SKIN NSSG. (Lancs & South Cumbria) Constitution and Terms of Reference 2015

Transcription

1 SKIN NSSG (Lancs & South Cumbria) Constitution and Terms of Reference 2015 VERSION : May

2 The constitution has been agreed by: Position: Chair of Skin NSSG Name: Chris Dobson Organisation: Lancashire Teaching Hospital Trust Date agreed: 26 May 2015 Skin NSSG Date agreed: 14 May 2015 Position: Clinical Lead for Cancer Name: Dr Gerry Skailes Organisation: Greater Manchester, Lancs & South Cumbria Strategic Clinical Network Date agreed: 19 June

3 INTRODUCTION The Skin NSSG is a multi-professional group made up of health professionals from organisations across the Lancashire & South Cumbria Cancer Network covering a population of 1.6 million. This document outlines the Skin NSSG Constitution and Terms of Reference and will be reviewed on an annual basis. Network Configuration of Teams Measure 14-1C-101 Local Hospital Skin Multidisciplinary Teams and referral services into the LSMDT(s) and into the Specialist Skin MDT. The Specialist MDT at LTHT acts as a Local MDT for its constituent population Locality Trust Local Diagnostic Teams/MDTs Lead Clinician Central Lancs Fylde Coast East Lancs Morecambe Bay Lancashire Teaching Hospitals Foundation Trust Blackpool, Fylde & Wyre Hospitals Trust East Lancashire Hospitals Trust University of Morecambe Bay Hospitals Trust MDT location: Royal Preston Hospital Lead Clinician:Dr Christopher Dobson Consultant Dermatologist MDT frequency: Weekly Facilities and Services: Care Levels 1-4 Referral to MDT via: GPs and General Surgeons MDT location: Clifton Hospital Lead Clinician: Dr Walter Bottomley Consultant Dermatologist MDT frequency: Fortnightly Facilities and Services:Care Levels 1-4 Referral to MDT via: GPs and General Surgeons MDT location: Burnley General Hospital Lead Clinician: Mr Ken McAlister Consultant OMF Surgeon MDT frequency: Weekly Facilities and Services: Care Levels 1-4 Referral to MDT via: GPs and General Surgeons MDT location: Royal Lancaster Infirmary Lead Clinician: Mr Stuart McKirdy Consultant Plastic Surgeon MDT frequency: Weekly Facilities and Services: Care Levels 1-4 Referral to MDT via : GPs and General Surgeons Specialist MDT Network Specialist MDT MDT frequency: weekly Facilities and Services: Care Levels 1-4 as LSMDT Care Level 5 as SSMDT Population: 1.6m Referral to MDT via: dermatology/plastic surgeons Principal Referring CCGs Greater Preston Chorley & South Ribble Blackpool Fylde/Wyre Blackburn with Darwen East Lancashire Cumbria (Furness and South Lakeland) North Lancashire (Lancaster) Catchment Population 212, , , , , , , ,537 Supranetwork MDT: Care level 6 Total Surface Electron Beam Therapy (TSEBT) to Christie Hospital and Referral for Photopheresis Rare skin cancers are referred to the Christie Hospital for management. The Skin NSSG have agreed liaison with the Supra-regional Haemato-Oncology MDT at the Christie Hospital/MRI, Manchester for rarer or more aggressive lymphomas, including T and B-cell skin lymphoma thus formalising existing long established referral practices to Manchester, often via the Network Haemato-Oncology MDT. The Network has no current plans to provide a Melanoma MDT (MMDT). Penile skin cancers are dealt with by the Network Specialist Urology MDT and then cases forwarded through to the Supranetwork Penile Cancer MDT (Mr Vijay Sangar, Supranetwork Penile MDT Lead Clinician) 3

