South West Strategic Clinical Network Somerset, Wiltshire, Avon and Gloucestershire (SWAG) Cancer Services

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1 Meeting of the SWAG Network Skin Cancer Education and Business (SSG) Thursday, 24 th September 2015 at The Penny Brohn Cancer Centre, Chapel Pill Lane, Pill, BS20 OHH This meeting was sponsored by LEO, DERMA, PROSTRAKEN AND STIEFEL PHARMACEUTICALS Chair: Amrit Darvay Notes (To be agreed at the next SSG meeting) Actions 1. Round 1 dermoscopy cases 1.1 North Bristol Hospital Presented by Amrit Darvay Case study 1. Dermoscopy Workshop and Update An out of character lesion on back. Dermoscopy showed asymmetry, irregular dots and an off centre blotch. It was considered suspicious of malignancy. The lesion was excised and was histologically benign, giving an example of the many benign lesions excised for appropriate reasons. Case study 2. In 2014, a shave biopsy from the nose showed actinic keratosis and was seen for a re-biopsy in The dermoscopy showed a classic example of a basal cell carcinoma (BCC): note types of telangiectasia: sharply focused, narrow arborizing and wider, less in-focused telangiectasia. Histology confirmed a diagnosis of an infiltrative BCC and the patient was referred for Mohs Micrographic Surgery (Mohs). The necessity for a biopsy in an obvious case was questioned. Histological diagnosis was required prior to referral for complex surgery. Case study 3. A growing darkening lesion on the cheek. Features under dermoscopy: yellow opaque areas, a well-demarcated, continuous, 'moth-eaten' border. No LM or LMM-type changes. All agreed this looked like a solar lentigo which was confirmed after incisional biopsy through the area. The patient can be discharged to self-monitor. Case study 4. A lesion on the end of the nose showing slow progressive change over two years. The dermoscopy showed clear atypical pigmented areas around appendageal openings aka rhomboid structures. Histological diagnosis: lentigo maligna. Page 1 of 15

2 Case study 5. A clinically similar looking lesion to a solar lentigo had a histological diagnosis of lentigo maligna melanoma. Case study 6. A new slow growing lesion on mouth in young patient on azathioprine: melanosis, basal layer pigmentation and pigment incontinence. No melanocytic proliferation. Removed as immunosuppressed and unclear if it wasn t melanocytic. Case study 7. Growing lesion on right thigh. Dermoscopy shows asymmetry, veil, atypical vascular structures, regression, and radial streaks. Histological diagnosis: 0.9mm VGP Melanoma Mitotic Rate 1 per square mm. Case study 8. Out of character mole on thigh possibly increasing in size. Dermoscopy shows bland, some asymmetric dots and globules, colour variation, hints of regression, no obvious network. Histological diagnosis: uncertain. Melanoma in situ or odd benign naevus. Treated as melanoma in situ. Case study 9. Growing mole on shoulder. Dermoscopy shows asymmetry, hint of a veil, abnormal network & radial streaks. Histological diagnosis: Uncertain. atypical spitz or 1.1mm MM. A second opinion could not exclude a 1.1mm MM in this severely atypical compound melanocytic lesion with spitzoid features. Case study 10. New lesion left flank. Dermoscopy shows striking regression area - scar-like, atypical network and blue-black veil. Histological diagnosis: 1.02mm VGP melanoma. Mitotic rate 7 per HPF. Case study 11. New asymptomatic lesion on temple. Dermoscopy shows erythema around follicular openings, monomorphic structures. Histological diagnosis: Jessner s Lymphocytic Infiltrate of the Skin. Case study 12. 5mm lesion on arm grown over the last 6 month. Dermoscopy shows globules, vascular structures, comma-like and hairpin vessels. Intradermal naevus Page 2 of 15

