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The Constitution, Role and Responsibilities
of the
Greater Manchester and Oswestry Sarcoma
Multi-Disciplinary Team
for the Diagnosis and Treatment of Bone and Soft
Tissue Tumours
for the
Greater Manchester and Cheshire Cancer Network
Greater Midlands Cancer Network
North Wales Cancer Network
THE GREATER MANCHESTER AND OSWESTRY
SARCOMA MDT
Terms of Reference
Background
The Greater Manchester and Oswestry Sarcoma MDT has been formed as a single
expert multi-disciplinary team for the management of patients with bone and soft
tissue sarcoma. This team has been formed from three previously existing smaller
sarcoma teams at Oswestry, Manchester Royal Infirmary and Christie Hospital which
have already a significant reputation and experience in providing services to these
patients.
This service has been developed to comply with recent NICE guidance to improve
outcomes for people with sarcoma.
The service is configured with two diagnostic services for soft tissue sarcoma and one
diagnostic service for bone sarcomas and a single treatment MDT as illustrated in the
following diagram:
Manchester Royal Infirmary
The Manchester Royal Infirmary is the central university hospital in Manchester, and
provides comprehensive tertiary level care.
There is a 15 year practice of sarcoma surgery with particular reference to soft tissue
tumours and expert radiology and histopathology
Christie Hospital
Non-surgical oncological services have been provided at Christie Hospital for over 50
years and there is a strong site specific practice in sarcoma including an active
research portfolio. Expert pathology review service is provided for the network and
nationally. Sarcoma surgery has also been developed here with particular reference to
reconstructive surgery.
Robert Jones and Agnes Hunt Orthopaedic Hospital
The Robert Jones and Agnes Hunt Orthopaedic Hospital has an international
reputation as a centre of excellence for orthopaedics and research into disorders of
bone and joints. The Oswestry Bone Tumour Unit has been selected by the National
Specialist Commissioning Advisory Group (NSCAG) as one of six centres in the
country to provide the diagnosis, treatment and follow up of patients with Primary
Malignant Bone Tumours. The unit has combined with the Greater Manchester and
Cheshire Cancer Network in compliance with NICE Guidance to improve the
outcome for people with bone sarcomas.
North Wales Cancer Treatment Centre
Patients registered with a Welsh GP will be repatriated for local oncology
management to The North Wales Cancer Treatment Centre where possible.
National Specialist Commissioning Advisory Group
NSCAG provides central funding for the diagnosis of patients who have suspected
primary malignant bone tumours and the surgical treatment and follow up of
confirmed primary malignant bone tumours. It is therefore important to ensure robust
referral systems are in place for rapid access to diagnostic services (see referral
guidelines).
The diagnostic pathway
While confirmed sarcoma diagnoses are rare, they are clinically indistinguishable
from a variety of common benign conditions. Even by applying the criteria for urgent
referral, it is thought that the ratio of benign to malignant diagnoses will be about 10
to one. It is clear therefore that there is a significant diagnostic workload which must
be addressed to identify the small number of patients with confirmed sarcoma and
route them to the expert multi-disciplinary team.
As described in the IOG, ad hoc referral from GPs to local general surgeons may be
contributing to the problem of delays in diagnosis of sarcomas and treatment by nonspecialist clinicians and may account for poorer than necessary outcomes. The
guidance mandates commissioners to set up, in each cancer network, centralised
diagnostic services that will link smoothly and directly with Sarcoma MDTs for those
with confirmed diagnoses. The diagnostic services must be clearly defined and
publicised to local GPs and secondary tier services.
The centralised diagnostic service for patients in the Greater Manchester and Cheshire
Cancer Network with soft tissue tumours suspected as sarcoma is provided under the
supervision of Mr Ashok Paul FRCS, Consultant Orthopaedic Surgeon at Manchester
Royal Infirmary.
The centralised diagnostic service for patients in the Greater Midlands Cancer
Network for patients with soft tissue tumours and for all 3 cancer networks for
patients with lesions suspected as primary bone sarcoma is provided under the
supervision of Mr Paul Cool FRCS, Consultant Orthopaedic Surgeon at Robert Jones
and Agnes Hunt Orthopaedic and District Hospital, Oswestry.
Project Vision and Purpose
The GMOSS aims to provide a comprehensive service for the diagnosis and
management of patients with bone and soft tissue sarcoma within the Greater
Manchester and Cheshire Cancer Network, the Greater Midlands Cancer Network and
the North Wales Cancer Network to provide specialist opinion and treatment, where
appropriate, to patients referred in from other geographical locations as well both
nationally and internationally.
Objectives
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To minimise diagnostic delay in patients with sarcoma
To minimise diagnostic error in patients with sarcoma
To reduce inappropriate investigation and intervention in patients with sarcoma
To increase the proportion of patients with sarcoma who have a pre-operative
diagnosis prior to first definitive treatment.
To improve the clinical outcome (morbidity and mortality) and patient experience
for patients diagnosed with sarcoma within the joint cancer networks covered by
the Team.
To be an internationally recognised expert group with regard to the treatment of
sarcoma.
To perform high quality research into the causes and treatment of sarcoma.
To provide excellent training for all health care disciplines that have a role in the
management of patients with sarcoma.
Scope
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The diagnostic service is available to all patients fulfilling the GP criteria for
urgent referral with suspicion of soft tissue sarcoma living within the boundaries
of the joint cancer networks. Referrals from further afield are welcomed with a
particular view towards North and Mid Wales and according to patient choice
The team will also accept referrals from any secondary tier clinician within the
cancer networks of a patient with a clinical suspicion of soft tissue sarcoma
Additionally, the service will provide expert advice and, if appropriate, accept
referrals of patients who do not fulfil the criteria for urgent referral but are
strongly suspected to have a sarcoma diagnosis.
The Sarcoma MDT will offer a treatment service to all patients with bone or soft
tissue sarcoma diagnosed and or living within the boundaries of the joint cancer
networks.
This will include:
 soft tissue sarcoma of limb, limb girdle and trunk
 bone sarcoma at any site
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Soft tissue sarcoma of intra-abdominal and retroperitoneal sites including
GIST (gastro-intestinal stromal tumour)
 Pelvic and gynae soft tissue sarcoma