4 Network Configuration of Skin Cancer Services in the Community Measure 14-1C-102 The Network currently has no Community Skin Cancer Service. Distribution of Clinics for Immunocompromised Patients Skin Cancer Measure 14-1C-103 Transplant patients on immunosuppression should all be assessed in such a clinic, and reviewed at least annually for full skin assessment and for management of any skin cancer(s) detected. Advice on sun protection and avoidance should be given in these clinics. Below are details for agreed Clinics where Immunocompromised patients receive follow up care in the Network. Consultant Trust Frequency Number of patients Dr. Alison Duncan and DSN Michelle LTHT Bi-monthly/every fourth Friday 4 new and 8 follow-up Twice weekly DSN transplant per week 12 patients ( 8 and 4 per clinic respectively) Banks Dr Walter Bottomley BFWHT Alternate weeks 1 patient per clinic Dr. Moosa UHMBT There are 2 slots reserved for Immunosuppressed patients in a dedicated skin cancer follow-up clinic on a Tuesday afternoon every other week. Dr Arun ELHT Every month Every third Tuesday of the month at Burnley General Hospital In addition the Skin Cancer Clinical Nurse Specialist holds a Skin Cancer Education clinic every Friday to which all transplant patients have been invited. 2 patients can be seen per clinic - If they are not filled a few days before the clinic then they are used for other follow-ups. 6 new patients/10 follow-ups 24 patients The location of Transplant Centres to which patients are referred are as follows: Kidney transplant patients are referred to Manchester Royal Infirmary part of Central Manchester University Hospitals. Liver transplant patients are referred to Leeds Teaching Hospitals Trust. Heart transplant patients are referred to Wythenshawe Hospital part of the University Hospital of South Manchester NHS Trust. 4

5 TERMS OF REFERENCE AND MEMBERSHIP Measure 14-1C-104 Name Job Title Organisation Dr Christopher Dobson Consultant Dermatologist/MDT LC/Chair LTHT Dr Alison Duncan Consultant Dermatologist LTHT Mr Iyer Sriinivasan Consultant Plastic Surgeon LTHT Mr Milind Dalal Consultant Plastic Surgeon LTHT Mr Jeyaram Srinivasan Consultant Plastic Surgeon LTHT Dr Deepa Pandit Consultant Pathologist LTHT Prof Jon Hill Consultant Radiologist LTHT Dr Ruth Board * Consultant Medical Oncologist LTHT Ms Clare O'Doherty ** Melanoma Support Nurse/Cancer Nurse Specialist LTHT Ms Nina Deacon Skin Cancer Nurse Specialist LTHT Ms Elaine Stringfellow Skin Cancer Nurse Specialist LTHT Mr Ken McAlister Consultant OMF Surgeon/MDT LC ELHT Mr Billy Hefferon Skin Cancer Clinical Nurse Specialist ELHT Mr Stuart McKirdy Consultant Plastic Surgeon/ MDT LC UMBHT Dr Ann Myatt Consultant Dermatologist UHMBT Ms Julie Tait Skin Cancer Nurse Specialist UMBHT Dr Walter Bottomley Consultant Dermatologist/MDT LC BFWHT Ms Heather Baines Skin Cancer Clinical Nurse Specialist BFWHT Mr Tony Eaton Skin Cancer Clinical Nurse Specialist BFWHT Dr Karim Mashayekhy GPwSI Dermatology LTHT Mr Stuart Gibson Patient Representative CPG Group Miss Vicki Wagstaff Admin Support SCN Extended members Mr Gerard Laitung Consultant Plastic Surgeon LTHT Mr Anil Agarwal Consultant Plastic Surgeon LTHT Mr Sofiane Ramouche Consultant Plastic Surgeon LTHT Dr Graham Read Consultant Oncologist LTHT Dr Natalie Charnley Consultant Oncologist LTHT Dr Claribel Cardozo Consultant Pathologist LTHT BFWHT: Blackpool, Fylde & Wyre Hospitals Trust UHMBT: University Hospitals of Morecambe Bay Trust ELHT: East Lancashire Hospitals Trust LTHT: Lancashire Teaching Hospitals Trust MDT LC: MDT Lead Clinician The Skin NSSG will have a Chair elected from within the membership of the NSSG. The term of office for the Chair of NSSG will be for a period of two years but the Chair may be re-elected after this period of tenure. Dr Christopher Dobson, Consultant Dermatologist at Lancashire Teaching Hospitals Trust is the current Chair. The group will be deemed to be quorate if there is representation from three of the four localities. Clare O Doherty ** Cancer Nurse Specialist at Lancashire Teaching Hospital Trust has specific responsibility for user issues and information for patients/carers. Considerable work has been undertaken to date. Patient information is regularly reviewed every 2 years through a series of consultation exercises with patient representatives, agreed forums and NSSG. Dr. Ruth Board * Consultant Medical Oncologist, UMBHT has responsibility for ensuring that recruitment into trials and other well designated studies is integrated into the function of the NSSG. Extended membership - the group will identify and recommend membership of other appropriate professionals as required, to achieve the objectives of the group. The group has a mechanism for seeking additional patient advice from the Network Cancer Partnership Group which continues to meet regularly. 5