3 considered but in view of clear history of change lesion was excised as atypical. Histological diagnosis: Uncertain. Spitzoid Tumour of Uncertain Malignant Potential STUMP. 1.2 Gloucestershire Hospitals Presented by Tom Millard There are currently problems with accessing medical photography in Gloucestershire Hospitals affecting the quality of the photos. Case study 1. Lesion on nose with dermoscopy that shows asymmetry, many colours and areas of regression. The pathology showed inflammation. Melan-a stain showed melanoma in situ. This is an example of the ugly duckling sign, when a pigmented lesion looks different to all its neighbours: identification of the common characteristics of naevi in an individual as a basis for melanoma screening. The three processes of image recognition: Overall pattern recognition (Gestalt) Analytical recognition (ABCD) Differential recognition Ugly duckling. Case study 2. Ugly duckling lesion on back. Dermoscopy shows pigment network expanded to the edge, asymmetry, three colours, dots, and a milky veil. Histological diagnosis: severely atypical compound naevus. After discussion at MDT, changed to a melanoma in situ. Factors that might influence pathologists when looking at borderline cases and how to manage this were discussed. Case study 3. Lesion on back with dermoscopy that shows asymmetry, scalloped border, 4 colours, milky white veil and dots. Histological diagnosis: Superficial spreading malignant melanoma. Case study 3. Firm nodule on leg. Dermoscopy shows pseudonetwork surrounding a pale amorphous area. Histological diagnosis: Dermatofibroma. Case study 4. Lesion on heel with dermoscopy showing globules on ridges. Histological diagnosis: Talon Noir. Page 3 of 15

4 Case study 5. Long standing ugly duckling lesion on arm. Dermoscopy shows slate blue grey uniform that is without other structures. Histological diagnosis: blue naevus. Case study 6. Multiple lesions on shoulders with dermoscopy that shows monomorphic, regular pigment network. Histological diagnosis: ink spot lentigo with sun damage components. 2. Dermoscopy of acral pigmented lesions Please see the presentation uploaded on to the SWSCN website Presented by Kat Nightingale Acral melanomas make up to 2-3% of all melanomas. They are more common on darker skin and are found more often on the feet than the hands. Five years survival is approximately 80.3%, and ten year survival approximately 67.5%. Acral skin structure: Thick compact cornified layer Dermatoglyphics ridges and furrows Absent hair follicles Well-developed eccrine ducts 2 types of Rete ridges: Crista profunda limitans (CPL) furrow and Crista profunda intermedia ridge Melanocytes distributed mainly in the CPL. Acral dermoscopy patterns acquired: Parallel furrow % Lattice 15% arch area Fibrillar 10-20% Pressure bearing areas Parallel ridge - melanoma Globular Acral reticular Homogenous Transition. If pigment is found predominantly in the furrows, the lesion is considered benign. If pigment is found predominantly on the ridges, the lesion is considered malignant. The furrow ink test makes this easier to determine by staining the furrows and allowing the dermatologist to establish, with the use of dermoscopy, whether pigmentation follows the furrows or the ridges, safely reducing the amount of surgery performed on such lesions. Different features of the lesions were viewed as detailed in the presentation. The talk was thought to Page 4 of 15

5 be useful to give to podiatrists, including the information that any non-healing lesion after two months should be referred to a dermatologist. The 3-step dermoscopic algorithm: Step 1 The lesion is examined for the presence of the parallel ridge pattern. If the parallel ridge pattern is found in any part of the lesion, the lesion should be biopsied regardless of the size. If the lesion does not show the parallel ridge pattern, proceed to Step 2. Step 2 The lesion is examined for the presence of one or an orderly combination of the typical benign dermoscopic patterns (i.e. typical parallel furrow pattern, typical lattice-like pattern, regular fibrillar pattern). If the lesion shows one or a combination of two or three typical benign patterns, further dermoscopic follow-up is not needed. If the lesion shows equivocal dermoscopic features (i.e. absence of any typical/regular patterns) proceed to Step 3. Step 3 The maximum diameter of lesions that do not show typical benign patterns is measured. Lesions >7 mm should be excised or biopsied for histopathologic evaluation. Lesions 7 mm should be monitored clinically and dermoscopically at three- to six-month intervals. 3. Spitz naevus and Spitzoid Tumour of Uncertain Malignant Potential (STUMPs) Presented by Katherine Finucane Spitz naevus Dome shaped, reddish-brown Can be darker papules/nodules 70% in people under 20 yrs old Fair skinned people Spindle naevus of Reed - similar to pigmented Spitz. The lesions previously called juvenile melanoma were renamed spitz naevus to reflect their benign nature. Examples of the domed, reddish, reverse strawberry like features were displayed, as were a variety of example of STUMPS. 4. Round 2 dermoscopy cases Further case studies from Taunton and Somerset Trust and University Hospitals Bristol were discussed in depth. Page 5 of 15