 Bone and soft tissue sarcoma occurring in the Head or Neck
The team will accept referrals from any clinician within the joint cancer networks
of a patient with a confirmed sarcoma diagnosis of either bone or soft tissue
Management of sarcoma in special anatomical locations may involve close liaison
with a sister MDT (see section on Relationships and Links)
The team will provide expert input on children and teenagers with sarcoma and
will work in conjunction with the Paediatric Oncology MDT (see section on
Relationships and Links)
The team will also accept referrals from other geographical locations both
nationally and internationally as would be appropriate for a highly specialised
expert team.
Constitution of the team
The team will be surgeons, pathologists, radiologists, oncologists, nurses, allied health
professionals and administrative officers who have demonstrated expertise and
experience in the treatment of patients with bone and soft tissue sarcoma.
A full membership list will be found in appendix A – Awaiting confirmation of
membership
Role of Diagnostic Services
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To provide a diagnostic service with the capacity to see all patients fulfilling the
criteria for urgent referral within 2 weeks of receipt of referral
To disseminate and publicise information about the service including the means
of referral to all GPs and to relevant clinical services in the acute Trusts.
To liaise with regard to the reporting of biopsies with nominated specialist
sarcoma pathologists
To provide initial key worker support to patients with confirmed diagnosis of
sarcoma
To ensure the appropriate discharge and transfer of patients found on assessment
to have conditions other than sarcoma
To monitor and audit their service with regard to activity and outcome
Role of Treatment Group
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To deliver clinical management of the patients refereed to the team
To deliver teaching and training regarding the management of sarcoma
To promote research in sarcoma in conjunction with scientists and clinical
academics
To provide advice to heath services managers where necessary
Deliverables
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Regular audits of activity and outcome for both diagnostic services and the
Sarcoma MDT published at least annually
Records of all cases referred and all cases discussed at the MDT
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A documented discharge / referral plan for all cases referred to each diagnostic
service
A documented multidisciplinary treatment plan for all cases discussed at the MDT
A single comprehensive population based database of all incident cases of
sarcoma within the joint networks
Records and minutes of regular development meetings
Standard referral guidelines for patients with sarcoma published through all
appropriate channels within the joint cancer networks.
Stakeholders
NSCAG
Greater Manchester Strategic Health Authority
Greater Manchester & Cheshire Cancer Network
Central Manchester and Manchester Children’s University Hospital NHS Trust
South Manchester University Hospital NHS Trust
Christie Hospital NHS Trust
Other Acute Trusts in GMCCN
Shropshire Strategic Health Authority
Greater Midlands Cancer Network
Shrewsbury and Telford Hospitals
Robert Jones and Agnes Hunt Orthopaedic & District Hospital NHS Trust
North Wales Cancer Network
Other Acute Trusts in GMCN
Other Acute Trusts in North and Mid Wales
Roles and Responsibilities in Group
Core Team Roles
 The following roles will be considered core to the team. In some cases a member
may fulfil more than one role. Generally core roles should always be represented
at the MDT meeting. Cover for absence and leave will be provided
 A complete list of members is found in Appendix A
Diagnostic Radiologist
Histopathologist
Orthopaedic Surgeon
Reconstructive Surgeon
Clinical Oncologist
Medical Oncologist
Paediatric Oncologist
Clinical Nurse Specialist
Macmillan Clinical Therepist
Physiotherapist
MDT co-ordinator
Secretary
Data manager
Key Worker
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At the appropriate time in the patient’s pathway a single named key worker for
each individual patient will be identified and agreed by the multi-disciplinary
team and dealt with in accordance with the following policy:
 It is the responsibility of the clinician to assign a key worker to each patient
 In most circumstances the named key worker will be the clinical nurse
specialist
 A record of the allocated key worker is recorded in the individual patient’s
casenotes
 The patient is given the key workers contact details
The key worker may change over time depending upon the needs/ location of the
patient. The patient will be kept informed of any changes at all times.
The remit/role of this key worker will be to ensure:
 They act as a patient liaison between the multi-disciplinary team and the
patient
 Disseminate both verbal and written information to all relevant parties
 Ensure changes in strategy or treatment is documented and accessible.
The key worker is a person who, with the patient's consent and agreement, takes a
key role in co-ordinating the patient's care and promoting continuity in
collaboration with other health and social care professionals e.g. ensuring the
patient knows who to access for information and advice. This may be any
healthcare professional.
For patients who come under the care of the MDT before the implementation of
this policy, if they should present to the team again e.g. as a result of a recurrence
they too will be assigned a key worker.
Core business
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6.
7.
8.
Diagnostic work-up of patients referred with suspected sarcoma
Liaison between MDT and diagnostic services
Delivery of multi-disciplinary treatment for patients with sarcoma
Service planning
Service improvement / redesign (modernisation)
Workforce development
Training and teaching
Research
Delivery of Diagnostic Service
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Availability of rapid access clinics with the capacity to see all patients referred
under the two week rule
Patients will be seen, assessed, provided with appropriate information and
undergo a planned investigation protocol aimed at most efficient diagnosis
Availability of ‘one stop’ appointments/admissions where all investigations can be
undertaken, especially for patients from out of area.
All patients with a suspected/confirmed malignant tumour will be discussed at the
MDT meeting
Patients with malignant tumours will be reviewed for initial counselling of the
results of their tests and onward referral to the appropriate treatment team.
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Patients with non-malignant tumours will be referred back to their GPs for
appropriate management.
Liaison between Diagnostic Services and Sarcoma MDT
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To promote and encourage pre-operative diagnosis of sarcoma before first
definitive treatment is delivered so that this can be planned and delivered within
the Sarcoma MDT
