North Trent Cancer Network
Skull Base(SB)
Multidisciplinary TeamOperational Policy
Last updated 23rd March 2012
Approved by the NSSG 23rd March 2012
Specialist Skull Base Multidisciplinary Team Operational Policy1
Multidisciplinary Team Operational Policy
Content Page Number
List of abbreviations 3
1. Introduction 4
2. MDT Structure 6
3. Cover Arrangements 8
4. MDT Meetings 9
5. MDT Referral Guidelines 11
6. Functions of the team 14
7. Roles and responsibilities in the MDT 19
8. Appendices to operational policy 23
9. Agreement of policy 24
10. Implementation date 24
11. Review date 24
Specialist Skull Base Multidisciplinary Team Operational Policy2
List of Abbreviations
AHP Allied Health Professional
BNOS British Neuro Oncology Society
BSBS British Skull Base Society
CNMDT Cancer Network MDT
CNS Central Nervous System
CSMT Cancer Services Management Team
CWT Cancer Waiting Times
ENT Ear Nose and Throat
EQA External Quality Assessment
GP General Practitioner
IOG Improving Outcome Guidance
MDS Minimum Dataset
MDT Multi-disciplinary Team
MDTM Multi-disciplinary Team Meeting
NGH Northern General Hospital
NDSG Neuro-oncology Disease Site Groups
NSSG Network Site Specific Group
NSMDT Neuroscience MDT
RHH Royal Hallamshire Hospital
SB Skull Base
SCH Sheffield Children's Hospital NHS Foundation Trust
STH Sheffield Teaching Hospitals NHS Foundation Trust
TYA Teenage and Young Adult
Specialist Skull Base Multidisciplinary Team Operational Policy3
1 Introduction
1.1 The Sheffield Specialist Skull Base MDT, which has been running since 2003, is
listed as part of the North Trent Cancer Network.
1.2 Skull base disorders include meningiomas arising from the meninges over the base of
skull, acoustic neuromas, and cancers involving the skull base or cancers close to the skull
base where skull base techniques are required to achieve an appropriate treatment result.
1.3 The Sheffield Skull Base MDT provides a means to implement the BRAIN & CNS
IOG specifically concerning skull base tumours, working to agreed NDSG agreed guidance
(measure 11-1C-103k). The MDT aims to provide best possible care for patients (and also
their families/carer) with skull base disorders including through implementation of this
operational policy, as well as through service improvement, audit and research as described
in the MDT's Annual Report and Work Plan.
1.4 The Sheffield Skull Base MDT receives referrals from other MDTs within North Trent,
in particular the Brain & CNS, Head & Neck Cancer, Pituitary, and Sarcoma MDTs.
1.5 The referring Trusts include Doncaster and Bassetlaw Hospitals NHS Foundation
Trust, Barnsley Hospital NHS Foundation Trust, Chesterfield Royal Hospital NHS Foundation
Trust, United Lincolnshire Hospitals NHS Trust, and Rotherham NHS Foundation Trust.
1.6 Supraregional referrals are also sometimes received from the Head & Neck Cancer
MDT at Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, and the
Neuroscience Brain & CNS MDT at Hull Royal Infirmary, Hull & East Yorkshire Hospitals NHS
Trust1. Considering the MDT’s particular interest in cancers involving the skull base, referrals
from other regions, including Manchester, Leeds, Glasgow, and Greater London area have
been occasionally received.
1.7 The specialist Skull Base MDT is based within Sheffield Teaching Hospitals NHS
Foundation Trust (STH).
1.8 All multidisciplinary team meetings, specialist skull base multidisciplinary clinics,
operating theatres, neuroradiology provision, HDU / ITU facilities, and surgical (neurosurgical
and head & neck cancer) wards are on the Royal Hallamshire Hospital campus of STH
(measure 11-1A-205k).
1 In 2011, the number of patients from Hull and Leicester discussed at the Sheffield Skull Base MDT meeting was six and nine respectively.
Specialist Skull Base Multidisciplinary Team Operational Policy4
1.9 The neurosurgery department (subdirectorate) has a 24 hour on-call rota staffed by
consultant surgeons based with junior doctor support covering primarily the Royal
Hallamshire Hospital (measure 11-1D-109k). Similar 24 hour on-call rotas for both
maxillofacial surgery and ENT, staffed by consultant surgeons with junior doctor support, are
also in place at the Royal Hallamshire Hospital.
1.10 The anaplastology (craniofacial prosthetics) service, although based at the Northern
General Hospital, also covers the Royal Hallamshire Hospital.
1.11 Chemotherapy and radiotherapy treatments, including Intensity-Modulated
radiotherapy, are given at the Weston Park Hospital campus just adjacent to the Royal
Hallamshire Hospital. Hearing services, ophthalmology, and plastic surgery are also sited on
the Royal Hallamshire campus.
1.12 The Skull Base MDT has direct access to CT, MRI, radio-isotope, and PET imaging,
as well as diagnostic 3D angiography and interventional neuroradiology at STHFT.
1.13 In addition, considering the extent to which gamma knife is used to treat tumours of
the skull base, the specialist MDT includes clinician representation from the National Centre
for Stereotactic Radiosurgery based at Sheffield. STHFT has two gamma knives for the
purposes of stereotactic radiosurgery, a newly opened Perfexion machine at the Royal
Hallamshire Hospital, and a second older machine at Weston Park hospital.
1.14 The Skull Base MDT also supports a paediatric skull base oncology service at
Sheffield Children’s Hospital NHS Foundation Trust.
1.15 The MDT is listed as part of the Sheffield Directory of Cancer Services, March 2010
and can be accessed on via the following links:
http://sthnet/STHcontDocs/STH_SCS/DirectoryOfCancerServices.doc http://www.northtrentcancernetwork.nhs.uk/Network-Cancer-Services-
Directory/sheffield%20directory%20of%20cancer%20services%20-%20july%202009.pdf
1.16 The Skull Base MDT has an internet presence on the Trust's website: http://www.sth.nhs.uk/neurosciences/neurosurgery/sheffield-skull-base-group
Specialist Skull Base Multidisciplinary Team Operational Policy5
2 MDT Leadership / Structure
2.1 Core membership (measure 11-2K-205)
MDT Lead Clinician Mr T Carroll
Consultant Neurosurgeon: Mr S Sinha (& Mr T Carroll)
Consultant Stereotactic Radiosurgeons: Mr J Rowe
Mr A Kemeny
Consultant ENT Surgeons: Mr M Yardley (Lateral Skull Base)
Mr S Mirza (Anterior Skull Base Endoscopy)
Mr A Jebreel (Head & Neck Cancer)
Mr T Westin (Head & Neck Cancer)
Consultant Maxillo Facial Surgeon: Mr A Yousefpour
Consultant Plastic Surgeon: Mr A Fitzgerald
Consultant Ophthalmologist: Miss Z Currie
Consultant Neuroradiologists: Dr N Hoggard
Dr C Romanowski
Clinical Nurse Specialist: Sister L Gunn
Consultant Clinical Oncologist: Dr O Purohit
Consultant Neuropathologists: Dr M Fernando (see footnote2)
AHP (neurorehabilitation services): See 2.5 below
MDT Coordinator/Facilitator: Miss C Allsop
2.2 The Skull Base MDT core member responsible for users’ issues and patient
information is Mr T Carroll.
2.3 The Skull Base MDT core member responsible for audit, research, and clinical trial
participation is Mr T Carroll.
2.4 Microvascular surgery in the context of free flap reconstruction is performed by Mr A
Yousefpour and Mr A Fitzgerald. Both Mr A Yousefpour and Mr A Fitzgerald are accredited in
reconstructive surgical specialities including microvascular surgery, are contracted in
microvascular surgery to STH as per their posts' job descriptions and job plans, and regularly
provide microvascular free flaps for the Head & Neck Cancer service.