6 5. Network audit of SCC at tricky sites Please see the presentation uploaded on to the SWSCN website Presented by Joanna Fawcett Audit and quality control study of squamous cell carcinoma excised from scalp, nose, dorsum of hand with narrow deep margin (<1mm), and SCC with perineural or lymphovascular involvement with <1mm any margin clearance at all body sites. Data had been contributed from throughout the region; results from RUH were still pending. Royal Devon and Exeter and North Devon and Barnstaple have also shared their data. Background: At skin cancer MDTs, a group of lesions with narrow margins (<1mm) of excision give rise to debate: Limited subcutaneous. Tissue of the: Elderly scalp Dorsum of the nose Dorsum of the hand Perineural or lymphovascular involvement. Data on the relevant patients, managed in 2009/10, was examined to establish the 5 year outcomes. Standards (target 100%): Qualifying tumours will have a management plan arising from the MDT (NICE IOG Guidance 2006) There is evidence in the clinical notes that the MDT management plan was discussed/communicated with the patient or other responsible person (NICE IOG Guidance 2006) A follow up plan was determined by the MDT (NICE IOG Guidance 2006) The follow up plan was within SSG guideline (SSG management of SSC guideline) There is evidence in the clinical notes that the MDT follow up plan was undertaken (NICE IOG Guidance 2006) The outcome at 5 years post treatment will be documented in the hospital record (Provisional) Page 6 of 15

7 Sample: 101 patients were identified. The majority of patients were male and the majority of lesions were on the scalp. Results: The MDTs perform well at creating management plans. Follow up plans vary across Trusts, as detailed in the presentation. It was noted that the follow up guidelines were documented within the SWAG clinical guidelines. Patients should be provided with information for self-management of follow up where appropriate. A full analysis of the results is documented in the presentation. Conclusions: There is approximately an 11% recurrence rate with all recurrences occurring on the scalp or head and neck. The depth of the excision would be interesting to establish in the next audit. Actions: To ensure that follow up plans are discussed and recorded in the MDT outcomes, share best practice between Trusts, and potentially look at redesigning follow up once more data has been gathered, as recommended in the National Survivorship Initiative. The audit will be repeated on the 2014 cohort of patients. David de Berker (DdB) will circulate the action plan. DdB Business Meeting 6. Welcome and apologies Please see the separate list of attendees and apologies uploaded on the South West Strategic Clinical Network (SWSCN) website. The new user representative members, Sharon Scrivens (SS) and Lauren Waldron (LW), were welcomed to the group. A third user representative, Sharon Keenan has also agreed to be a member of the group, but was not available to attend today. 7. Review of previous minutes and actions A letter was sent to the Chief Executive Officer at RUH by Amrit Darvay (AD) in March 2015 to enquire when they would be able to offer a medical photography service. A response was received in May, stating that this was in the job plan for 2016, and a project group had been established to seek solutions. The situation still remains unresolved. TST and GLOS have no funding for a medical photography service at present; photographs are taken and stored by the team. The Clinical Guidelines, Constitution and Work Programme are now available on the SWSCN website. These will be amended as necessary in line with updates to Page 7 of 15

8 National Guidelines. SSG members are to consider the subject for the next annual network audit. Many of the surgical SSG members are using the database developed by Adam Bray to keep a detailed log of all tumours excised. All surgeons are to be encouraged to contribute to the dataset so that a complete picture of excision rates is available for comparison with peers. Recording the data has led to a steady improvement in excision rates. Gloucestershire Hospitals conduct an annual audit using the data, which is presented at their annual meeting. The database is available online here. The lack of resources for dealing with the 2WW referrals in NBT has been addressed. A business case produced by Catherine Carpenter-Clawson (CCC) proposed increasing staffing levels within the fast track office so that the service was comparable with other Trusts. An apprentice has subsequently been recruited and a further 2 members of staff will commence in post in the near future. The new SSG lead for research is Consultant Clinical Oncologist Chris Herbert, who will inform SSG members of all research opportunities available. TST members will now join the Peninsula SSG due to the patient referral pathways between TST and Royal Devon and Exeter Hospital (RD&E). The Peninsula group are considering adopting the SWAG clinical guidelines to ensure a unified approach across the South West. The possibility for the Peninsula and SWAG group to have a combined annual SSG will be explored. All other subject matters from the previous notes that are relevant for further discussion will be addressed within the current SSG meeting. 8. Coordination of patient pathways 8.1 The new NICE referral guidance and referral form The new NICE suspected cancer referral guidance had now been published. As discussed in the previous meeting, this includes a recommendation to refer basal cell carcinomas via the two week wait pathway if there is a particular concern that a delay may have a significant impact, because of factors such as lesion site or size. This may cause a significant increase in referrals. It was thought that there would be an initial bulge that may affect meeting the 31 day target, which should then level out. Despite the problems on capacity that this might cause, seeing all patients within shorter time frames is the service that the group aspires to offer. Jonathan Miller (JM) is amending the 2WW referral forms to reflect the new guidelines. The CCGs have asked for a delay in the development of site specific forms while opinions are sought from SSGs on a new Cancer Concern referral form. This is one generic form for all suspected cancer referrals. The form was Page 8 of 15