As described in the NICE IOG for Sarcoma, it is the responsibility of the Sarcoma
Treatment MDT to develop, in conjunction with the Cancer Network teams, a
centralised diagnostic service in each cancer network covered by the MDT for
patients with symptoms and signs suspicious for sarcoma as indicated in the NICE
Referral Guidelines for Patients with Suspicion of Cancer
Delivery of Treatment
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Availability of clinics with the capacity to see all patients within 31 / 62 day
targets
To review all cases diagnosed with bone and soft tissue sarcoma in GMCCN
NWMCN and NWCN in a properly convened multi-disciplinary setting
To provide expert pathological review of diagnosis
To provide multi-disciplinary treatment planning for all first definitive treatments
for patients with bone and soft tissue sarcoma reviewed in the MDT meeting.
To deliver first definitive treatment within the team where it is within the clinical
experience of the team members or to liaise closely with other MDTs for
sarcomas in special anatomic locations where appropriate (see section on
Relationships and Links)
Service improvement and development
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To provide leadership for service improvement for patients with sarcoma in the
joint networks
To advise the development the Cancer Network teams with regard to service
development
To set up outreach clinics from Oswestry to Manchester to increase accessibility
for patients from North West
Training
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To set up and maintain training programs in surgery, pathology, and oncology
regarding the treatment of patients with sarcoma
Research
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To develop a portfolio of clinical trials for patients with sarcoma and to actively
encourage recruitment to these trials for patients treated within the Team
To maintain a clinical database on all incident cases of sarcoma within the joint
cancer networks and any other cases managed by the Team collecting data on
presentation, treatment and outcome
To set up and maintain a tissue bank of clinical samples for use in translational
research
To actively seek collaborations with clinicians and scientists to advance the
knowledge of the causes and treatment of sarcoma
Implementation Plans
Constitution
Chair
The Team will have a Chair and Vice Chair (or Co-Chair) selected by and from
within the group. These posts will be endorsed by the Network Director on behalf of
the Network Board.
The Chair will represent the MDT on ….
The term of office for the Chair will be three years, renewable once subject to the
discretion of the membership.
The role and duties of the chair are:
 To provide leadership and co-ordination for the group
 To ensure the documentation of the group is produced according to the provisions
above
 To call the development meetings, produce an agenda and ensure minutes are kept
 To ensure that audit is performed and published as above
 To ensure the group meets its obligations with regard to Clinical Governance
Clinical Lead for Diagnostic Service
Each diagnostic service will appoint a Clinical Lead endorsed by the relevant
Network Director on behalf of the Network Board.
The term of office for the clinical lead will be three years, renewable indefinitely
subject to the discretion of the Network Director
The role and duties of the clinical lead are:
 To provide leadership and co-ordination for the diagnostic service
 To ensure the documentation of the diagnostic service is produced according to
the provisions above
 To call the development meetings, produce an agenda and ensure minutes are kept
 To ensure that audit of the diagnostic service is performed and published as above
 To ensure the diagnostic service meets its obligations with regard to Clinical
Governance
Standard Operating Procedures
SOP for referral of a patient with symptoms or signs
suspicious of sarcoma (Urgent 2-week wait referral)
Summary
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Cases meeting the referral criteria for suspected cancer with regard to sarcoma
(see appendix) should be referred without delay
Referral should be made before any investigations are carried out, if possible
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Biopsy should, if possible, be performed by the surgical team undertaking the
definitive surgery
A referral proforma should be completed and faxed to 01691 404268 or emailed
to [email protected]. Referrals will also be accepted via telephone if followed
by a fax or letter.
Telephone advice is available on a call back provision on 0845 83 83 429
Receipt of the referral will be confirmed
Patients meeting criteria will be seen within two weeks
Referral of patients not meeting the criteria will be accepted at the discretion of
the clinical lead
SOP for conduct of assessment clinic
Summary
First clinic attendance
History proforma
Clinical examination proforma
See selection
criteria
Immediate blind
per-cutaneous Trucut biopsy
Immediate ultrasound guided Trucut biopsy
Between clinics
Elective CT guided
Tru-cut biopsy
MRI / CT scan of lesion
Second clinic attendance
Review with results of tests
Provide information and support
Malignant
case
No
Refer back to GP
Yes
Refer to
treatment MDT
SOP for referral of confirmed cases of sarcoma
Summary
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All new confirmed sarcoma cases diagnosed by MRI soft tissue diagnostic service
and Oswestry soft tissue and bone diagnostic service will be reviewed at the
GMOS MDT meeting for treatment planning.
Referrals will also be accepted for any other confirmed sarcoma cases diagnosed
by other services.
A Case Review Proforma should be completed by the responsible clinician and
faxed to the MDT co-ordinator as soon as possible.
Histopathological review may require up to two weeks if slides and blocks have to
be requested and special tests performed.
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Radiological review requires that films are available at least 2 days prior to the
meeting.
SOP for conduct of MDT meeting
Summary
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Each meeting will elect or nominate a chair to ensure order and timeliness of
meeting
Attendance records will be kept
All patients will initially be discussed in the local clinico-pathological meeting
All patients with a histological diagnosis of sarcoma will be discussed at the next
available MDT meeting and a management plan agreed and documented.
Following formal resection the patient will be re-presented to the MDT for a
decision regarding adjuvant therapy and follow-up.
The clinical details of each case will be presented by the referring clinician if
possible. If that clinician cannot be present s/he should provide a written
summary of the salient details.
The results of diagnostic radiology will be presented details will be documented
including name of radiologist and which films were available for review
The results of pathology review will be presented including size, depth, histotype,
grade, and margin. The details will be documented including the name of the
histopathologist and which biopsies were available for review