2 Considering that the more challenging roles of pathology and histopathology relate to tumours predominantly of a Head and Neck nature and are not meningioma / schwannomas, the Skull Base MDT consensus has been to assume for the core histopathology member to be a Head and Neck Cancer Pathologist and not a Neuro Pathologist. The Head and Neck Pathologists are however supported by the Neuro Pathologists.During the period of consultation for the Brain / CNS measures, a specific submission was made concerning this issue. The Skull Base MDT still maintains that this is the most appropriate provision in terms of patient care.
Specialist Skull Base Multidisciplinary Team Operational Policy6
2.5 Patients requiring neuroscience AHP input as a result of a neurological deficit are
referred to the Cancer Network Brain & CNS MDT. Patients requiring head & neck cancer
AHP input as a result of skull base cancer resections are referred to the Head & Neck Cancer
MDT. The extent of subsequent AHP provision is supervised by the patient's Skull Base Key
Worker.
2.5 The responsibilities of the Skull Base MDT Lead Clinician and the Skull Base MDT
Co-ordinator are as per Appendix 2 of the National Cancer Peer Review Programme Manual
for Cancer Services: Brain and CNS Measures Version 1.1 and separately set out in Section
7 of this operational policy.
2.6 Extended membership (measure 11-2K-211)
Consultant ENT Surgeons: Mr L H Durham (STH)
Mr M Haneefa (Chesterfield Royal Hospital)
Mr M Quraishi (Doncaster Royal Infirmary)
Consultant Maxillo Facial Surgeons: Mr A Smith (STH)
Mr P Doyle (Chesterfield Royal Hospital)
Mr R Orr (Chesterfield Royal Hospital)
Clinical Nurse Specialist: Ms L Marley, Head and Neck Oncology (STH)
Ms T White, Head and Neck Oncology (STH)
Oncologist: Dr B Foran
Ophthalmologist: Ms J Tan
Plastic Surgeon: Mr D Lam
Consultant Psychiatrist Dr P Gill
2.7 There is currently no palliative care team member or clinical psychologist having
membership of the Skull Base MDT or attending the Skull Base MDT Meeting. This is
addressed as a need in the current Work Plan. Currently, any patient requiring palliative care
is formally referred to the STH palliative care team by the Skull Base key worker. Clinical
psychological assessment is accessed through the Brain & CNS MDT.
2.8 Referring teams Lead Clinicians:
North Trent Brain & CNS MDT Mr D Jellinek
North Trent Pituitary MDT Dr J Newell-Price
North Trent Head & Neck Cancer MDT Mr A Yousefpour
Hull Brain & CNS MDT Mr K Morris
SCH Paediatric Oncologist Dr V Lee
Leicester Head & Neck Cancer MDT Mr A Moir
Specialist Skull Base Multidisciplinary Team Operational Policy7
3 Cover Arrangements
3.1 All core group members provide cross cover for their professional group (measure
11-2K-215)
3.2 Cross cover is as follows:
Lead ClinicianCore Member Agreed CoverMr T Carroll Mr S Sinha
Consultant NeurosurgeonCore Member Agreed CoverMr T Carroll Mr S SinhaMr S Sinha Mr T Carroll
Consultant NeuroradiologistCore Member Agreed CoverDr N Hoggard Dr C RomanowskiDr C Romanowski Dr N Hoggard
Consultant HistopathologistCore Member Agreed CoverDr J Channer Dr M Fernando / Dr S Morgan
Consultant Clinical OncologistCore Member Agreed CoverDr O Purohit Dr B Foran
Clinical Nurse SpecialistCore Member Agreed CoverSister L Gunn Sister L Marley/Sister T White
Consultant ENT SurgeonsCore Member Agreed CoverMr S Mirza Other ENT surgeonsMr T Westin Other ENT surgeonsMr M Yardley Other ENT surgeonsMr A Jebreel Other ENT surgeons
Consultant Maxillo Facial SurgeonCore Member Agreed CoverMr A Yousefpour Mr A T Smith
Consultant Plastic SurgeonCore Member Agreed CoverMr A Fitzgerald Mr D Lam
Consultant OphthalmologistCore Member Agreed CoverMs Z Currie Ms J Tan
MDT CoordinatorCore Member Agreed CoverMs C Allsop Ms B Conwill
Specialist Skull Base Multidisciplinary Team Operational Policy8
4 MDT Meetings
4.1 Venue
The meetings are held in the N Floor Lecture Theatre, Royal Hallamshire Hospital. Access to
the room is via the MDT Facilitator. The venue provides dual digital projection, access to
PACS, microscope projection, as well at videoconferencing.
4.2 Scheduling of MDT meetings (measure 11-2K-214)
The meeting is held every second week. The MDT meeting is timetabled on a Monday from
8.00 – 9.00 a.m. and precedes the Head & Neck Cancer MDT meeting.
4.3 Cancellation of MDT meetings
MDT meetings can only be cancelled in exceptional circumstances, e.g., both neurosurgeons
unavailable. If meetings are to be cancelled, 1 months notice is required and agreed by Mr T
Carroll, MDT Lead Clinician. The dates agreed for Skull Base MDT meetings for 2011 are as
follows:
2011Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec1024
721
721
4 91623
1327
1125
8 519
31731
1428
12
4.4 Attendance (measures 11-2K-114 and 11-2K-216)
All core members of the MDT or their arranged cover are to attend the MDT meetings. Staff
are required to ‘sign in’ on arrival. It is the responsibility of the individual to sign in. Miss C
Allsop, MDT Coordinator/Facilitator, verifies the attendance register. Attendance records of
the MDTM are calculated on a 6-monthly basis and fed back to the individual core member
and Mr T Carroll as Lead Clinician. Attendance records of the extended members are
available from Miss C Allsop, MDT Coordinator/Facilitator. If core members are unable to
attend they are asked to send their apologies in advance to the MDT Coordinator/Facilitator
and to make arrangements for their nominated cover to be at the MDT meeting. Annual
attendance is documented in the respective Annual Report.
4.4 Operational meeting (measure 11-2K-217)
The Skull Base MDT is to hold an annual meeting to discuss, review, and agree MDT
operational policies. All core, extended and additional team members are welcome to attend.
If it felt that additional meetings are required, ad hoc meetings can be arranged. All
operational meetings will be minuted and distributed to core / extended members. The
minutes of the most recent meeting are included in the respective annual report.
4.5 Representation and Contribution to the North Trent Cancer Network Site
Specific Group (measure 11-2K-213)
Specialist Skull Base Multidisciplinary Team Operational Policy9
The Specialist SB MDT will send core member representation to the Brain & CNS NSSG
(NDSG) meetings. MDT representation will attend at least two thirds of the Brain & CNS
NSSG (NDSG) meetings. MDT representation at the NSSG (NDSG) meetings will be
submitted as part of the MDT annual report. Communications, policies, and guidelines from
the NSSG (NDSG) will be fed back to the members of the MDT.
4.6 Neuroradiology (measure 11-2K-232)
The consultant neuroradiologist core membership Dr N Hoggard and Dr C Romanowski have
at least 50% of their job planned programmed activities in the area of neuroradiology.
Specialist Skull Base Multidisciplinary Team Operational Policy10
5 MDT Referral Guidelines (11-1C-105k, 11-1C-106-k, 11-1C-107k, 11-1C-108k, 11-2K-
233, 11-2K-234, 11-2K-235, 11-2K-236)
5.1 All NHS patients with a suspected or newly diagnosed tumour, either benign or
cancerous, and private patients for which STH provides some contribution to their care, will
be referred into the Skull Base multidisciplinary team, and dealt with in a skull base
multidisciplinary clinic, skull base MDT meeting, or both. Skull base tumour patients that are
not formally reviewed in the skull base MDT meeting are managed to a skull base MDT-
agreed policy as laid out in the Pathway Design document (see Appendix 1 and Appendix 6).