9 not considered fit for purpose due to the lack of information deemed necessary for triaging purposes. Development of a site specific form was recommended. The feedback will be sent to JM by HD. HD 8.2 New NICE melanoma guidelines Please see the presentation uploaded on to the SWSCN website Presented by Amrit Darvay The NICE melanoma guidelines were published in July Helpful pictorial algorithms are available on pages Dermoscopy is recommended for all pigmented lesions by individuals trained in the technique. Evidence of members training is therefore required. Medical photography including dermoscopic imaging is recommended. The teams that are having issues with providing this can refer managers to the guidance. Other recommendations: Vitamin D levels are to be measured at diagnosis and GPs are to be requested to provide supplements if necessary Melanoma in situ - at least 5mm clinical wide local excision margins Consider topical imiquimod to treat stage 0 melanoma if surgery to remove the entire lesion with a 0.5 cm clinical margin would lead to unacceptable disfigurement or morbidity. Repeat biopsies after treatment to assess response 1cm WLE for Stage 1 and 2cm WLE Stage 2 Offer as staging SLNB to IB to IIC. Do not offer for 1mm or less CT staging for IIC, III and IV (MRI <24 years-old). It was noted that patients should be made aware that treatment with topical imiquimod can dramatically blister and redden the skin, but that this resolves with time. All patients to be given verbal and written information on the advantages and disadvantages of SLNB (page 111) Consider completion lymphadenectomy if SLNB positive but also give verbal and written information on advantages and disadvantages Do not give adjuvant radiotherapy in Stage III disease unless a reduction in the risk of local recurrence is estimated to outweigh the risk of serious adverse effects. Genetic testing: Do not offer genetic testing of Stage IA IIB primary melanoma at presentation except as part of a clinical trial (less than 4mm thick with ulceration or greater than 4mm thick without ulceration, no BRAF testing) Page 9 of 15

10 Consider genetic testing of stage IIC primary melanoma or the nodal deposits or in-transit metastases for people with Stage III melanoma If insufficient tissue is available from nodal deposits or in transit metastases, consider genetic testing of the primary tumour for people with Stage III melanoma. Follow up: Stage 0. Discharge after completing treatment IA no mitoses 2 to 4 FUs in year 1 then discharge IB-IIC (SLNB Neg) 3 monthly for 3 years then 6 monthly for 2 years and discharge after 5 years Those that may benefit from early intervention (IIC, III, early IV) consider surveillance imaging six monthly for 3 years. Explain pros and cons. (page 220) Decided by local policy and funding (therefore can devise own imaging according to local guidance). 9. Patient experience / Survivorship update The Lead Cancer Nurses across the region plan to offer support to the CNS teams to coordinate collaborative patient experience agenda items for SSG meetings. Sian Middleton will provide support to the Skin CNS team at the next meeting. The user representatives were invited to share the experiences of a close relative and former patient who had since passed away. The following issues were identified. 6 week wait for diagnosis Diagnosis of Stage IIB melanoma given without relative / friend present Delayed diagnosis and treatment of metastatic disease due to referral between MDTs, a breakdown in communication between hospitals, cancelled surgery, and symptoms being dismissed (back ache caused by spinal metastases) Incorrect information given to the patient on their disease status Post-operative infection not acted upon by GP. Thanks were given for the sobering and thought provoking summary of a tragic event. There was a need to ensure that the pathways for patients are as slick and organised as possible and that a process for getting direct access back to the correct services is in place. Patients should have an advocate who can address concerns throughout the pathway. The process of referring to a breast cancer clinic for axillary node metastasis was routine, but presented a clear problem in this case. It was essential to understand the rationale behind each separate issue, For example, the six week time frame for pathology to be confirmed may have been unavoidable. 10. Quality indicators, audits and data collection Page 10 of 15

