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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