Pathology should be reported using the standardised format
A treatment plan will be formulated and documented including the names of the
surgeons and oncologists who contributed to the plan.
Those patients undergoing larger resections where reconstruction may be
necessary should be discussed with the plastics team An action plan will be given
for the delivery or communication of the treatment plan.
Cover arrangements will be agreed for each core member, as far as resources
permit and dealt with under the following arrangements:
 In the absence of a core member a nominated staff member will provide cover
for attendance at MDT meetings
 It is expected that core members or their cover should attend at least 2/3 of all
MDT meetings
 Cover refers to an SpR on a Consultant’s team or core members of the same
discipline providing cover for each other eg surgeon for surgeon, pathologist
for pathologist.
Patients who require a treatment planning decision before the next scheduled
meeting will be dealt with in the following manner:
 Verbal discussions (i.e. face to face or by telephone) will take place between
the relevant people associated with each individual patient’s care
 Records of any discussions will be placed in the patient’s notes
 The patients will be discussed retrospectively at the next scheduled MDT
meeting
Frequency of meetings
Diagnostic assessment clinics
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Manchester: It is intended to move to a weekly clinic as soon as is feasible.
Oswestry: Two clinics per week available for all urgent referrals
Case conference MDT meetings
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MDTM held weekly Wednesday 3.30pm - 5.00pm.
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1st and 3rd held at Manchester Royal Infirmary MDT Coordinator Jaime Collinge
0161 2764194
2nd and 4th held at The Christie MDT Coordinator Rosie Tunstall 0161 9187272
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Diagnostic Service development meetings
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Quarterly
MDT development meetings
A development meeting will be held on the fifth Wednesday of the month when that
occurs.
Accountability and lines of reporting
The diagnostic services will be responsible to the Cancer Network Teams of the
Greater Manchester and Cheshire Cancer Network, Greater Midlands Cancer
Network and The North Wales Cancer Network respectively, in compliance with the
guidance set out by the National Institute of Clinical Excellence “Advice to
Commissioners on Improving Outcomes in people with Sarcoma”
The Sarcoma MDT will be responsible to the Cancer Network Teams of joint Cancer
Networks covered by the Team in compliance with the guidance set out by the
National Institute of Clinical Excellence “Advice to Commissioners on Improving
Outcomes in people with Sarcoma”
Sub-groups
N/A
Relationships with other groups
Paediatric Oncology MDT
A relatively high proportion of patients with sarcoma are of a young age. Sarcoma is
one of the most frequent malignant tumours seen in childhood and the common bone
sarcomas (osteosarcoma and Ewing’s sarcoma) have peak incidence in the teenage
years.
Close collaboration with the Paediatric and TYA services is therefore vital.
 The Sarcoma MDT will offer pathological review treatment advice for all patients
with a sarcoma diagnosis referred and managed by Paediatric Oncology
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Delivery of care may be best within Paediatric services and location of treatment
will be decided on a case by case basis in conjunction with the Paediatric
Oncology Team taking into account patient choice where appropriate.
GI MDTs
Intra-abdominal, retoperitoneal, sarcoma forms about 20% of the incident case load
and close collaboration with the upper and lower GI MDT is therefore required.
 The Sarcoma Team pathologists will offer histological review on all mesenchymal
and or spindle cell tumours diagnosed in the GI MDTs. All such cases should
have a path review by a tertiary histopathologist. Where the MDT is a tertiary
MDT then referral for review by the Sarcoma pathologists may not be required if
the GI histopathologist is experienced in mesenchymal and or spindle cell
histologies but should be performed for all cases diagnosed in a secondary tier
MDT.
 The Sarcoma Team oncologists will offer input and advice on the non-surgical
oncological management of patient with GI and retroperitoneal sarcoma
 In most cases the first definitive surgery will be performed by surgeons of the GI
MDTs and the patients will be managed within those teams unless there is the
need for non-surgical oncological management
 Key worker and CNS support will usually be more appropriate coming from the
GI MDT.
 The Sarcoma Team will develop a special interest group of expert surgeons for the
surgical management of patients with intra-abdominal and retroperitoneal
sarcoma. This group will: Offer review of primary surgery performed
 Advise on need for salvage surgery
 Offer salvage surgery where required
 Review patients potentially suitable for mega-surgical resections and deliver
such operations if appropriate
Gynae MDTs
Pelvic and gynae sarcomas form about 15% of incident cases. Close collaboration
with the Gynae MDT is therefore required.
 The Sarcoma Team pathologists will offer histological review on all mesenchymal
and or spindle cell tumours diagnosed in the Gynae MDTs. All such cases should
have a path review by an expert histopathologist.
 The Sarcoma Team oncologists will offer input and advice on the non-surgical
oncological management of patient with GI and retroperitoneal sarcoma
 In most cases the first definitive surgery will be performed by surgeons of the
Gynae MDTs and the patients will be managed within those teams unless there is
the need for non-surgical oncological management.
 Key worker and CNS support will usually be more appropriate coming from the
Gynae MDT.
Appendix A: Membership of Service – AWAITING
CONFIRMATION OF MEMBERSHIP
Member
Post / Role
Mr Ashok Paul
Orthopaedic
surgeon
Orthopaedic
and Paediatric
surgeon
Histopathologist
Mr Tahir Khan
Prof Tony
Fremont
Dr Jeremy
Jenkins
Dr Rick
Whitehouse
Dr Patrick
Wilson
Sister Susan
Hamby
Ms Gaynor
Jones
Mr Lester Barr
Dr Sanka
Bannerjee
Dr James Wylie
Dr Michael
Leahy
Mr Jim Murphy
Dr Rao
Gattamaneni
Mrs Lena
Richards
Mr Paul Cool
Dr Chas
Mangham
Radiologist
Radiologist
Radiologist
Clinical Nurse
Specialist
MDT coordinator
General
Surgeon
Histopathologist
Consultant
Orthopaedic
and Oncological
Surgeon
Clinical Lead for
Oswestry
Histopathologist
RJAH
Orthopaedic
Hospital
Oswestry
Sister Caroline
Pemberton
Clinical Nurse
Specialist
Miss Elizabeth
Phillips
Macmillan
Clinical
Therapist
Histopathology
Sec/
Coordinator
Data
Manager/Patient
Tracker
Mrs Ellen
Harrison
Christie Hospital
Christie Hospital
Radiologist
Contact details
Manchester
Royal Infirmary
Manchester
Royal Infirmary
Manchester
Royal Infirmary
Manchester
Royal Infirmary
Manchester
Royal Infirmary
Manchester
Royal Infirmary
Christie Hospital
Clinical
Oncologist
Medical
Oncologist
Plastic and
Reconstructive
surgeon
Clinical
Oncologist