11 10.1 Registration improvement of non-melanoma skin cancer Please see the presentation uploaded on to the SWSCN website Presented by Carlos Rocha The National Cancer Intelligence Network (NCIN) cancer registry software system was centralised in 2013 to improve efficiency, with all information now being entered onto the Encore software database, rather than the 8 separate regional databases used previously. A project is currently being undertaken to address the long standing issues relating to incomplete registration of non-melanoma skin cancers. The sheer quantity of data that requires processing to achieve this would require a further 20 staff to be employed, due to the time it currently takes to interpret information coming from pathology reports. This could be resolved if pathology was reported in standardised profomas, rather than in free text, that could automatically populate the registry. Occasionally, contradictory information from PAS and pathology is received which requires the NCIN staff to consult guidelines to try and verify which diagnosis is the correct one to document. The project aims are firstly to answer the following: Identify how many BCC + SCC reports we are receiving from each Trust Liaise with Trusts to determine whether we are receiving all reports, if not, how can we resolve this Which histopathologists are/are not using proforma reporting Why are some histopathologists not using proforma reporting and how do we encourage them to do so How many BCC + SCC records are submitted in COSD submissions How does the NCRS then identify proforma reports, provide initial feedback on pathology + COSD and then process them more efficiently in ENCORE. Objectives: Complete and consistent SNOMED coding on all Pathology reports Trust Pathology extract criteria identifies all non-melanoma skins. Proforma reporting on all non-melanoma skin cancers (COSD xml pathology extracts will help with this) NCRS record each and every occurrence of BCC + SCC by processing the majority of pathology reports and COSD data automatically Using the COSD reporting process to provide feedback on the completeness of the data (both submitted and processed) Detailed reports purely for NMSC. The target date for Trusts to start reporting pathology data in this format is January The numbers of pathology reports sent across the UK will be monitored and, Consultant Histopathologists Page 11 of 15

12 where numbers seem low, Trusts will be contacted to check their reporting processes. Currently approximately 130,000 BCC reports are sent for registration. It is thought that a more realistic figure will be closer to 270,000pa. It will not be possible to receive appropriate remunerated for the workload relating to this until the complete number has been established. Use of the pathology proforma will be encouraged across the network. 11. Research Update Presented by Maxine Taylor (MT) The West of England Clinical Research Network will provide information and support to Gloucestershire and Swindon Hospitals in addition to the geography of the previous network. Taunton and Yeovil are now part of the Peninsula CRN, but data on their research can also be provided. Recruitment activity has reduced in comparison to the 2014 portfolio, with one patient in each Trust being recruited in NBT, UH Bristol and YDH this year. Several studies are open that have yet to recruit. Details of two relevant studies currently in set-up can be found on the portfolio website here. Research reports with details of any new studies that are opened throughout the region will be available on the SWSCN website here. SSG members are to contact MT about any content they might want to include in the research report in the future. Research Lead, Chris Herbert, will represent the group nationally and provide updates on studies available elsewhere in which patients may wish to participate; some travel may be involved. Research nurses will be encouraged to liaise with their colleagues in the region when relevant trials emerge. 12. Service development 12.1 Mohs Micrographic Surgery Presented by Adam Bray (AB) The Mohs Micrographic Surgery network service, based in a newly built day case theatre unit in NBT, has been available for seven months. The service has two surgeons with Consultant Dermatologist Dr Pawal Boguki recently joining the team. Excellent links have been forged with the plastics, maxilla-facial and oculoplastic teams. Clinical staff are welcome to visit the unit for their own professional development. Patients eligible for referral would have a tumour that could not confidently be excised with the recommended clinical margins and optimal repair. Referral and patient information will be available on the SWSCN website here. HD In comparison with standard pathology and the issues in assessing margins from slices of tissue, Mohs allows for 100% of margins to be seen on one plane as the procedure exerts downwards pressure on the tumour, squashing it flat to then be inked and removed. Page 12 of 15

