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Mount Vernon Cancer Network Skin NSSG Clinical Guidelines Version number as approved and published Author Date Written Date Revised Review Date NSSG Ratified 2.2 Dr Veronique Bataille, Chair of the MVCN Skin NSSG January 2010 February 2013 (Sarcoma pathway added) August 2015 August 2012 Agreed by: Position: Chair of Network Board Name: Jane Halpin Organization: Hertfordshire PCTs Date agreed: 5th September 2012 Position: Skin NSSG Chair Name: Veronique Bataille Organization: West Hertfordshire Hospitals NHS Trust Date agreed: 28th August 2012 1 Contents Page 1. Introduction 4 2. Referral Guidelines 4 4 4 2.1 Primary Care Referral Guidelines and their distribution 2.2 Skin NSSG Referral Guidelines 3. Melanoma 4 4. Squamous Cell Carcinoma 5 5. Basal Cell Carcinoma 5 6. Lymphoma 5 7. Merckel Cell tumours and other rare tumours such as sarcomas 5 8. Rarer cancer Pathways 6 6 6 6 7 8.1 Children 8.2 Teenagers & Young Adults 8.2.1 Options for 19-24 year olds place of treatment 8.3.2 Skin Sarcomas APPENDICES 8 Appendix 1: Urgent Two Week Referral, Suspected Skin Cancer 8 Appendix 2: Sarcoma Pathway 11 2 1. Introduction The clinical guidelines used by the NSSG are nationally approved guidelines via the British Association of dermatologists and the Melanoma Study group for the treatment of melanoma, SCC, BCC and lymphoma. These guidelines are embedded within this document. Below are the local referral guidelines with information regarding locally agreed pathways for the MVCN. However for all the therapeutic approaches for each type of skin cancer please refer to the national guidelines. 2. Referral Guidelines 2.1 Primary Care Referral Guidelines and their distribution Patients meeting the criteria for urgent referral as determined by NICE referral guidance should be referred using the agreed referral proforma to the relevant 2WW office of the agreed diagnostic service. There is a central fax number for each locality which is stated towards the bottom of the proforma. At the Skin agreed the MVCN Skin 2 week wait (2WW) Urgent Cancer Referral proforma in October 2010. The agreed version is attached in Appendix 1. All the site specific MVCN 2WW Urgent Cancer Referral proformas were relaunched in May 2011. There are 12 forms in total, one form per tumour site. Each was developed and approved by the relevant NSSG involving cancer specialists from all three Trusts in MVCN. The forms are modelled on those which have been operating successfully at West Herts Trust and elsewhere for some time. The proformas were all uploaded onto the Mount Vernon Cancer Network website for primary care practices to download. To help the practices, three versions of the forms have been provided; Word, EMIS and VISION. The website also includes links to the NICE referral guidance where the national requirements for these proformas is set out. A letter from Barbara Gill, Network Director and Phil Sawyer, Network Primary Care Lead, explaining the background to the new proformas and the process, was circulated via Gateway at NHS Hertfordshire, Luton, and South Bedfordshire. This communication followed discussions and presentations about the new process at various GP consortia, Executive and LMC meetings attended by the Network Director in March and April 2011. These referral guidelines will also be circulated through the medical committees of the respective acute trusts via the MVCN Trust Forum. 2.2 Skin NSSG Referral Guidelines The NSSG operational policy has a referral guideline for skin cancer in Hertfordshire. All Melanoma and SCCs are referred via the 2 ww via a dedicated fax number for the respective three Trusts in the network ( see LMDT operational policy for each Trust). All BCCs are referred via the urgent and not the 2ww. Low risk BCCs and precancerous skin conditions such as solar keratoses, Bowenoid Keratoses and Bowen disease can be treated in the community or by CATS clinics if the diagnosis is clear. Not all CATS clinics can deal with low risk BCCs so enquire with your local CATS service before referring. High risk BCCs such as face, larger than 2 cm, histological subtype such as morphoeic or infiltrative. Young patients with multiple BCCs ( probably Gorlin) should be referred to secondary care Immunsuppressed patients with any type of skin tumour should be referred to secondary care Any tumours on the lips, genitals or digits should be referred to secondary care Unsuspected melanoma already excised in the community should be referred via the 2 ww. For SCC or high risk BCC excised in the community these should be referred via the urgent referral route. All melanomas, SCCs and high risk BCCs removed in the community will be