5.2 The following patients will be formally reviewed at the MDT Meeting (measure 11-2K-
218):
5.2.1 All patients having a known or potential malignant neoplasm of the
skull base on initial presentation.
5.2.2 All patients having a malignant neoplasm abutting the skull base for
which planned resective surgery would involve skull base expertise for
clearance.
5.2.3 All patients that have undergone surgery for benign tumours of the
skull base (e.g., meningiomas, schwannomas) and for which histology and a
baseline post-op scan available.
5.2.4 All patients that have undergone surgery for malignant tumours
involving the skull base and for which histology is available.
5.2.5 All patients having disorders involving the skull base that do not fit to
agreed management protocols, on completion of initial diagnostic work-up.
5.2.6 All patients undergoing interval imaging for which subsequent issues
of concern do not fit to agreed management protocols.
5.2.7 Any other patients having disorders of the skull base as considered
appropriate by individual Skull Base MDT members.
5.3 All patients aged 16-24 inclusive will be discussed at both the SB MDT and the
Teenage & Young Adults MDT (measure 11-2K-241). Appropriate referrals are made if
required see NSSG constitution for referral pathways.
5.4 All patients whose skull base cancer histological diagnosis is relevant to other MDTs,
e.g., head and neck, sarcoma, melanoma, will also be discussed at these other MDTs both
prior and following any Skull Base MDT-led interventions.
5.5 How to refer to the Sheffield Skull Base MDT
The contact point for the skull base service as listed on the STH website skull base MDT
page www.sth.nhs.uk/neurosciences/neurosurgery/sheffield-skull-base-group is:
Specialist Skull Base Multidisciplinary Team Operational Policy11
Mr Thomas Carroll
Consultant Neurosurgeon
Department of Neurosurgery
Royal Hallamshire Hospital
Glossop Road
Sheffield
S10 2JF
Tel 0114 2712192
Fax 0114 2765925
Mr T Carroll can be contacted after-hours through the STH switchboard. In addition to the
above, an alternate means of referral, in particular if for specifically MDT Meeting discussion,
is to the Skull Base MDT Coordinator:
Tel 0114 2712010, Miss Caroline Allsop, Skull Base MDT Coordinator
Fax 0114 2268795, for the attention of the Skull Base MDT Coordinator
Via the NHS.net generic account ([email protected]), for the
attention of the Skull Base MDT Coordinator.
5.6 Anticipated imaging on initial patient referral
The minimum imaging modality for referral is a CT scan of head for an intracranial base of
skull tumour or a CT of paranasal sinuses or temporal bones for a potential malignancy
involving the base of skull. In the specific context of asymmetric hearing loss where the
concern is the possibility of an acoustic neuroma (vestibular schwannoma) tumour, an MRI of
'IAMs' would be expected. Any additional investigation recommendations by the Skull Base
MDT would be on a case by case basis or would be arranged directly by the Skull Base MDT
on receipt of referral.
5.7 The referral deadline for the MDT Meeting is Friday at midday.
5.8 Protocol for taking action between meetings (measure 11-2K-214)
The following applies to patients with skull base tumours for which referral to the skull base
MDT meeting is required as per the MDT-agreed Pathway Design document. It may be
necessary for patients that would normally be expected to be discussed at the MDT meeting
to have decisions made concerning their results and/or their treatment plans prior to the next
MDT meeting. Such discussions will be subsequently endorsed at the next MDT meeting.
Such actions and discussion outside the MDT meeting are formally recorded in the notes,
e.g., the specialist MDT clinic letter copied to patient, GP, referring clinician, and involved SB
MDT members.
Specialist Skull Base Multidisciplinary Team Operational Policy12
5.9 Patient management review and individual patient’s treatment plans (measures
11-2K-118 and 11-2k-227)
At the MDT Meeting an agenda of the patients discussed will be presented including working
identity of the patient, stage of patient pathway, working diagnosis, and summary of treatment
plan to date (if any). Final minutes of the MDT Meeting will include a reviewed stage of
patient pathway, working diagnosis, any new treatment plan or the elements of change (or
not) to a previous treatment plan, including specifically any referral or involvement of
palliative, supportive, or rehabilitation disciplines, all having been inputted/updated onto the
MDT database by the MDT Facilitator. The reviewed stage of patient pathway, working
diagnosis, any new treatment plan or the elements of change (or not) to a previous treatment
plan, including specifically any referral or involvement of palliative, supportive, or rehabilitation
disciplines will be separately recorded in an individual patient’s notes. For patients managed
to protocol as per Pathway Design document, e.g., with a small acoustic neuroma, the stage
of patient pathway, the working diagnosis, any new treatment plan or the elements of change
(or not) to a previous treatment plan, including specifically any referral or involvement of
palliative, supportive, or rehabilitation disciplines will be recorded in the relevant skull base
multidisciplinary clinic letter and copied to patient, GP, referring clinician, and relevant Skull
Base MDT members, as well as being filed in the patient’s notes. Note that stage of patient
pathway examples are: ‘referred (diagnostic)’; ‘pre-biopsy (presentation)’; ‘post-biopsy
(presentation)’; ‘pre-definitive surgery (follow-up)’; post-definitive surgery (follow-up)’; ‘interval
imaging (follow-up)’; ‘pre-adjuvant therapy (follow-up)’; ‘post-adjuvant therapy (follow-up)’.
Specialist Skull Base Multidisciplinary Team Operational Policy13
6 Functions of the team
6.1 Skull Base Multidisciplinary Clinics (measures 11-1A-205k, 11-2K-230, 11-2K-
231)
6.1.1 The Skull Base MDT runs a number of specialist skull base multidisciplinary clinics,
including anterior skull base clinic (3 per month, clinic codes TACAS and SS5AS), lateral skull
base clinic (2 per month, clinic code TACEN), an NF2 clinic (clinic code TACNF), and ‘ad hoc’
general skull base clinics in between formal clinics to accommodate patients with urgent skull
base tumour-related problems.
6.1.2 Patients with non-cancerous tumours of the skull base are followed up by the Skull
Base MDT in specialist clinics. In general, patients are subjected to interval cranial imaging,
usually MRI, over a minimum period of ten years, following initial diagnosis or first
intervention. Where interval MRIs are unchanged, clinic attendance is generally at the choice
of the patient.
6.1.3 Patients with skull base cancers have long term follow-up in the Head & Neck Cancer
multidisciplinary clinics at which a clinician core member of the Skull Base MDT is usually
present.
6.1.4 The Skull Base Clinics are usually run in the ENT Outpatient Department at the Royal
Hallamshire Hospital to facilitate multi-disciplinary participation and run in parallel with Head &
Neck Cancer oncology clinics. An oncologist does not participate directly in the skull base
clinics as the majority of patients seen have benign tumours for which radiotherapy is not part
of any potential treatment. For the small number of skull base cancer patients, they are either
seen in the head & neck cancer clinic which runs in parallel to the skull base clinics in the
ENT Outpatient Department and the skull base surgeon attends or in the skull base clinic and
the oncologist participating in the head & neck cancer clinic attends.
6.1.5 Patients for planned radiosurgical treatments are separately referred to and seen in
radiosurgical clinics operating as part of the National Centre for Radiosurgery, based also at
the Royal Hallamshire Hospital. An exception is the TACNF NF2 clinic in which Mr J Rowe,
consultant neurosurgeon and radiosurgeon attends.
6.1.6 Ms L Gunn, the Skull Base MDT core nurse MDT member, attends the skull base
multidisciplinary clinics.
6.2 Key worker (measure 11-2K-220)
Specialist Skull Base Multidisciplinary Team Operational Policy14
A key worker will be allocated to all patients by the MDT. This individual will be responsible
for guiding the patient through the patient pathway. Patients and / or carers may gain access
to members of the MDT to discuss problems or concerns via their Key Worker. The name
and contact number of the patient’s key worker will be recorded in the patient’s case notes.