6 Role and Function of Group The role and purpose of the Skin NSSG is to improve the experience and outcomes of cancer care for Skin patients in the Lancashire & South Cumbria Cancer Network. This involves consideration of strategies and plans for service improvement and service development across the patient pathway, incorporating all aspects of care at appropriate stages of the patient s journey. The aim is to achieve the best possible outcomes and best quality of life for all patients who use Skin cancer services within the Network. The Skin NSSG: Is the Network s primary source of clinical opinion on issues relating to Skin cancer for the Network Is the Group with corporate responsibility for co-ordination and consistency across the Network for policy, practice guidelines, audit, research and service improvement relating to Skin cancer. Will consult with the relevant cross-cutting Network groups on issues involving chemotherapy, cancer imaging, histopathology and laboratory investigation and specialist palliative care; and with the Head of Service on issues involving radiotherapy. Members of the NSSG will be responsible for feeding back information/decisions from the NSSG to their clinical and managerial colleagues. Network Group Meetings Measure 14-1C-105 The group will meet twice per annum as a minimum with one educational meeting. Notes of the meeting will be produced and attendance recorded. The Annual Report lists details of attendance at NSSG meetings for the previous calendar year. Annual Report and Work Programme Measure 14-1C-106 The NSSG will produce an annual report and work programme. The NSSG will annually review its Constitution and Terms of Reference. Designated Hospital Practitioners for MOHS Surgery Measure 14-1C-107 There is no Mohs Surgery service available in the Network, but a business case is being prepared for provision within our Network. Currently patients are referred to Dr Hamid Tehrani at Whiston Hospital, St. Helens. Training Policy for Model 2 Community Practitioners with Named Trainers/Assessors Measure 14-1C-108 The Network currently has no agreed Community Skin Cancer Service. Skin Network Wide Clinical Guidelines Measure 14-1C-109 The Skin NSSG have an agreed set of Clinical Guidelines for the treatment of BCC, SCC, MM and lymphomas. See separate document. Imaging Guidelines Measure 14-1C-108 The Skin NSSG has an agreed imaging guideline for the diagnosis and assessment of skin cancer (malignant melanoma). Details on shown on page 8 of the Clinical Guidelines. 6

7 Pathology Guidelines Measure 14-1C-109 The Skin NSSG have agreed the Royal College of Pathology Skin Cancer guidelines as the Network-wide pathology guidelines. Links to the relevant documentation are contained within the Clinical Guidelines. Dr Deepa Pandit, Consultant Histopathologist at Lancashire Teaching Hospitals Trust is Network Lead for Skin SSMDT, with Dr C Cardozo as Deputy. Dr Alison Armour (Consultant Histopathologist, Lymphoreticular Pathology) primarily reports Skin lymphomas with Dr Pandit and Dr Gudur. Double reporting is undertaken on all malignant melanomas and difficult melanocytic lesion. In case of difficult cases, second opinions are sought from Dr Patrick Shenjere at the Christie Hospital, Manchester or Dr Thomas Brenn, Western General Hospital, Edinburgh. The pathology requesting and reporting protocol is detailed in Appendix 1. Chemotherapy Treatment Algorithms Measure 14-1C-110 The NSSG have an agreed set of Chemotherapy Treatment Algorithms for skin cancer which has been approved by the Chemotherapy NSSG. A copy of the algorithm can be found at Appendix 2. Patient Pathways Measures 14-1C-111 to 14-1C-114 The Skin Cancer NSSG has agreed pathways for: Primary Care; Measure 14-1C-111 Pathways between MDTs; Measure 14-1C-112 Pathways for Supranetwork MDTs Measure 14-1C-113 Pathways shared with other MDTs Measure 14-1C-114 All pathways can be found in the Clinical Guidelines document. Referrals are made to the Speciast Skin MDT by ing the Proforma. (Appendix D) The Schematic on page 9 describes the referral pathway/guideline between teams and the levels of care are described in the table overleaf. 7