flagged up by the respective pathology 3. Melanoma All melanomas should be referred via the 2 ww and GP should not biopsy suspicious melanocytic lesions. Melanoma patients are referred to dermatologists or plastic surgeons depending on the Trust. Once histology is confirmed the patient is offered if necessary a re-excision in house or by the plastics department if needed. The case will be discussed at the LMDT and if needed will be referred to the SSMDT based at East and North NHS Trust. All melanomas needing re-excision, sentinel node biopsy, LN biopsy or lymphadenectomy are referred to the SSMDT. Primary melanomas which cannot be operated in house because of size or difficult anatomical sites are also referred to the SDSMDT. All melanoma AJCC IIB or higher, all melanoma below the age of 24, all ocular or mucosal melanomas and all Merckel cell tumours should be referred to the SSMDT for an oncological opinion by Paul Nathan after being first added to the LMDT list. Paul Nathan is in charge of entry into clinical trials for melanoma in the network. In case of urgency a patient can be both referred to the LMDT and SSMDT at the same time. All referral to the SSMDT is done via an SSMDT proforma which is faxed to the SSMDT coordinator, Helen Bradford, at East and North. The LMDT are taking place in each Trust and run every 2 weeks. All second pathology opinion for melanoma go to Dr Eduardo Calonje at St John’s Institute of Dermatology in London or Dr Nigel Krirkham in Newcastle. Sentinel node biopsies are performed at the Royal Free. All sentinel node biopsy referral should be made to the SSMDT and a copy letter to Mr Ash Mohasebi in the dermatology department at Watford for the patient to be added to his clinic at Watford. The patient will be consented and seen at Watford for preop assessment but the procedure will be done at the Royal Free in Hampstead. If the SN is positive patients will be referred back to the SSMDT for complete lymphadenectomy at East and North by Nick James team. In rare circumstances when frozen sections are used at the Royal Free the patient may undergo lymphadenectomy at the same time if appropriate consent has been obtained. Follow up of melanoma patients occur in the respective Trust unless there is a need for further plastics or oncology input. The SSMDT will keep the referring physician informed of the outcome of the MDT discussion and of the histology and will refer the patient back once the treatment has been received. Patients with multiple atypical moles syndrome are referred to the dermatology department. If these patients have positive family history of melanoma, multiple primaries and/or strong family history of cancer they will be referred to the genetic clinic run by Dr Bataille at Harpenden Hospital on the 4th Wednesday of the month. Some of these patients are also sent for genetic counselling and/or genetic testing at the Kennedy Galton Institute at Northwick Park. Patients are also offered entry into NIHR registered genetic trials. Revised melanoma guidelines 2010.pdf 4. Squamous Cell carcinoma SCCs are referred via the 2ww. If the clinical features suggest a solar keratosis or Bowenoid keratosis or Bowen disease this can be managed in the community. SCCs are usually managed in house by dermatologists but in some cases need plastics input for large lesions, re-excision, flap or grafting. Primary SCCs in elderly patients in the background of sun damage can be curetted or excised. All SCCs are discussed at the LMDT and referred to the SSMDT if further surgery is required. All renal transplant recipient with SCC should be referred to the SSMDT. Moderately or poorly differentiated SCC as well as SCC on digits, lips or genitals should be referred to the appropriate SSMDT. When SCCs are treated with radiotherapy after discussion at the MDT these should be referred to the SSMDT as there is at present no clinical oncologists at the local MDTs. Squamous Cell Carcinoma guidelines.pdf 5. Basal Cell Carcinoma BCCs are referred via the urgent referral route and not 2ww. Low risk BCCs can be seen in the community. All high risk BCCs , face, above 2 cm, high risk histology such as morphoeic or infiltrative or multiple lesions in young individuals ( ?Gorlin) should be referred to secondary care via the urgent route and not 2 ww. Some BCCs will be referred to the SSMDT for radiotherapy, re-excision, flap or grafting. PDT is also available on several Trusts. Gorlin syndrome should be referred to the genetic clinic at Harpenden on the 4th Wed of the month by referring patients to Dr Bataille. Basal_Cell_Carcinom a guidelines.pdf 6. Lymphoma All T lymphomas of the skin are assessed at St John’s Institute of Dermatology for work up and may be referred back to the referring Trust for follow up and treatment. Referrals should be made after discussion at the MDT to the SSMDT at St John Institute of Dermatology with a copy letter referral to Dr Sean Whittaker. All B cell skin lymphomas are referred to the local haematology MDT of the local Trust. T cell lymphoma guidelines.pdf 7. Merckel Cell tumours and other rare tumours such as sarcomas All rare tumours should be referred to the SSMDT. Merckel cell tumour will be seen by Paul Nathan in oncology. All sarcomas will be seen by Mr James. When necessary referrals may be made to the sarcoma supranetwork SSMDT at the Marsden but this will be done via the MVCN SMMDT. 