The key workers for the Skull Base MDT are Mr T Carroll with cross cover provided by Mr S
Sinha and Ms L Gunn. All patients and/or carers are given Mr Carroll’s business card at the
time of clinic attendance (Appendix 4) – which includes his secretary’s direct line number, fax
number - and for all patients with a diagnosis of cancer or undergoing a major skull base
tumour resection, his mobile telephone number. Patients are also given the contact details
(email / voicemail / bleep) of Ms L Gunn.
6.3 Specified Surgical Programmed Activities (measure 11-2K-229)
6.3.1 Mr T Carroll has greater than 50% of his job plan put aside for skull base oncology,
including the alternate week skull base MDT meeting, a weekly skull base clinic and ad hoc
skull base clinics otherwise, and a weekly all day extended length theatre list with the facility
for over-runs into the evening.
6.3.2 Mr S Sinha has greater than 50% of his job plan put aside for oncology, primarily of
skull base and pituitary, including alternate week skull base MDT meeting attendance,
alternate week Pituitary MDT meeting attendance, a monthly skull base clinic, an alternate
week pituitary multidisciplinary clinic, and a weekly all day pituitary/skull base theatre list, in
addition as a paediatric neurosurgeon he also attends a monthly paediatric neuro-oncology
clinic, weekly paediatric neuro-oncology MDT and has a weekly theatre session to deal with
any paediatric oncology cases.
6.3.3 Skull base tumours resective surgery, other than as per emergency surgical
intervention protocol below, is only carried out by Mr T Carroll and Mr S Sinha, i.e., other
consultant neurosurgeons at the Sheffield Department of Neurosurgery do not carry out skull
base tumour resective surgery.
6.4 Emergency Surgical Interventions
6.4.1 Patients with large skull base tumours may present acutely through the on-call
neurosurgical service at the Royal Hallamshire Hospital. Patients presenting in extremis
requiring emergency skull base tumour resective surgery are extremely rare (e.g., two such
events at Sheffield within a ten year period). In general, the greater majority of such patients
can be appropriately managed on Dexamethasone pending additional investigations and
inpatient referral to the Skull Base MDT.
6.4.2 For patients whose initial presentation includes a hydrocephalus, emergency CSF
diversionary surgery by the on-call neurosurgery service may be required, depending on
clinical status.
6.4.3 For patients who have undergone definitive surgery for their skull base tumour and
who subsequently suffer a post-operative neurosurgical complication, e.g., hydrocephalus,
bone flap infection, any required emergency operation during working hours in the absence of
Specialist Skull Base Multidisciplinary Team Operational Policy15
a neurosurgeon being available from the Skull Base MDT or afterhours would be carried out
by the on-call neurosurgical service.
6.4.4 For patients who have undergone definitive surgery for their skull base tumour and
who subsequently suffer a post-operative reconstructive complication, e.g., free flap failure,
any required emergency operation would be carried out by a reconstructive surgical member
of the Skull Base MDT or in his absence by a relevant reconstructive surgical member of the
Head & Neck Cancer MDT, with support by a neurosurgeon from the Skull Base MDT or in
his absence by the on-call neurosurgical service.
6.5 The Skull Base MDT works in close relationship with other North Trent Cancer
Network MDTs.
6.5.1 For patients with cancers involving the skull base, subsequent post-operative
radiotherapy and/or chemotherapy is provided by the North Trent Head & Neck Cancer MDT
oncologists with such adjuvant treatment having being agreed at the time of the original
agreed treatment plan by the Skull Base MDT.
6.5.2 For patients whose skull base cancers are sarcomas, the patient is additionally
referred to the Sheffield Sarcoma MDT for confirmation of treatment plan.
6.5.3 For occasional non-cancerous tumours of the skull base where adjuvant radiotherapy
is a possibility, referral is made to the Sheffield Neuroscience MDT for neuro-oncologist
consideration.
6.5.4 All appropriately aged patients with skull base tumours, i.e., teenagers, and young
adults up to the age of 24 years, are also referred to the Teenage and Young Adult MDT.
6.5.5 Patients with skull base tumours and who have a significant neurologic deficit
requiring rehabilitation are referred to the North Trent Brain & CNS Cancer Network MDT.
6.6 Patient permanent consultation record (measure 11-2K-224)
All patients with skull base tumours managed by the Skull Base MDT, when seen in one of
the Skull Base clinics and/or when dealt with as an inpatient, are given a permanent summary
of consultations recording their diagnosis, treatment options, and follow-up. Specifically, all
patients receive copies of their clinic letters and also inpatient discharge summaries, which
are also sent to the patient’s GP and any professionals involved in their care. This
correspondence is provided at the point of diagnosis, discussion of treatment plan, discharge
from hospital, and follow up appointments (see appendix 7 for anonymised copies of clinic
letters / discharge letters / results letters). Note that patients do not receive copies of MDT
discussion / outcomes.
6.7 Communication with GPs (measure 11-2K-219)
In general, patients being managed with a skull base cancer have their cancer diagnosis
established prior to referral to the skull base MDT, this diagnosis having been made by the
relevant Head & Neck cancer MDT or other MDT. For the occasional patient, in which a new
cancer diagnosis is established while under the care of the Skull Base MDT, the patient’s GP
will be informed of the diagnosis the same or following day. To achieve this, the MDT
Specialist Skull Base Multidisciplinary Team Operational Policy16
proforma will be faxed to the GP by the MDT Co-ordinator (Appendix 8). The proforma will
then be filed in the patient’s notes. See also STH Policy for Communication of a New
Diagnosis of Cancer to the GP – 01/08/05. An audit of the fax-back process was undertaken,
please see annual report.
6.8 Patient Information (measure 11-2K-226)
6.8.1 General information to patients with skull base cancers is provided by Mr T Carroll
and the Head & Neck Cancer Clinical Nurse Specialist.
6.8.2 General information to patients with benign tumours involving the skull base is
provided by Mr T Carroll and Ms L Gunn.
6.8.3 Categories of general information include:
MDT specific information, e.g., process and relevant team members
Local cancer services information
Self help group information
Psychological/social care information
Tumour treatment option information
6.8.4 A range of patient information leaflets are provided including concerning acoustic
neuromas and 'craniotomy'. All patient correspondence is copied to the patients including
details of any specific operation such as indication/key surgical steps/risks. Any proposed
patient information leaflets are given in the Work Programme.
6.8.5 The provision of information is updated at least on an annual basis.
(See appendix 4)
6.9 Clinical Trials/Research (measure 11-2K-240)
6.9.1 The MDT will produce an annual written response to the NSSG’s approved list of
trials which will include the following:
For each clinical trial the MDT will agree to enter patients or state the reason why it
will not be possible to do so.
The remedial action arising from the MDT’s recruitment results, agreed within the
NSSG
Sign off by the NSSG / MDT Lead Clinician and the North Trent Cancer Research
Network Clinical Lead.
If the MDT chooses to participate in additional trials, these will be agreed by the MDT, priority
will be given to the NSSG agreed trials, and agreed trials will be signed-off by the MDT Lead
Clinician.
6.9.2 The Cancer Network clinical trials link person is Mrs Leslie Bruce, Research Network
Manager ([email protected], 0114 2265210).
6.9.3 Mrs J Keyworth ([email protected]), Neurosciences Research Coordinator
is available to provide Neuroscience Academic Directorate support.
6.10 Service Evaluation/Audit (measure 11-2K-239)
Specialist Skull Base Multidisciplinary Team Operational Policy17
In addition to any patient experience exercise (see 6.11 below), the Skull Base MDT will
engage in periodic service evaluation and clinical audit, looking to benchmark its quality of
care and outcomes, including in a national and international context, e.g., by submitting to
British Skull Base Society and British Association of Head & Neck Oncologist Conferences,
and provide such information in the public domain, e.g., by peer reviewed publication or on
the Skull Base MDT page of the STH website.