8 Table 1 Locality Trust Local Diagnostic Teams/MDTs Lead Clinician Central Lancs Fylde Coast East Lancs Morecambe Bay Lancashire Teaching Hospitals Foundation Trust Blackpool, Fylde & Wyre Hospitals Trust East Lancashire Hospitals Trust University of Morecambe Bay Hospitals Trust MDT location: Royal Preston Hospital Lead Clinician:Dr Christopher Dobson Consultant Dermatologist MDT frequency: Weekly Facilities and Services: Care Levels 1-4 Referral to MDT via: GPs and General Surgeons MDT location: Clifton Hospital Lead Clinician: Dr Walter Bottomley Consultant Dermatologist MDT frequency: Fortnightly Facilities and Services:Care Levels 1-4 Referral to MDT via: GPs and General Surgeons MDT location: Burnley General Hospital Lead Clinician: Mr Ken McAlister Consultant OMF Surgeon MDT frequency: Weekly Facilities and Services: Care Levels 1-4 Referral to MDT via: GPs and General Surgeons MDT location: Royal Lancaster Infirmary Lead Clinician: Mr Stuart McKirdy Consultant Plastic Surgeon MDT frequency: Weekly Facilities and Services: Care Levels 1-4 Referral to MDT via : GPs and General Surgeons Specialist MDT Network Specialist MDT MDT frequency: weekly Facilities and Services: Care Levels 1-4 as LSMDT Care Level 5 as SSMDT Population: 1.6m Referral to MDT via: dermatology/plastic surgeons Principal Referring CCGs Greater Preston Chorley & South Ribble Blackpool Fylde/Wyre Blackburn with Darwen East Lancashire Cumbria (Furness and South Lakeland) North Lancashire (Lancaster) Catchment Population 212, , , , , , , ,537 LSCCN have agreed the levels of care to be provided at each MDT as follows: LSMDT Care Levels 1 4 SSMDT Care Level 5 Supranetwork MDT Care Level 6 Total Surface Electron Beam Therapy (TSEBT) to Christie Hospital and Referral for Photopheresis 8

9 Table 2: LEVELS OF CARE Care Level Person or Team Case Mix/Procedure 1 Any general practitioner in the community Benign lesions Actinic Keratoses Precancerous SCC in situ/bowens 2 Community practitioners working to the DES/LES model (Level 2a) or the Model 1 service model (Level 2b). DES/LES list of BCCs (level 2a) Model 1 list of BCCs (level 2b) 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 MDT) 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. High risk BCC SCC }Other than categories below High risk BCC } Recurrent or with +ve excision margins SCC } Malignant Melanoma (MM) new, single primary, adult, non-metastatic, not for approved trial entry, up to and including stage II a (must fulfil all 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 SSMDT core member (as per network clinical guidelines) Radiotherapy (as per Network clinical guidelines). If not discussed and treated by LSMDT clinical oncology core team member. Metastatic SCC on presentation or newly metastatic MM stage 11b 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 approved trial entry Any cases for adjuvant therapy (as per Network clinical guidelines) Histology opinion from SSMDT 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 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) 6 Supranetwork team - Selected Networks only. Agreed with Specialist Commissioning Groups. Note: there should be agreed working arrangements with site specialised MDTs for SCC of Head and Neck and Sarcoma and mucosal malignant melanoma. T-cell cutaneous lymphoma: total body surface electron beam therapy T-cell cutaneous lymphoma: photopheresis Clinician responsible for named facilities for photopheresis (very small number of patients) agreed with SCGs. 9