8. Rarer cancer Pathways 8.1 Children Children with Skin cancer (up to 16 years) must be referred to one of the two network agreed primary treatment centres, GOSH or Addenbrookes. 8.2 Teenagers & Young Adults The Principal Treatment Centre (PTC) for MVCN patients aged 16 – 24 is University College London Hospital. As a reminder the main principles in the Teenage & Young Adult guidance are as follows: The 16-18 age group should be seen and treated at the TYA PTC and have their management plans discussed by the TYA PTC. Although shared care can be arranged as part of the pathway. -24 years must be given choice where they would like to be treated. Either in the TYA Principal Treatment Centre, or within an adult service that has been designated by commissioners to treat young adults 19 to 24 years. The North Thames Teenage & Young Adult Cancer Network Co-ordinating Group (CTYACNCG), which includes the MVCN catchment population, have confirmed that East & North Herts Trust is the only Trust within MVCN that has been designated to treat those persons that fall within the Teenage & Young Adult guidance. Therefore cancer pathways that are not provided through East & North Hertfordshire will need to be referred to UCLH. 8.2.1 Options for 19-24 year olds place of treatment Tumour Site Breast Colorectal Gynae NSSG Haematology NSSG Head & Neck NSSG Lung NSSG Skin NSSG Upper GI NSSG Urology NSSG Place of Treatment Surgery Oncology Lister/QEII, UCLH UCLH, MVCC Lister/QEII, UCLH UCLH, MVCC UCLH UCLH, MVCC N/A UCLH, Lister, MVCC UCLH UCLH, MVCC UCLH MVCC Lister, UCLH MVCC UCLH MVCC Lister, UCLH MVCC 8.3 Management of Soft Tissue Sarcomas 8.3.1 London & South East Sarcoma Network As defined in the NICE Improving Outcomes Guidance for the management of Sarcoma (2008) all sarcomas are to be discussed at a designated sarcoma centre. MVCN does not host a sarcoma centre, nor does it have a designated clinic operating in any of the 3 acute hospital trusts. All patients must be referred to the sarcoma (supranetwork) multidisciplinary team for discussion at the earliest suspicion of sarcoma, or when histology identifies an unexpected sarcoma. The MVCN designated centre is the London and South East Sarcoma Network, which is hosted by the Royal National Orthapedic Hospital, for bone sarcomas and UCLH for soft tissue sarcomas. The UCLH MDT is held on Fridays at 08:00, and is a joint MDT, video-conferenced with the RNOH Bone and soft tissue sarcoma MDT. The contact details are: MDT Co-ordinator Maria Jose [email protected] Telephone - 0207 691 2303 ext 4821 Fax - 020 3447 9536 UCLH Sarcoma MDT Lead Clinician Dr Jeremy Whelan [email protected] 0207 380 9346 Please note: cut off for referrals is the Wednesday preceding the Friday meeting. 8.3.2 Skin Sarcomas Sarcomas arising in the dermis are rare. Subcutaneous sarcomas occur more commonly and should be managed by the sarcoma MDT as for other extremity and truncal sarcomas. The sarcoma MDT will be informed of all new skin sarcomas, excluding kaposi’s sarcoma, including details of the pathology and treatment undertaken. The sarcoma MDT will review all new cases except fully resected dermatofibrosarcoma protuberans and will review all recurrences. Management will be undertaken in accordance with guidelines agreed across the two sarcoma MDTs. LSESN shared Care Pathway Skin Sarcoma.doc Mount Vernon Cancer Network Appendix 1 URGENT TWO WEEK REFERRAL. SUSPECTED SKIN CANCER This form to be used only if the patient fulfils the following criteria. PATIENT DETAILS Surname GP DETAILS Title Forename (s) Name Practice Code DOB Age Telephone NHS Number UBRN Fax Address Postcode Practice name/address Telephone Home Postcode Work Translator required Mobile Specify language Confirm that the patient has been given a 2-week wait referral information leaflet. Confirm that the patient understands this is a referral to rule out suspected cancer. Confirm that the patient is willing and able to attend in the next 2 weeks. MALIGNANT MELANOMA - Pigmented lesion (refer in presence of ANY