6.11 Patient Experience Exercise (measure 11-2K-225)
The MDT will undertake an annual survey of patients’ experience of the services offered by
the team. The survey will ascertain whether patients experienced or were offered: (1) a key
worker (2) the MDT’s relevant written information for patients and carers, (3) the opportunity
of a permanent record / summary of a consultation at which their treatment options were
discussed3, and (4) an assessment that included a holistic approach (i.e., with respect to
physical, practical, emotional, psychological, and spiritual) The results will be discussed at an
operational meeting and an action plan agreed. Users will be invited to comment upon the
design of the questionnaire, results and action plan. The results of the survey/action plan will
be sourced in the annual report.
6.12 Minimum Data Set (measure 11-1C-104k / 11-2K-238)
The MDT will record the network-wide minimum data set (MDS) proposed by the NCIN CNS
SSG as agreed by the Cancer Network Brain and CNS NSSG. The dataset will be collected
in an electronically retrievable format. The MDS is outlined in appendix 5.
6.13 National Brain Tumour Registry
The Skull Base MDT participates and will continue to participate in the forwarding of data to
the National Brain Tumour Registry www.nbtr.nhs.uk.
6.14 Advanced Communications Course (measure 11-2K-221)
All core members of the team who have direct clinical contact with patients should have
attended the national advanced communications skills training. Please see annual report for
evidence as to who has attended or who is on the waiting list for this course.
6.15 Area-Wide Communication Framework (measure 11-2K-237)
The North Trent Brain and CNS NSSG Area Wide Communication Framework has been agreed by Mr H Zaki, Chair, with the trust leads for brain and CNS tumours and lead clinicians of the MDTs of the following providers: Sheffield Teaching Hospitals NHS Trust, Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Barnsley Hospital NHS Foundation Trust, Chesterfield Royal Hospital NHS Foundation Trust, Rotherham NHS Foundation Trust and United Lincolnshire Hospital NHS Trust. These can be found in the NS MDT Operational Policy page 14.
3A patient experience to the prescribed format was not performed up to the period ending December 2010. For details of any other patient assessments, please see Annual Report. A patient experience exercise to this format is proposed in the Work Programme.
Specialist Skull Base Multidisciplinary Team Operational Policy18
7 Roles and Responsibilities
7.1 Skull Base MDT Lead Clinician – Job Desciption (measure 11-2K-205)
7.1.1 There is allocated time in the Skull Base MDT Lead Clinician’s Job Plan over and
above direct clinical care activities and alternate week skull base MDT attendance4. The
current Skull Base MDT Lead Clinician is Mr T Carroll.
7.1.2 The Skull Base MDT Lead Clinician is to ensure effective working of the Skull Base
MDT including:-
To ensure that the designated specialists work effectively together within the
multidisciplinary team.
To ensure that decisions regarding diagnosis, treatment and care of individual
patients are multidisciplinary.
To ensure that the MDT’s operational policies are decided upon by the team.
To ensure that care is given according to recognised guidelines (including guidelines
for onward referrals).
To seek clinical co-operation and support for system improvement that leads to
existing time targets being met. To escalate to the Trust Cancer Site Management
Team Lead Clinician or Trust Lead Cancer Clinician if co-operation is unreasonably
withheld.
To ensure that appropriate information is collected to inform clinical decision making
and support clinical governance/audit.
To ensure that mechanisms are in place to support the entry of eligible patients into
clinical trials, subject to patients giving fully informed consent.
7.1.3 The Skull Base MDT Lead Clinician is responsible for ensuring that the MDT meets
peer review quality measures including to ensure that attendance levels of core members are
maintained in line with the peer review quality measures and to ensure that the target of
100% of cancer patients discussed at the MDT is met.
7.1.4 The Skull Base MDT Lead Clinician is to provide the link to the Network Site Specific
Group (NSSG) either by attendance at meetings or by nominating another MDT member to
attend.
7.1.5 The Skull Base MDT Lead Clinician will lead on, or nominate the lead for, service
improvement in liaison with the STH Cancer Services Management Team (CSMT).
7.1.6 The Skull Base MDT Lead Clinician will organise and chair a Skull Base MDT annual
meeting which will:-
Examine the functioning of the team.
Review operational policies.
Collate activities required to ensure optimum functioning of the team eg training for
team members.
4 The current job plan allocation is an additional three programmed activities on an annual basis.
Specialist Skull Base Multidisciplinary Team Operational Policy19
Include members of the CSMT if not already included within the MDT.
7.1.7 The Skull Base MDT Lead Clinician will ensure the MDTs activities are audited and
the results documented.
7.1.8 The Skull Base MDT Lead Clinician, with support from members of the CSMT, will
ensure that the outcomes of the meeting are clearly recorded and clinically validated and data
is appropriately collected.
7.1.9 The Skull Base MDT Lead Clinician will ensure that MDT outcomes are
communicated to primary care and patients.
7.1.10 Agreed by Dr D Hughes, Trust Cancer Lead Clinician.
7.2 Agreed responsibility policy for all keyworkers (measure 11-2K-220)
7.2.1 The current Skull Base MDT Keyworkers are Mr T Carroll, Mr S Sinha, and Mrs L
Gunn.
7.2.2 At the multidisciplinary team meeting where a patient is discussed, the core nurse
specialist will confirm patient key worker allocation. The key worker will provide support to
carers/relatives.
7.2.3 Once the key worker has been allocated the nurse specialist will have responsibility
for ensuring the name of the key worker and relevant date is entered on to a communications
sheet in the medical notes and other patient documentation such as clinic letters.
7.2.4 At key points throughout the patient’s journey, the assigned key worker and any
changes will be documented on the communications sheet with written confirmation that the
patient has been made aware of who is their key worker..
7.2.5 The key worker should be present when a tumour/cancer diagnosis is discussed and
any other key points in the patient’s journey whenever possible.
7.2.6 The key worker will offer verbal and written information with regard to diagnosis,
investigations, treatment options and support groups. Written information concerning these
issues will include patient information leaflets concerning acoustic neuroma, skull base
meningiomas, and skull base cancers.
7.2.7 The key worker will support the continuity of patients care. This may include
organising appropriate investigations and referral to appropriate specialties.
7.2.8 The key worker will ensure that the patient is given their contact details.
Note that nurse Specialist can be taken to include Nurse Consultant, Nurse Practitioner and
Clinical Nurse Specialist.
7.3 Agreed responsibilities for all core nurse members (measure 11-2K-223)
7.3.1 The Skull Base MDT core nurse member is Mrs Lynda Gunn.
7.3.2 The core nurse member will contribute to the multidisciplinary discussion and patient
assessment/care planning decision of the team at their regular meetings.
7.3.3 The core nurse member will provide expert nursing advice and support to other health
professionals in the nurse’s specialist area of practice.
7.3.4 The core nurse member will be involved in clinical audit.
Specialist Skull Base Multidisciplinary Team Operational Policy20
7.3.5 The core nurse member will lead on a patient’s communication issues and co-
ordination of the patient pathway for patients referred to the team.
7.3.6 The core nurse member will be the key worker or be responsible for nominating the
key worker for the patient’s dealings with the Skull Base MDT.
7.3.7 Additional responsibilities (measure 11-2K-222) for the core nurse member include
contributing to the management of the service and utilising research in the nurse’s specialist
area of practice.
7.3.8 The keyworker will ensure that the results of patient’s holistic needs assessments are taken into account in the decision making.
7.4 Responsibilities of the Skull Base MDT Coordinator
7.4.1 The Skull Base MDT Coordinator is Miss C Allsop.
7.4.2 The Skull Base MDT Coordinator is required to facilitate and co-ordinate the functions
of the multidisciplinary team meetings including:
To ensure the appropriate patients are discussed at MDTs as per Operational Policy.
To ensure lists of patients to be discussed at meetings are prepared and distributed in
advance. To ensure all correspondence, notes, x-rays, and results are available for
the Skull Base MDT meetings.