10 LSCCN Skin Cancer Referral Pathway Patient presents General Practitioner Care Level 1: Refers all others Refers low risk BCC GPwSI Care Level 1 and Care Level 2: Refers all others Rapid direct referral if identified as Care Level 5 to SSMDT LSMDT Care Levels 1 & 2: Care level 3: Treatment by core MDT member without mandatory MDT discussion and Care level 4: Mandatory MDT discussion by LSMDT Refers for Care Levels 5 & 6 Rapid direct referral if identified as Care Level 5 to SSMDT Refers direct to Level 6 if identified Refers Level 5 & 6 GP local to SSMDT Care Level 1 Refers to SSMDT as local MDT SSMDT Care Levels 1, 2, 3 and 4: SSMDT in local role Plus Care level 5: Mandatory MDT discussion by SSMDT Refers for Care Level 6 GPwSI local to SSMDT Care Levels 1 & 2 Refers to SSMDT as local MDT CTCL Supranetwork MDT - TSEBT Selected facility Photopheresis Liaise with related SSMDT Care Level 6 10

11 Agreed Network Referral Guidelines to Named Supra-Network T-cell Lymphoma MDT for TSEBT and Erythrodermic cutaneous T-cell lymphoma The agreed Network Referral Guideline for cases of mycosis fungoides stage 1b and overis that they will be referred for discussion and consideration of TSEB, to the Supranetwork MDT at the Christie Hospital. The agreed Network Referral Guideline for cases of erythrodermic cutaneous T-cell lymphoma, stages 3 and 4, having both skin involvement and circulating T-cell clonal cells, will be discussed at the Supranetwork MDT at the Christie Hospital, which can then where appropriate discuss with the clinician in charge of the photopherisis service at St Mary s Hospital Manchester. Pathways for Skin Cancer in specific Anatomical Sites The Skin Cancer NSSG has a set of agreed patient pathways with relevant network groups specifying which out of the site specific MDTs or the Skin Cancer MDT should deal with cases in which clinical situations and which parts of the patient pathway for the following: Head and neck skin cancer; Anal and perianal skin cancer; Skin cancer of external female genitalia; Skin cancer of external male genitalia; Lymphoma involving skin; Sarcoma involving skin All Sarcoma patients are referred to the Merseyside Sarcoma MDT except for those identified as Group A There is an agreed pathway for Teenage and Young Adults and for any patient presenting with a Cancer of Unknown Primary. All pathways can be found in the Clinical Guidelines document. Patient Experience Measure 14-1C-115 The Skin Cancer NSSG will annually review patient feedback of their associated MDTs and any actions implemented and agree an improvement programme with them. Clinical Outcomes Indicators and Audits Measure 14-1C-116 The Skin Cancer NSSG will annual review the progress (or discuss completed results) of it s associated MDTs outcome indicators and audits. Clinical Governance Arrangements for Community Practitioners Measure 14-1C-117 The Network currently has no Community Skin Cancer Service. Research & Development Measure 14-1C-118 The Skin Cancer NSSG will discuss the clinical trials reports of it s associated MDTs and agree improvement programmes with them. VERSION : May

12 Appendix 1 PATHOLOGY GUIDELINES FOR DIAGNOSIS AND ASSESSMENT OF SKIN CANCER Gross: Specimens should be described and cut up according to Royal College Minimum Datasets (new datasets are expected to be available later this year, Draft guidelines are out at present). Microscopy: Reported according to Royal College Minimum datasets, see above. This will include reporting of squamous cell carcinoma, basal cell carcinoma and melanoma. All melanomas should reported by 2 Pathologists. Synoptic reports can be used for all tumours and are preferable for melanoma (Appendix A). TNM staging according to AJCC 7th edition should be included in reports. Merkel cell carcinoma reported according to AJCC 7th edition. Suggested immuno panels for skin tumours are given below (Appendix B). Histopathology Referral of cases to SSMDT Cases which are to have histopathology review at the SSMDT are requested by Plastic Surgery Secretaries or by Skin MDT Coordinator, from the peripheral hospitals. There is a standard format for request of cases which can be sent by e- mail or fax TO THE Histopath departments (Appendix C). If these cases do not arrive by the time of skin MDT, a reminder is sent by Skin MDT Co-ordinator. Skin Lymphoma These are seen by and primarily reported by the Haematolymphoid Pathology Lead at RPH, Doctor Alison Armour. These cases are also seen by the Skin MDT Lead Dr Pandit. The Skin Cancer Network has agreed that skin lymphoma pathology be sent to the Manchester HOMD service, to mirror the clinical pathways for high grades of T lymphoma. VERSION 3: May