13 Possible indications in order of strength: Poorly defined borders Anatomical location: - H-zone (high risk of recurrence) - Sites where sparing tissue highly important Recurrent Incompletely excised Infiltrative/Morphoeic Large (>2cm) Immunosuppressed/Gorlin syndrome. Mohs is usually used for head and neck BCC, but other sites and tumours can be considered. Strongly consider Mohs for recurrent or incompletely excised tumours, unless it is straightforward to take a generous deeper layer, or skin margins of 6-10mm+ (for recurrences) or 4-6mm+ (for positive margins) as recommended for standard excision/pathology. SCC could be considered where poorly defined. Situations where Mohs is difficult: If a GA is unavoidable If bone is involved (but Mohs can still be useful to clear skin) Consider other margin controlled surgery e.g. spaghetti technique. Three case studies showing the removal of tumours and reconstructive techniques were displayed. The current waiting time for patients is approximately three months Cancer Strategy update Please see the presentation uploaded on to the SWSCN website Presented by Catherine Carpenter Clawson (CCC) In January 2015, an independent cancer task force was established to develop a five year strategy for cancer services, with the aim of improving cancer survival. The recommendations published in July 2015 identified six strategic priorities: Upgrade in prevention and public heath Achieve earlier diagnosis Ensure patient experience is on a par Provide support for living with and beyond cancer (the survivorship initiative) Investment to deliver modern high-quality service Overhaul for commissioning, accountability and provision. These will be examined to see if the strategy can assist in promoting improvements. For example, how this fits with other local and network priorities Page 13 of 15

14 and activities, such as the review of diagnostic capacity, and of patient pathways alongside the new NICE guidelines. The strategy also suggests establishing cancer alliances across the UK. 13. Peer Review - Work Programme review 1. Business case for a second consultant to perform Mohs micrographic surgery. Complete 2. Business case for photodynamic therapy service. Ongoing. Pawel Boguki PB) is going to assist AD in the process. 3. Business case for electrochemotherapy (ECT) specialist commissioning. Ongoing. The ECT service is now embedded in NBT. Attempts to engage with the CCGs were abandoned after three appointments with Antonio Orlando were cancelled last minute, all of which had involved cancelling clinics 8 weeks in advance. The machine required to administer ECT is on loan free of charge from a pharmaceutical company, so there is no increased cost to the Trust from that perspective. The General Manager of NBT is to be informed and an appropriate member of the CCG invited to attend the next SSG meeting. 4. Business case for sentinel node biopsy commissioning. As above. 5. To explore the role of teledermatology within the network. Ongoing. This is being used for triaging advice and guidance, but presents a challenge with the mixed quality of imaging received. 6. Development of community skin cancer service. Ongoing. There are no trained personnel available in Bristol to provide this service. It was thought that private companies might be interested in provided the service and perhaps commissioners might make a request for tenders. Gloucestershire do have a service where low risk BCCs are triaged out to the community. The last audit of their excisions had positive results. There are however issues with GPs occasionally removing SCCs and melanoma, which the team repeatedly police by reinforcing the requirement for patients to be triaged by dermatology services. Oxford also has a community model that works well which could help Bristol to set up an appropriate service. 7. Produce clinical guidelines. Complete. 8. Produce constitution. Complete. 9. Recruit user representatives. Complete. 10. Provide advice on the content of the new 2WW referral proformas. In progress. DdB is in contact with Jonathan Miller about this. 11. Clinical audit suggestions. Audit of melanoma patients to see if follow up should be re-stratified. A snapshot of MDT outcomes and management plans of the next 10 BCCs and 5 SCCs excised from October to see if the results require changing the MDT dataset. Vitamin D levels in myeloma to be audited in December and August to check for seasonal differences. AD / PB HD AO DdB 14. Any other business Punch biopsies of small lesions were not recommended due to the risk of getting misleading results. Page 14 of 15

15 Amrit Darvay stepped down as Chair. An requesting expressions of interest in the role will be circulated by HD. HD Date and venue of next meeting To be confirmed once the new Chair has been recruited. The next meeting will be further north to facilitate attendance from Gloucestershire members. -END- Page 15 of 15