Physiotherapist
Dr Victor
Pullicino
Mrs Jan Wintle
Organisation
where based
Manchester
Royal Infirmary
Manchester
Royal Infirmary
Christie Hospital
Christie Hospital
Christie Hospital
Christie Hospital
RJAH
Orthopaedic
Hospital
Oswestry
RJAH
Orthopaedic
Hospital
Oswestry
RJAH
Orthopaedic
Hospital
Oswestry
RJAH
Orthopaedic
Hospital
RJAH
Orthopaedic
Hospital
RJAH
Orthopaedic
Hospital
01691 404096
Appendix B: Criteria for urgent referral for suspicion
of soft tissue sarcoma
Soft tissue sarcomas are a rare and heterogeneous group of tumours. Their recognition
is important because timely investigation and treatment can result in cure. Their
management requires close collaboration between designated specialists in a multi
disciplinary team and early referral to a specialist service will lead to the best clinical
and cost effective care. The role of this team is to investigate and treat soft tissue
‘lumps’ which are potentially cancerous.
Soft tissue sarcomas increase in frequency with age. Some, particularly in younger
patients, may be associated with familial syndromes such as neurofibromatosis.
They usually present as a painless mass.
Features of soft tissue lump suggestive of a malignancy are:
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Size > 5cm diameter
Enlarging
Painful
Deep to the fascia
Recurrence at the site of previous excision regardless of histology
Any patient with such lesions should be immediately referred to the diagnostic
service.
Patient will be seen within two weeks of receipt of referral
Appendix C: Criteria for urgent referral for suspicion
of primary bone sarcoma
Introduction
Bone sarcomas are a rare and heterogeneous group of tumours. Their recognition is
important because timely investigation and intervention can lead to cure. Their
management requires close collaboration between designated specialists in a
multidisciplinary team and early referral to a specialist service will lead to the best
clinical and cost effective care. The role of this team is to investigate and treat all
suspected bone tumours which are potentially cancerous.
Presentation
Primary bone tumours can occur at any age. Osteosarcoma and Ewings have their
peak incidence in adolescence and early childhood. However, chondrosarcoma and
osteosarcomas secondary to radiation or Pagets disease increase in frequency with
age. Pain is the commonest presenting symptom in patients with primary bone
tumours. Unfortunately, this is a common complaint after a minor injury and sporting
injuries, particularly in young children and adults, and a high level of suspicion is
required.
Features suggestive of bony malignancy are:
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Night pain
Non-mechanical pain (i.e. continuous pain not aggravated by exercise)
Swelling not associated with a joint.
The changes seen on plain radiographs can be subtle, such as periosteal reaction, bone
destruction, new bone formation, calcification and soft tissue swelling. These findings
are not specific to bone tumours but are suggestive and always warrant further
investigation.
Any patient with such lesions should be immediately referred to the diagnostic
service.
Patient will be seen within two weeks of receipt of referral
Appendix D: Suspected soft tissue sarcoma pathway
The Patients Journey
Referral
Referral from General Practitioner or
Consultant seen within two weeks
Attendance at Specialist Tumour Unit
Clinical Assessment
X-ray of relevant area and chest
MRI of lesion
Tru cut or US biopsy after imaging
Discussion at MDT
After Histological Confirmation of Diagnosis
See Patient in clinic to discuss treatment options
CT Chest
Admission
Surgery performed at RJAH Orthopaedic
Hospital
Radio/chemotherapy
Pre/post operative
Oncological treatment is
administered at Christie
Hospital or NWCTC
Follow up Care
Joint Oncological Clinic
at RJAH, Christie or
NWCTC
Appendix E: Suspected primary malignant bone
tumour pathway
THE PATIENT’S JOURNEY
Referral
Referral from General
Practitioner/Tertiary seen
within two weeks
Orthopaedic Oncologist
Out Patient attendance at Specialist Tumour Unit
Clinical Assessment
Plain X-rays of relevant area
Urgent imaging MRI/CT/Bone Scan/CT chest
OR
One Stop in-patient assessment. All necessary scans + biopsy
MDT Discussion of
imaging
Inpatient Assessment
Haematology/Biochemistry
CT Guided/Open Biospy
Or Outpatient Ultra sound guided biopsy
Histological Diagnosis
Discussion at Multi disciplinary meeting
as soon as diagnosis available regarding
treatment plan.
Review in clinic to discuss treatment
options with the patient and relatives
Treatment
Surgery is performed at the Robert Jones and
Agnes Hunt Orthopaedic Hospital
Oncological treatment is administered at the
Christie Hospital Manchester or NWCTC
Ongoing Care
Joint follow up with the Oncology Clinic (RJAH,
Christie or NWCTC
Close communication with General Practitioner
Appendix F: Summary Care Plans for Sarcoma Management
Adult-type
soft tissue sarcoma
Extremities
or superficial trunk
Standard
Comment
Soft tissue mass
Send the patient to a
referral centre, IF DEEP
AND/OR >5 cm AND/OR
PAINFUL
U/S for screening. MRI if
high index of suspicion.
Histological Diagnosis
Staging
Core needle biopsy
CT Thorax
Primary, low-grade,
superficial
Surgery: wide excision
Radiologically guided
Avoid in atypical
lipomatous tumour where
CXR sufficient
Aim to achieve > 1 cm
margin and deep fascia*
Primary, low-grade, deep &
<5 cm
Surgery: wide excision
Primary, low-grade, deep &
>5 cm
Surgery: wide excision
Primary, high-grade,
superficial
Surgery: wide excision
Primary, high-grade, deep,
<5 cm
Surgery: wide excision +
adjuvant XRT (pre or
post op)
Surgery: wide excision +
adjuvant radiation
therapy (pre or post op)
Primary, high-grade, deep,
>5 cm
Embryonal sarcomas
i.e. PNET, embyonal
rhabdo
Pre-op chemotherapy +
wide excision +/adjuvant radiation
Aim to achieve > 1 cm
margin or intact fascial
layer*
Aim to achieve > 1 cm
margin or intact fascial
layer. Adjuvant XRT if
smaller margin achieved*
Aim to achieve 1-2 cm
margin and deep fascia.
Adjuvant XRT if smaller
margin achieved
Consider avoiding XRT if >
2 cm margin or intact
fascial
Consider amputation if
more than 1 compartment
involved. Isolated limb
perfusion may also be
considered
Follow up, low grade
6 monthly for 5 years.
CXR and examination
Follow up, high grade
3 monthly for 2 years and
6 monthly for 3 years
CXR and examination
*
Accept smaller marging for atypical lipomatous tumours
RADIOTHERAPY GUIDELINES FOR SOFT TISSUE
SARCOMA (STS)
Patients with Sarcoma are discussed at an SMDT attended by a multidisciplinary team
which takes place weekly on a Wednesday at MRI and Christie
A decision to treat with radiotherapy is made at the meeting and documented in the
minutes.
Patients with sarcoma requiring radiotherapy fall into the following groups:
1.
Soft tissue sarcoma
2.
Bone sarcoma
3.
Non sarcomatous soft tissue lesions (e.g. fibromatosis)
4.
Non sarcomatous bone lesions. (e.g. giant cell tumour, chordoma, aggressive
osteoblastoma)
These guidelines cover those patients with STS and non-sarcomatous soft tissue
lesions.
General considerations when planning radiotherapy for a patient
with a sarcoma