13 APPENDIX A (Suggested Synoptic report for melanoma) Histological subtype Pathological feature Ulceration (diameter in mm) Breslow thickness Clark level Predominant cell type Mitotic index (per sq mm) Vascular or lymphatic invasion Neurotropism Tumour infiltrating lymphocytes (TIL) Features of regression Satellites Associated naevus Nearest lateral margin to in situ component Nearest lateral margin to dermal invasive component Distance from invasive tumour to nearest deep margin Solar elastosis If any areas of uncertainty this can be put as free text and prefaced with explanatory comments Also in shave bx etc free text can be added eg estimated Breslows/Clarks. APPENDIX B (IMMUNO PANELS): MELANOMA - S100 protien (stains all melanomas including desmoplastic melanomas) - Melan A - HMB45 LENTIGO MALIGNA & LENTIGO MALIGNA MELANOMA - Melan A: useful to see extent of in-situ component - S100 protein: invasive component may be desmoplastic & can be missed on H&E SQUAMOUS CELL CARCINOMA V/S BCC - Ber EP4: stains BCC - EMA: stains SCC SEBACEOUS TUMOURS - EMA positive (mature sebocytes) - CK 7 positive - CEA negative - Ber EP4 negative ATYPICAL FIBROXANTHOMA (AFX) VERSION 3: May

14 Diagnosis of exclusion At least 2 CK, 1 pancytokeratin and 1or 2 high molecular wt to rule out poorly differentiated SCC - MNF CK5/6-34 beta e 12 - Ck14 - p63 (see Note below) 2 melanoma markers - S100 protein - Melan A For leiomyosarcoma - SMA - Desmin AFX - CD10 +ve - SMA can be focally positive (Note: p63 + (favours SCC over AFX, but at least 1 CK should be +ve) (Ref: Utility of p63 in the differential diagnosis of atypical fibroxanthoma and spindle cell squamous cell carcinoma. Gleason et al; J Cut Path: 2009: 36: ) MERKEL CELL CARCINOMA - CD20 dot +ve - Cam 5.2 dot +ve - MNF TTF 1 usually negative; if +ve lung primary has to be excluded - CK 7 negative - CD56 + POORLY DIFFERENTIATED EPITHELIOD TUMOUR - Melanoma : S100 protein, Melan A - Carcinoma : MNF 116, AE1/AE3 (at least 2 pan-cytokeratins; Cam 5.2 is negative in squamous carcinomas) - Anaplastic large cell lymphoma : CD 45 (+ in only 50-60% cases), CD30 - Epitheliod angiosarcoma : CD31, Fli1 VERSION 3: May

15 APPENDIX C REQUEST FORM FOR HISTOLOGY CASES FOR SKIN MDT NETWORK SKIN MDT MEETING Date of meeting:.. Please send the slides and/ or blocks and reports from the following cases to: Dr. Deepa Pandit/ Dr Claribel Cardozo Dept. of Pathology Royal Preston Hospital Sharoe Green Lane Fulwood Preston PR2 9HT. Telephone No deepa.pandit@lthtr.nhs.uk PATIENT DOB NHS NO Specimen Histology Number (if known). NAME details VERSION 3: May

16 Appendix D VERSION 3: May

17 Appendix 2 SYSTEMIC TREATMENT ALGORITHM FOR MELANOMA ADJUVANT THERAPY No standard treatment, consider entry into clinical trial LOCALLY ADVANCED/RECURRENT INOPERABLE DISEASE AFFECTING SINGLE LIMB Treat as metastatic disease or consider referral for isolated limb perfusion or ECT METASTATIC DISEASE BRAF + 1 st line options: Consider entry into clinical trial BRAF inhibitor (vemurafenib or dabrafenib) Consider first line ipilimumab for low burden, slow progressing disease BRAF - 1 st line options: Consider entry into clinical trial ipilimumab 2 nd line options: Consider entry into clinical trial Ipilimumab if first line BRAF inhibition BRAF inhibition if first line ipilimumab 2 nd line options: Consider entry into clinical trial PD1 antibody if available 3 rd line options: Consider entry into clinical trial PD1 antibody Decarbazine chemotherapy Carboplatin/Taxol chemotherapy 3 rd line options: Consider entry into clinical trial Decarbazine chemotherapy Carboplatin/Taxol chemotherapy VERSION 3: May