the 3 major features and also indicate if any minor features are present). Major features change in size irregular shape/change in shape irregular colour/change in colour Minor features largest diameter 7mm or more oozing inflammation change in sensation (itching) SQUAMOUS CELL CARCINOMA Non healing / expanding lesion with crusting induration ulceration Slow growing lesion >1 cm Immuno-suppressed or renal transplant patient with new or enlarging lesion LOCATION & HISTORY OF LESION : Additional information / other reasons for requesting urgent referral. other primary cancer, specify site Histology: Lesion has been biopsied Please fax histology report with this referral. Please attach (if appropriate) printout of PMH, drugs and any other relevant information. FAX East & North Herts NHS Trust: 01438 781835 If you have not received acknowledgement within 48hrs (Mon-Fri) please telephone 2/52 Wait Supervisor on 01438 285206. FAX West Herts Hospitals Trust: 01727 897492 FAX Luton & Dunstable NHS Foundation Trust: 01582 497910 or 497911 FOR HOSPITAL USE ONLY Date referral received: 1st appt date: If 1st appt not accepted give reason/s: 2nd appt date: Mount Vernon Cancer Network Urgent “2 week wait” referral to Hospital Why have I been referred to the hospital? The hospital will send you an appointment letter within a week; if there is not sufficient Your General Practitioner (GP) or Dentist has time to send you a letter they will contact you by asked for an urgent hospital appointment for you, phone. because you have symptoms that might indicate cancer. Let your GP surgery know if you have not heard from the hospital a week after you have seen Does this mean I have cancer? your GP. After the examination, we find that most patients If you are unable to attend the appointment sent who come to us do not have cancer, but another to you, please phone the hospital immediately. It condition. is important that you arrange another date and time if you have to cancel an appointment. So why has my GP referred me? Your Hospital Appointment GP’s can diagnose and treat most complaints and illnesses themselves. However, on some occasions they need to arrange for you to have a At your first appointment, based on the hospital assessment, so that you can see a information from your GP and your consultation specialist hospital doctor. The “two week wait” with the hospital doctor, the clinic staff will give appointment system was introduced so that you you more information about what will happen can have investigations done and be seen as next. quickly as possible. There could be several reasons why your doctor Please feel free to bring someone with you to your appointment. has sent you for a special test, for instance, Your symptoms need further investigation The treatment already prescribed has not worked Investigations your GP arranged have shown some abnormal results To make sure you don’t have a serious disease. Will I need any tests? If you have any queries regarding the arrangements for your appointment, please telephone the hospital you have been referred to on one of the numbers below Monday to Friday 8.30am - 5.00pm East & North Herts NHS Trust: You may require specialised tests and these tests Two-week-wait office: 01438 285206 may take place either before your first West Herts Hospitals Trust: appointment with the specialist hospital doctor, or Two-week-wait office: 01727 897199 during it. This will help the doctor to understand Further Information the cause of your symptoms. Luton & Dunstable Hospital Trust What do I need to do now? Outpatient Appointment line: 0845 1270193 Make sure that your GP has your correct address and telephone number, including mobile number, if possible. Further Information NHS Choices (Guide to waiting times) It is very important that you are available to attend www.nhs.uk/ an appointment within two weeks of NICE (Clinical Guidelines, Referral for Suspected seeing your GP. Please tell your GP if you if you Cancer) www.nice.org.uk are likely to be away, or unable to attend hospital for any reason, within two weeks after you have seen your GP. London and South East Sarcoma Network Shared Care Pathway for Soft Tissue Sarcomas Presenting to Site Specialised MDTs Skin Background Sarcomas arising in the dermis are uncommon and are mostly associated with a good prognosis. Those arising in subcutaneous tissue also have a better prognosis than deep sarcomas but may present to different services e.g. dermatology, plastic surgery, GP ‘lumps and bumps’ services. Initial unplanned excision is common. This guidance is to provide direction for the management of patients with sarcomas that may present through skin cancer services and to define the relationship that should exist with the specialist sarcoma MDT. This guidance refers to the care of patients in the London and South East Sarcoma Network and therefore recognises that specialist services for soft tissue sarcomas are provided by the Sarcoma Unit at The London Sarcoma Service provided through joint working of UCLH and RNOH. Principals This guidance is being developed in accordance with the relevant measures in the Manual for Cancer Services: Sarcoma Measures and the Manual for Cancer Services: Skin Measures. They are also written in accordance with the LSESN referral guidelines (see www.lsesn.nhs.uk) and the LSESN Patient Management Policy. 