Consider the indications for treatment and the potential benefit/detriment to
the patient.

What is the ideal position for the patient for radiotherapy? How will the
patient be immobilised for treatment? Is CT planning needed? – and can they
get through the scanner in the treatment position? Ask for one of the planning
radiographers to attend clinic or mould room to advise re. immobilisation.

Consider organs at risk.
Obtain informed consent for planning and treatment
All patients are warned to expect:
 Tiredness
 Erythema which may progress to moist desquamation (especially in
groin/perineum/axilla or when irradiating skin graft)
 Late skin changes/pigmentation/sensitivity to sunshine
 Small risk of second malignancy many years after irradiation
If bladder, bowel, gonads, liver, heart, lungs, brain, or mucosa are in field:
 Advise patient of specific acute and long term side effects and possible
measures to reduce these
For a limb sarcoma, patients should expect:
 Fibrosis and thickening of soft tissues over a period of years
 Stiffness of tissues and joints
 Lymphoedema of the limb, may not start for months/years
o advise about lymphoedema care and refer to specialist service if
needed promptly


Emphasise the need for exercise and use of the limb in order to minimise late
effects. Patients will often have seen the specialist sarcoma physiotherapist in
outpatients and been advised accordingly.
Long bone fracture. Especially if whole boner circumference irradiated and
especially in post menopausal women
Indications for radiotherapy in soft tissue sarcoma
Primary, low-grade,
superficial
Surgery: wide excision
Aim to achieve > 1 cm
margin and deep fascia*
Primary, low-grade, deep &
<5 cm
Surgery: wide excision
Primary, low-grade, deep &
>5 cm
Surgery: wide excision
Primary, high-grade,
superficial
Surgery: wide excision
Primary, high-grade, deep,
<5 cm
Surgery: wide excision +
adjuvant XRT (pre or
post op)
Surgery: wide excision +
adjuvant radiation
therapy (pre or post op)
Aim to achieve > 1 cm
margin or intact fascial
layer*
Aim to achieve > 1 cm
margin or intact fascial
layer. Consider adjuvant
XRT if smaller margin
achieved*
Aim to achieve 1-2 cm
margin and deep fascia.
Adjuvant XRT if smaller
margin achieved
Consider avoiding XRT if >
2 cm margin or intact
fascial
Consider amputation if
more than 1 compartment
involved. Isolated limb
perfusion may also be
considered
Primary, high-grade, deep,
>5 cm
Embryonal sarcomas
Pre-op chemotherapy +
i.e. PNET, embyonal
wide excision +/rhabdo
adjuvant radiation
Wherever possible the patient should be given written information regarding
radiotherapy treatment and side effects.
Other indications include:




Consider XRT if initial incision unplanned and genuine concern about
contamination irrespective of final pathology report
Local recurrence following re-resection e.g. low grade lesions
Low grade lesion which would be unresectable if it recurred e.g. some head
and neck sarcomas
Lesion is not resectable without pre operative treatment

Preoperative radiotherapy may be helpful in lesions which lie close to critical
structures (eg brachial plexus, spinal cord) or where major re-construction will
be needed post resection making it difficult to accurately determine the target
volume.
Radiotherapy planning for Soft Tissue Sarcoma
Pre operative or definitive radiotherapy

Consider the best position for treatment delivery. This may need to be changed
if normal tissue cannot be spared.

An immobilisation device is used to ensure a stable comfortable position
which must be reproducible.

CT planning scan (at least 1cm cuts unless in head and neck location when
0.5cm appropriate).

GTV is tumour plus consider including surrounding oedema as defined on
MRI (or CT if MRI not possible), other information (e.g. EUA) may need to
be taken into account.

The CTV is the GTV plus a margin of 2-3cm in all directions. It may be less
in the axial plane if an intact barrier to spread (e.g. fascia, bone, inter-osseous
membrane intervenes.

The standard PTV is CTV plus 5mm.

When outlining volumes, critical structures need to be taken into account.

A strip or corridor of normal / un-irradiated skin and subcutaneous tissue must
be left to allow lymphatic drainage; this should be as wide as possible without
compromising the PTV. In those cases where it is not possible an individual
decision has to be made about whether to compromise the PTV or to treat full
width of the limb. The patient needs to be appropriately counselled and
consented.

Surgery to be planned 4-6 weeks from end of RT, to allow the acute reaction
to settle but before the process of fibrosis begins

During radiotherapy the surgical team MUST be informed of the intended
treatment finish day so that surgery can be booked
Post operative radiotherapy

Ensure the wound is healed – in rare cases radiotherapy can be started before
the wound has completely healed; this needs to be discussed with the patient
and the surgeon. In cases of delayed wound healing swabs, treatment of
infection and wound care advice may be needed.

Consider the best position and immobilisation device for treatment delivery as
above.

Wire all scars and drain sites for the planning scan.

CT planning scan (at least 1cm cuts unless in head and neck location 0.5cm).

Preoperative imaging and final pathology report should be used to reconstruct
the tumour location.

GTV is preoperative tumour volume as defined by MRI (or CT if MRI not
possible).
Post operative radiotherapy is often delivered in two phases:
Phase I

CTV in the cranio-caudal direction is the pre operative GTV plus a margin of
5cm or scar/drain site plus 1cm, which ever is the greater. Axial margin of 2-3
cm added to GTV unless there is an intact facial or bony boundary.

For non limb sites the expansion is similar bearing in mind that tumours
preferentially spread along the line of the muscle.

PTV is CTV plus 5mm.