To keep a comprehensive diary of all Skull Base MDT meetings including maintaining
a record attendance of such meetings, taking minutes, typing patient notes back in
the required format, and distributing meeting outcomes to all professionals
concerned.
To ensure members or their deputy are advised of meetings and any changes of date
and venue.
7.4.3 The Skull Base MDT Coordinator has data collection and recording roles including:
To ensure patients' diagnoses, investigations, management and treatment plans are
recorded with a suitable summary to be added to the patient's notes.
To manage systems that inform GP's of patient's diagnosis and treatment plan
including decisions made at outpatient appointment.
To work with staff to ensure all patients to be managed by the Skull Base MDT have
an appropriate booked first appointment, investigation and/or procedure.
To record the referral pathway of patients
To help with the introduction and changes to proformas used to record all patients
seen, discussed, or treated, including outcomes.
To be instrumental in the development of databases to capture patient information.
To generate appropriate reports, e.g., for the MDT clinicians on their request.
7.4.4 Other functions of the Skull Base MDT Coordinator:
To work with key MDT members to identify areas where targets are not achieved,
undertake process mapping to identify bottlenecks, and to undertake demand and
capacity studies as required..
To report changes to MDT structure or functioning.
Specialist Skull Base Multidisciplinary Team Operational Policy21
To manage patient database systems according to guidelines, monitoring milestones
and submitting the required reports in the given format and required times;
To inform lead cancer manager of waiting times for patients when these exceed
appropriate targets.
To ensure MDT policy, pathway, and other documents are produced with agreed
reviews.
To assist in capturing required cancer data on all cancer patients as a subgroup of
skull base tumours and assist in the development of systems to complement the
cancer audit system.
Specialist Skull Base Multidisciplinary Team Operational Policy22
Appendices to Operational Policy
Table of appendices
Appendix number
Title Page number
1 Skull Base Patient Pathway 26
2 Clinical Trials List 27
3 Anonymised copy of MDT Agenda post meeting 28
4 MDT Patient Information pathway 29
5 NSSG Minimum Dataset 34
6 Sheffield Skull Base MDT Pathway Design & Clinical Guidelines Document
36
7 Anonymised copies of patient permanent consultation records 48
8 Fax back to GP after MDT discussion 50
Specialist Skull Base Multidisciplinary Team Operational Policy23
Agreement of policy
This Operational Policy has been agreed by:
Position: MDT Lead Clinician
Name: Mr T Carroll
Organisation: Sheffield Teaching Hospitals NHS Foundation Trust
Date Agreed: 28th September 2011
Position: Trust Lead Clinician for MDT Leadership (measure 11-1D-101k)
Name: Dr D Hughes
Organisation: Sheffield Teaching Hospitals NHS Foundation Trust
Date Agreed: 23rd March 2012
The MDT members agreed Operational Policy on:
Date Agreed: 29TH September 2011
Version Control: 8
Implementation date: 23rd March 2012
Review date: 23rd March 2013
Specialist Skull Base Multidisciplinary Team Operational Policy24
Appendix 1 Skull Base Patient Pathway (measures 11-2K-234, 11-2K-235, 11-2K-236)
Specialist Skull Base Multidisciplinary Team Operational Policy25
Process
Trigger
Alternative process
Decision
Document
Predefined process
Data
Diagnostic pathway Follow-up pathwayPresentation pathway
Appendix 2
Clinical Trials List as of 2010 - 2011 (measure 11-2K-240)
STH 16152: Subtotal resection of large acoustic neuroma with possible stereotactic radiation
therapy (NCT01129687)
STH 15598: The Fanconi Anaemia and related DNA repair pathways in brain tumours
Specialist Skull Base Multidisciplinary Team Operational Policy26
Appendix 3 Sheffield Teaching Hospitals NHS Foundation TrustSB MDT Meeting Outcome Report (measure 11-2K-227)
Name RHH No Referrer DoB Past Medical History Working Diagnosis Outcome
Specialist Skull Base Multidisciplinary Team Operational Policy27
2
Appendix 4 (measure 11-2K-226)
Specialist Skull Base MDT Information Pathway – Information specific to the Specialist SB MDT about local provision of the services offering the treatment of SB disorders
Format of informationLeaflet/book/support group/video/audio
Title ProducedBy whom
How disseminated
Whendisseminated
By whomDisseminated
For Whom
Patient Carer Child Dependent
Business Card
Mr Thomas Carroll, Consultant Neurosurgeon, Contact Details for Skull Base Tumour patientsPD 6035v1
STHFT By handAt clinic appointment as required
Key Worker / Mr Carroll
X X
Pamphlet (PDF)
CraniotomyPD5339-PIL1722 v1Issue date: July 2009Review date: July 2011
STHFTBy hand By post
Treatment stage
Key Worker / Mr Carroll
X
LeafletSmall Vestibular Schwannoma Information Sheet
STHFT Skull Base MDT
By handBy post
At diagnosisKey Worker / Mr Carroll
X X
LeafletLarge Vestibular SchwannomaInformation Sheet
STHFT Skull Base MDT
By handBy post
At diagnosisKey Worker / Mr Carroll
X X
Websitehttp://www.sth.nhs.uk/neurosciences/neurosurgery/sheffield-skull-base-group
STH Skull Base MDT
- - -
X X
Website http://www.gammaknife.org.ukNational Centre for Radiosurgery, Sheffield
On referral to radiosurgery
Diagnosis & Treatment Stage
Key Worker
X X
Specialist Skull Base Multidisciplinary Team Operational Policy28
2
Specialist SB MDT Information Pathway – Information about the services offering psychological, social & spiritual/cultural support
Format of informationLeaflet/book/support group/video/audio
Title ProducedBy whom
How disseminated
Whendisseminated
By whomDisseminated
For Whom
Patient Carer Child Dependent
Website www.macmillan.org.ukMacmillan Cancer Support
On an individual patient basis
Diagnosis & Treatment stage
Key WorkerX X
Generic Information – General Patient Advice
Format of informationLeaflet/book/support group/video/audio
Title ProducedBy whom
How disseminated
Whendisseminated
By whomDisseminated
For Whom
Patient Carer Child Dependent
Business CardMr Thomas Carroll, Consultant Neurosurgeon, Contact DetailsPD 6044v1
STHFT By HandAt clinic appointment as required
Key Worker / Mr Carroll
X X
Websitewww.cancerhelp.cancerresearchuk.org
Cancer Research UK
On an individual patient basis
Diagnosis & Treatment Stage
Key WorkerX X
Website www.macmillan.org.uk Macmillan Cancer Support
On an individual patient basis
Diagnosis & Treatment stage
Key WorkerX X
Specialist Skull Base Multidisciplinary Team Operational Policy29
2
Specialist SB MDT Information Pathway – Self help groups
Format of informationLeaflet/book/support group/video/audio
Title ProducedBy whom
How disseminated
Whendisseminated
By whomDisseminated
For Whom
Patient Carer Child Dependent
Websitewww.brainandspine.org.uk
Brain and Spine Foundation
On craniotomy information PDF pamphlet
Diagnosis & Treatment stage
Key WorkerX X
Websitewww.braintumouruk.org.uk Brain Tumour UK
On craniotomy information PDF pamphlet
Diagnosis & Treatment stage
Key WorkerX X
Websitewww.mengintiomauk.org Meningioma UK
On craniotomy information PDF pamphlet
Diagnosis & Treatment stage
Key WorkerX X
Websitehttp://www.bana-uk.com/
British Acoustic Neuroma Association
In Lateral Skull Base Clinic
Diagnosis & Treatment stage
Key WorkerX X
Websitehttp://www.accoi.org
Adenoid Cystic Carcinoma Organization International