1) Notification All sarcoma patients presenting to a local skin MDT (LS MDT) or specialist skin MDT (SS MDT) should be notified to the sarcoma MDT nominated in the local network skin cancer operational policy. 2) Review by Sarcoma MDT a) Pathology All sarcomas arising in the skin or subcutaneous tissue presenting through skin services will have pathology review undertaken by the nominated specialist sarcoma pathology service (for details see MDT operational policies). Referral for review will include clinical information: patient age, gender, comorbidities, site of tumour, staging investigations, treatment undertaken. b) Management All new skin sarcomaswhich are greater than 2 cm, penetrate the superficial fascia, or round cell tumours, all tumours arising in children and young people, or recurrent sarcomas and all sarcomas that may require chemotherapy e.g. rhabdomyosarcoma or Ewing’s sarcoma will be discussed by one or the other sarcoma MDTs. 3) Site of Definitive Treatment If definitive surgical excision has not been undertaken as part of the diagnostic process, or if initial surgical excision is deemed inadequate by the sarcoma MDT then further surgical excision will be undertaken at a site recommended by the sarcoma MDT. Individual factors such as site, size, histological subtype, and patient comorbidities will be taken into account in advising appropriate place of surgical treatment. Chemotherapy and radiotherapy will be undertaken by designated practitioners as agreed by the SAG. 4) Recurrence All recurrent skin sarcomas will be discussed and reviewed by the sarcoma MDT. Role and Responsibility Presentation Diagnosis Specialist skin MDT/Clinic Assess new cases of suspected skin cancer Notify Sarcoma MDT of all new cases of skin sarcoma Refer all cases of skin sarcoma for pathology review Refer all new cases of skin sarcoma except completely excised DFSP for review by sarcoma MDT Treatment Moh’s excision of DFSP and excision of other skin sarcomas < 2cm where indicated Follow up Follow up according to agreed guidelines of all skin sarcomas Sarcoma MDT/Clinic Review pathology of all new cases of skin sarcoma Clinical review of all new cases including those that are greater than 2 cm, penetrate the superficial fascia, or round cell tumours, all tumours arising in children and young people, or recurrent sarcomas and all sarcomas that may require chemotherapy e.g. rhabdomyosarcoma or Ewing’s sarcoma Consider definitive excision of all subcutaneous sarcomas and reexcision of all incompletely excised or recurrent skin sarcomas. All chemotherapy All radiotherapy Follow up in accordance with sarcoma follow up guidelines all patients treated by the sarcoma MDT Pathway Summary: Local/Specialist Skin MDT Notify of all sarcoma patients Royal Marsden Sarcoma Servic e MDT Discuss All histology rev iewed by Specialist Sarcoma Pathologist Local/Specialist Skin MDT Moh’s excision of DFSP and other dermal sarcomas where indicated Individual factors such as site, siz e, histological subtype and patient comorbidities w ill be taken into account when advising appropriate place of surgical treatment all patients except DFSP, including: tumours which penetrate the superficial facia Round cell tumours Tumours > 2cm Tumours arising in children and young people Recurrent sarcomas Sarcomas that may require chemotherapy e.g, rhabdomyosarcoma or Ew ing’s sarcoma LSS MDT Coord inator Contact details: Ucltr.LondonSarcomaServ ice:nhs.net Tel: 020 3447 4821 Definitive surgical excision or (if not undertaken as part of diagnostic process or if surgical excis ion deemed inadequate by sarcoma MDT) Royal Marsden Hos pital Royal National Orthopaedic Hos pital Chemotherapy/Radiotherapy (by agreed designated practitioners) According to agreed skin MDT guidelines and LSESN sarcoma follow -up guidelines (for those patients treated by sarcoma MDT) London Sarcoma Service MDT Follow Up Recurrence Royal Free Hospital (plastic surgery service) Patients under 24 w ill also be referred to the teenage and young adult or paediatric MDTs as appropriate