Compromises may have to be made in the volume irradiated and the dose
delivered, taking account of the dose to organs at risk for sarcomas of the
trunk, or where the volume extends across a joint for limb lesions.

Natural barriers to tumour spread may allow PTV to be smaller in some places
(e.g. fascial planes, bone.)

A strip or corridor of normal / un-irradiated skin and subcutaneous tissue must
be left to allow lymphatic drainage; this should be as wide as possible without
compromising the PTV. In those cases where it is not possible an individual
decision has to be made about whether to compromise the PTV or to treat full
width of the limb. The patient needs to be appropriately counselled and
consented.
Phase II
Where needed

GTV as for phase 1.

CTV is typically unchanged in the axial plane but the cranio-caudal magin is
reduced to GTV plus 2-3 cms. Scars and drain sites do not need to be covered.

PTV is CTV plus 5mm.
Doses for soft tissue sarcoma radiotherapy
Pre operative radiotherapy
50Gy in 25#
Surgery to take place at 4-6 weeks from end of
radiotherapy (i.e. acute reaction settled, fibrosis
and other changes not started).
Post operative radiotherapy
60Gy in 30# if clear resection margins.
66Gy in 33# if positive margin.
Typically phase phase I 50Gy, phase II 10Gy
and phase III (only if +ve margin) 6 Gy.
For frail patients, 42.5-45Gy/15-20# can be used
.
Definitive radiotherapy
>70 Gy needed for radical approach. Rarely
delivered. Most of these cases are palliative.
Abdominal radiotherapy
45-50Gy in 25# or 50.4Gy in 28# depending on
volume to be irradiated.
Palliative radiotherapy
40-45Gy/15-20# if no bowel in field.
45Gy/20# if bowel/viscera in field or very
large volume.
30Gy/10#
20Gy/4 or 5#
10Gy/1#
Fibromatosis
Patients who have progressive disease which is inoperable can be treated with
radiotherapy. Immobilisation and planning techniques are the same as those for STS.
The dose used is 45 - 50.4Gy in 25-28# as a single phase.
Follow up
Continued follow-up of patients after completion of treatment is important and
valuable for the following reasons:



To detect relapse at the earliest possible point. This is important as certain
interventions may only be performed optimally if relapse is detected early. This
includes surgical resection of local recurrence and thoracotomy for resection of
pulmonary metastases. Also, response to systemic therapy is optimal if the patient
is in a good general condition (performance status 0 or 1) when treatment is
started.
To provide ongoing support to the patient
To provide ongoing quality control for the treating teams on clinical outcomes
from treatment. This should include not only relapse status and survival but also
functional and psychosocial recovery
Patient group
This care plan is for patients who have completed first definitive treatment of curative
intent for sarcomas of extremity, limb girdle, trunk and head and neck,
retroperitoneum, pelvis and intra-abdominal sites and includes gynae sarcoma and
bone sarcomas
A separate care plan deals with GIST in view of the more complex risk adapted
strategies for that sarcoma.
Scheduled assessments
Clinic visits (basic template)

Low grade sarcomas:


Review every 6 months until 5 year point
High grade sarcoma
 Review every 3 months for 2 years
 Then every 6 months until 5 year point
Patients considered by the treating clinician to be at higher risk of late relapse will
be offered extended FU annually for up to 10 years. This could include tumours
>5cms, deep and excised with positive margin. Grade itself is a poor
discriminator of late relapse
The following sarcomas can have a less intense annual follow up schedule because of
the very small risk of developing metastases. A baseline CXR is required but routine
CXR are not required during follow up. Patients should be advised to attend earlier if
any local abnormality detected between appointments
 Cunaneous leiomyosarcoma
 Dermatofibrosarcoma
 Atypical lipomatous tumour/well differentiated liposarcoma
Clinical assessment



Medical assessment: history and physical exam
Tumour site should be clinically examined for local recurrence
Patients who had a pelvic tumour (including gynae sarcomas) should have a
digital pelvic examination unless there has been recent pelvic imaging
Investigations


Chest X-ray at each visit
No routine blood tests required
Tumour Assessment
Intra-abdominal, retroperitoneal, pelvic sarcomas


Post op CT scan of abdomen and pelvis to re-baseline anatomy at not less than 3
months following all clinical wound healing has occurred
Consider annual CT scan of abdomen and pelvis at anniversary point until 10
years out
Extremity, limb girdle, trunk, head and neck soft tissue sarcoma

Routine post-op imaging is not required in the absence of symptoms or signs of
concern.
Data collection

Recommended data set for collection at each visit:
 Vital status, tumour site status, nodal status, distant site status
 Proforma for each patient seen filled for sarcoma database
Where should follow-up be performed?


Patients may be offered alternating visits between oncology and surgical clinics if
both teams agree to follow the above protocol.
If patients have received adjuvant RT then at least one visit per year should be
with the clinical oncology team.
Variations to the above basic template


Patients with significant sequelae from therapy may need more frequent follow-up
and additional investigations as clinically indicated
Patients who have undergone intensive chemotherapy should have ongoing organ
function monitoring as appropriate to the chemotherapy they have received.
Discharge
Discharge from further follow-up is appropriate after 5-10 years. Patients should be
briefed about this prior to their final visit. A report should be sent to the GP
summarising the treatment that the patient has had and indicating any remaining
health care issues that may affect future management.