On an individual patient basis
Diagnosis & Treatment Stage
Key WorkerX X
Specialist Skull Base Multidisciplinary Team Operational Policy30
3
Specialist SB MDT Information Pathway – Information specific to SB tumours about the disease & its treatment options
Format of informationLeaflet/book/support group/video/audio
Title ProducedBy whom
How disseminated
Whendisseminated
By whomDisseminated
For Whom
Patient Carer Child Dependent
Website www.gammaknife.org.ukNational Centre for Radiosurgery, Sheffield
On referral to radiosurgery
Diagnosis & Treatment Stage
Key Worker
X X
Pamphlet (PDF)
CraniotomyPD5339-PIL1722 v1Issue date: July 2009Review date: July 2011
STHFTBy hand By post
Treatment stage
Key Worker / Mr Carroll
X
LeafletSmall Vestibular Schwannoma Information Sheet
STHFT Skull Base MDT
By handBy post
At diagnosisKey Worker / Mr Carroll
X X
LeafletLarge Vestibular SchwannomaInformation Sheet
STHFT Skull Base MDT
By handBy post
At diagnosisKey Worker / Mr Carroll
X X
Specialist Skull Base Multidisciplinary Team Operational Policy31
3
Specialist SB MDT Information Pathway – Support with Patient Information FOR STAFF
Service Required Title ProducedBy whom
Located Last updated Review date
Sign language interpreting service
Sheffield City Council & STHFT
Paper copy No date offeredNo date offered
Translation of patient information
STHFTContact Jo Evans, Patient Information Manager
January 2008No date offered
Advice on writing patient information
STHFTSTHFT intranet (Reference number 157)
December 2007 01/01/08
Telephone communications to a deaf person
STHFT / Typetalk Customer Support Team
Sue Butler, Head of Patient partnership
No date offeredNo date offered
Advanced Communication
STHFT PD2861 05/2008 05/2008No date offered
Patient information last updated: 30 th September 2011
Specialist Skull Base Multidisciplinary Team Operational Policy32
3
Appendix 5 Minimum Dataset – BRAIN CNS NSSG Peer Review Measures11-1C-104k - Agreed area-wide minimum dataset (MDS)(measure 11-1C-104k / 11-2K-238)
Data Item Registry Wait TimesSurname X Forename X Sex X Date of Birth X Marital Status X Place of Birth X Ethnic Origin X NHS Number X Address X Date of Diagnosis X Morphology X Site X Laterality X Basis of Diagnosis X Sex at Diagnosis X Diagnosing Hospital X Hospital Number X Clinician X Clinician Specialty X Surgery Treatment Indicator X Radiotherapy Treatment Indicator X Chemotherapy Treatment Indicator X Hormonal Treatment Indicator X Other Treatment Indicator X
Organisation Code X
Source Of Referral For Cancer X
Delay Reason Referral To First Seen (Cancer And Breast Symptoms) X
Delay Reason Comment (First Seen) X
Urgent Cancer Or Symptomatic Breast Referral Type X
Cancer Or Symptomatic Breast Referral Patient Status X
Waiting Time Adjustment (First Seen) X
Waiting Time Adjustment Reason (First Seen) X
Source Of Referral For Out-Patients X
Primary Diagnosis (ICD) X
Multidisciplinary Discussion Indicator X
Multidisciplinary Team Discussion Date (Cancer) X
Recurrence Indicator X
Decision To Treat Date (Surgery) X
Start Date (Surgery Hospital Provider Spell) X
Specialist Skull Base Multidisciplinary Team Operational Policy33
3
Primary Diagnosis (Icd) X
Decision To Treat Date (Anti-Cancer Drug Regimen) X
Start Date (Anti-Cancer Drug Regimen) X
Decision To Treat Date (Teletherapy Treatment Course) X
Start Date (Teletherapy Treatment Course) X
Decision To Treat Date (Brachytherapy Treatment Course) X
Start Date (Brachytherapy Treatment Course) X
Decision To Treat Date (Specialist Palliative Treatment Course) X
Waiting Time Adjustment (Treatment) X
Waiting Time Adjustment Reason (Treatment) X
Delay Reason Referral To Treatment (Cancer) X
Delay Reason Decision To Treatment (Cancer) X
Delay Reason Comment (Referral To Treatment) X
Delay Reason Comment (Decision To Treatment) X
Decision To Treat Date (Active Monitoring) X
Start Date (Active Monitoring) X
Patient Pathway Identifier X
Organisation Code (Patient Pathway Issuer) X
Priority Type X
Cancer Referral To Treatment Period Start Date X
Consultant Upgrade Date X
Organisation Code (Provider Consultant Upgrade) X
Metastatic Site X
Cancer Treatment Event Type X
Cancer Treatment Period Start Date X
Treatment Start Date (Cancer) X
Cancer Treatment Modality X
Cancer Care Setting (Treatment) X
Clinical Trial Indicator X
Organisation Code (Provider Treatment Start Date (Cancer)) X
Radiotherapy Priority X
Radiotherapy Intent X
Delay Reason (Consultant Upgrade) X
Delay Reason Comment (Consultant Upgrade) X
Organisation Code (Provider Decision To Treat) X
Decision To Refer Date (Cancer Or Breast Symptoms) X
Specialist Skull Base Multidisciplinary Team Operational Policy34
3
Appendix 6 – Sheffield Skull Base MDT Pathway Design and Clinical Guidelines
11-1C-105k, 11-1C-106-k, 11-1C-107k, 11-1C-108k, 11-2K-233, 11-2K-234, 11-2K-235, 11-
2K-236
Slide 1
17/03/2011 Skull Base Patient Pathway
1
Sheffield Skull Base MDT Pathway Design &
Clinical Guidelines
Mr T Carroll
Lead Clinician
Specialist Skull Base Multidisciplinary Team Operational Policy35
3
Slide 2
17/03/2011 Skull Base Patient Pathway
1
Skull Base Service Structure
MDMManaged by Mr T Carroll, Clinical Lead, and Ms Caroline Allsop, Skull Base MDT Coordinator
Anterior Skull Base (TACAS/TAWAS) Clinic• Mr T Westin/Mr Showkat Mirza, Consultant ENT Surgeons• Mr T Carroll/Mr S Sinha, Consultant Neurosurgeons• Mr A Yousefpour, Consultant Maxillofacial surgeon
Lateral Skull Base (TACEN) Clinic• Mr T Carroll, Consultant Neurosurgeon• Mr M Yardley, Consultant ENT Surgeon
Ad hoc ‘Office’ Clinic(Urgent appointments)
H&N Cancer Clinic• Radiation oncologist• Mr T Westin/Mr L Durham, Consultant ENT Surgeon• Mr A Yousefpour, Consultant Maxillofacial Surgeon
Emergency Admission/Ward Review
Management to Protocol/Patient Choice
Management PlanManagement Plan
OR
Decided by:
Specialist Skull Base Multidisciplinary Team Operational Policy36
3
Slide 3
17/03/2011 Skull Base Patient Pathway
1
Cases to be discussed in Skull Base MDM
1. All patients having a known or potential malignant neoplasm involving the skull base on initial presentation.
2. All patients having a malignant neoplasm abutting the skull base for which planned resective surgery would involve skull base expertise for clearance.
3. All patients that have undergone surgery for benign tumours of the skull base (e.g., meningiomas, schwannomas) and for which histology and a baseline post-op scan available.
4. All patients that have undergone surgery for malignant tumours involving the skull base and for which histology is available.
5. All patients having disorders involving the skull base that do not fit to agreed management protocols, on completion of initial diagnostic work-up.
6. All patients undergoing interval imaging for which subsequent issues of concern do not fit to agreed management protocols.
7. Any other patients having disorders of the skull base as considered appropriate by individual Skull Base MDT members.
Specialist Skull Base Multidisciplinary Team Operational Policy37
3
Slide 4
17/03/2011 Skull Base Patient Pathway
1
Malignant Tumours of Skull Base: General
• All patients require CT skull base and contrast MR imaging to determine extent of involvement of skull base structures (in particular carotid artery involvement and brain invasion). Brain invasion in a histologically confirmed malignancy is a contraindication for skull base resection.
