathology and oncology. The following cases affecting the skin or subcutaneous tissue will be discussed in the Skin SMDT: - All new patients with Dermatofibromasarcoma protuberans (DFSP) - Atypical fibroxanthoma - Leiomyosarcoma Norfolk & Norwich University Hospital This team includes radiology, plastic surgery, pathology and oncology expertise. It meets every second week on a Friday morning from for a review of radiology and pathology followed by a clinical assessment of cases in the sarcoma diagnostic clinic held from All new cases of sarcoma are discussed. To refer a patient to the Sarcoma MDT please contact: E Roberts Sarcoma MDT coordinator (details not available) Mr Moncrieff s secretaries marc.moncrieff@nnuh.nhs.uk Tel jane.webster@nnuh.nhs.uk Available wed/thurs/fri Helen Stubbings MDT Lead helen.stubbings@nnuh.nhs.uk Dr Stubbings secretary Tel Page 15 of 18

16 Available Monday to Friday Lorraine Nelhams Jennifer Garioch ext Fax Chair Skin SMDT Addenbrooke s Hospital, Cambridge University Hospitals This team includes radiology, plastic surgery, pathology and oncology expertise. It meets weekly (times to be confirmed) All new cases of sarcoma are discussed. To refer a patient to the Sarcoma MDT please contact: Sue Foxwell Sarcoma MDT coordinator Sue.foxwell@addenbrookes.nhs.uk Helena Earl MDT Lead helena.earl@addenbrookes.nhs.uk To refer a patient for discussion at the skin SMDT contact: Claire Herbert Claire.herbert@addenbrookes.nhs.uk Pamela Todd MDT lead clinician for melanoma pamela.todd@addenbrookes.nhs.uk Dr Tom Ha MDT Lead Clinician for Non- melanoma Skin Cancer thomas.ha@addenbrookes.nhs.uk Page 16 of 18

17 Levels of care follow the glossary on next slide. AngCN (E&W) Skin Cancer Pathway Feb 2009 v2 (including cancer waiting times timelines & GFOCW targets) In some cases, this can Be Decision To Treat (DTT) and First Definitive Histo +ve 18ww patients that have not been upgraded enter the cancer pathway following unexpected cancer Dx Routine Follow Up Urgent GP 2WW Referral* Suspected Malignant Melanoma or Squamous cell carcinoma 18ww referral no suspicion of cancer MDT Referral (Head & Neck, Sarcoma, Urology Gynae, Colorectal) 1 st consultant upgrade point eg referral meets criteria for suspected cancer Dermatology (preferably one stop) Clinic Where patient agrees Tx must occur Within 31days 2 nd consultant upgrade point eg clinical /radiological suspicion /62 days from date of upgrade Return to Dermatology Clinic for Bx Or other Tx Clinical Diagnosis Made (no histo) No diagnostics needed Watch and wait Plastics +/- Histology 3 nd consultant upgrade point eg after test result indicate or confirm cancer For further diagnostics 4 nd consultant upgrade point eg MDT diagnose cancer upgrade before Decision to Treat (DTT) Local MDT Care levels 2,3&4 Specialist MDT Care level 5 For further diagnostic s For further diagnostic s Supra Network MDT Care Level 6 Discharged back to GP / joins 18 week pathway / referred to other MDT DTT Patient Returns for Diagnosis And Tx Plan (Non-urgent referrals with Dx cancer to be treated <31 days from this point) DTT Patient Returns for Diagnosis And Tx Plan (Non-urgent referrals with Dx cancer to be treated <31 days from this point) Surgery Dermatology Or Plastics Staging Entered into a study or treated off study Surgery Dermatology Or Plastics Stagin g Entered into A study or Treated off study +/- Post Tx MDT to assess Fitness for subsequent treatment Earliest clinically appropriate date Clinic for Decision to Treat Subsequent treatments Hormone Radiotherapy Chemotherapy Palliative care Chemo/RT at unit or centre Referral to extended MDT services at any point in pathway eg Palliative care specialists and AHP support. Consider Clinical Trial and Follow Up Ref Rec d Day 0 By Day 14 By Day 28 By Day 42 By Day 62 Day 0 By Day 31 Key: Unit / Centre Centre Access to specialist services GFOCW Elapsed time for follow up or presentation of recurrence or mets Page 17 of 18

18 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 Joint Chairs of the Skin SSG Name: Jennifer Garioch Organisation: Skin SSG Date agreed: 12 th May 2010 Other SSG Chairs Name: Tom Roques & Richard Benson Organisation: Head and Neck SSG Date agreed: 27th March 2009 Name: Hisham Abdel-Rahman Organisation: Gynaecology SSG Date agreed: 15th July 2009 Name: Nick Dodd Organisation: Haematology SSG Date agreed: 16th July 2009 The SSG Members Name: Pamela Todd Organisation: Skin SSG Date agreed: 12 th May 2010 Name: Richard Miller & Nigel Hall Organisation: Colorectal SSG Date agreed: 14th July 2009 Name: William Turner and Robert Mills Organisation: Urology SSG Date agreed: 27th March 2009 (RM) 17th July 2009 (WT) Name: Helen Stubbings Organisation: Sarcoma SSG Date agreed: 27th March 2009 This document was agreed to at the Joint Skin SSG Meeting on 12 th May This document was re approved at the SSG meeting 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 18 of 18