• All patients require biopsy (usually endoscopic) and histological confirmation by one of the skull base MDT pathologists prior to any treatment because of the potential spectrum of rare pathologies.
• Staging for systemic metastasis (usually neck imaging and CT thorax/abdomen/pelvis, also PSA blood test in males), in particular relevant to the malignancy (e.g., also bone scan for adenoid cystic carcinoma) is required before proceeding with surgery.
• Co-morbidity issues. Age and general health are important factors in considering the appropriateness in proceeding with skull base resection (e.g., may not be appropriate for patients older than 75 years).
• Tracheostomy if bilateral neck dissection, two stage procedure, lower cranial nerve loss, pre-existing respiratory disease, palatal resection.
• En bloc surgical specimen removal is the objective (unless specifically an endoscopic tumour resection of sphenoid/clivus).
• The surgical approach and extent of resection is pre-planned determined by individual patient pathologies and not to any individual patient-independent ‘recipe-book’ approach.
• Baseline post-op MR imaging is perfomed on all patients.
• Serial interval MR imaging as per Skull Base MDM discussion.• Specialist clinic follow-up is, in general, to be in Head & Neck Monday PM Cancer or ‘TAWAS’
Anterior Skull Base Clinics.
• Adjuvant radiotherapy is to be commenced at the earliest possible point from six weeks post-tumour resective surgery.
• Surgery-specific rehabilitatory aspects. A particular important aspect of follow-up is managing cosmetic and functional sequelae of skull base resective surgery (e.g., orbitofacial/ear/palatal prosthetics, abdominal incisional hernia repair).
• Specialist Nurse support is provided by the Head & Neck Cancer specialist nurse. Patients are also provided with skull base specific contact details including Mr Carroll’s secretary’s number and also Mr Carroll’s personal mobile phone number.
Specialist Skull Base Multidisciplinary Team Operational Policy38
3
Slide 5
17/03/2011 Skull Base Patient Pathway
1
Care Pathway: Anterior Skull Base Malignancy
†Surgery for cavernous sinus involvement only (1) if salvage surgery following good response to chemoradiotherapy and with disappearance of disease from cavernous sinus or (2) if neurotropic spread in a low grade malignancy (e.g., adenoid cystic carcinoma).
Disease involving:• Orbital apex• Pterygopalatine fossa• Foramen ovale• Cavernous sinus†‘‘Meckel’s Cave or Cavernous sinus exenteration’Meckel’s Cave or Cavernous sinus exenteration’(either from below or trans-cranial,(either from below or trans-cranial, internal carotid not resected)internal carotid not resected)
Disease involving infra-/superficial temporal fossaFossa ClearanceFossa Clearance
Disease involving ethmoids/nasopharyngeal roof/anterior sphenoid(e.g., ethmoidal squamous cell carcinoma)
Endoscope assisted anterior cranial fossa floor resectionEndoscope assisted anterior cranial fossa floor resection
• The appropriate skull base resection is combined with the head & neck surgical procedure relevant to the pathology, e.g., neck dissection, maxillectomy, parotidectomy. A neck dissection, if no free flap anastamosis, will generally be delayed until a second stage.
• A lumbar drain is used intra-operatively but not used post-operatively because of risk of ‘brain sag’ unless a B2-transferring positive CSF leak is demonstrated beyond 48hrs post-operatively.
• Cranial compartment closure (i.e., regional or free flap) is determined on an individual patient basis by size and location of defect, previous local radiotherapy, intact local vascular circulation, and age/general health of patient. Pedicled pericranium is always mobilised. Midline nasal roof defects are closed with pericranium/galea, sutured in place. Mobilised temporalis, e.g., if more extended skull base resection and orbital exenteration, is preferred to a rectus free flap unless, e.g., resection specimen includes infra-/superficial temporal fossae or maxillary artery.
Disease involving orbitOrbital exenterationOrbital exenteration
+/-
Specialist Skull Base Multidisciplinary Team Operational Policy39
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Slide 6
17/03/2011 Skull Base Patient Pathway
1
Lateral Skull Base Malignancy
• All temporal bone squamous cell carcinomas should be worked up for petrosectomy, irrespective of whether apparently initially confined to external auditory canal or extending beyond temporal bone to involve neck or internal carotid/jugular vessels (the only contraindications are systemic metastasis, brain invasion as manifested by high signal in brain on T2 MRI, patient age and general health issues).
• Defect reconstruction preference is for a rectus abdominis free flap, unless smaller defect suitable for mobilised temporalis. Note a pedicled pericranial flap is always mobilised.
• Surgery is generally in two stages:– Tues/Stage 1 …tracheostomy/parotidectomy/neck dissection– Thurs/Stage 2 …neuronavigation-assisted petrosectomy with
rectus free flap
• Extended lumbar CSF drainage and neck wound drainage to minimise CSFoma and seroma respectively.
• Facial palsy care issues. Subsequent eye lubricants, gold-weight insertion, and facial sling for obligate facial palsy.
• Radiotherapy unless free margins obtained in en bloc specimen.
• Titanium screw implants/ear prosthesis if required.
Specialist Skull Base Multidisciplinary Team Operational Policy40
4
Slide 7
17/03/2011 Skull Base Patient Pathway
1
Care Pathway: Acoustic Neuromas• Lateral Skull Base Clinic (TACEN). All patients are followed-up in a joint lateral skull base clinic,
that occurs alternate weeks, by Mr T Carroll, consultant neurosurgeon, and Mr M Yardley, consultant ENT surgeon, with on-site access to audiology and audiovestibular rehabilitation.
• Small acoustic neuromas. All patients with small acoustic neuromas, i.e., intracanalicular +/- CP-angle component ≤1.5cm, to be given choice of interval imaging (usually MRI), gamma knife radiosurgery, or open surgery. A specific information sheet is provided to the patient to facilitate patient choice. These patients are managed to protocol as per specific information sheet and are not routinely discussed in the skull base MDM.
• Medium acoustic neuromas. Treatment is recommended for all patients with an acoustic neuroma of size in the CP-angle between 1.5 and 3cm. Treatment choices are gamma knife radiosurgery or open surgery as per patient choice.
• Large/giant acoustic neuromas. All patients with acoustic neuroma tumours 3cm are more are in general considered for surgery rather than radiosurgery (occasional exceptions depend on patient age and general health).
• Specific other surgical indications. Surgery may be specifically recommended for patients with acoustic neuromas less than 3cm CP-angle diameter if refractive severe vertigo (specifically a trans-lab approach) or refractive severe trigeminal neuralgia. Surgery is not offered for the purposes of hearing preservation.
• Surgical approaches are either trans-lab or retromastoid and depend on individual patient/tumour anatomy.
• Facial nerve-associated tumour remnants. Although open surgery aims for a gross total resection, this is not to be at the expense of facial nerve function. In general, our preference is for a tumour remnant to be left on the facial nerve where the facial nerve is otherwise considered to be at risk. Such a facial nerve-related tumour remnant is followed with annual MR imaging and subject to gamma knife radiosurgery in the event of radiologic progression. Early radiosurgical treatment of the remnant may be indicated in specific clinical circumstances or on the basis of patient choice.
• Urgency. All patients listed for surgery with tumours ≥3cm CP-angle diameter, hydrocephalus/tonsillar descent, or refractive severe trigeminal neuralgia should be considered ‘urgent’. All patients, unless designated with a level of emergency to warrant direct admission or ad hoc office attendance, are seen in the next TACEN clinic following receipt of referral
• Imaging follow-up. All patients, irrespective of management choice, are subject to a minimum imaging monitoring period of ten years, but with the periods between interval imaging dependent on clinical circumstance. All patients undergoing surgery undergo a post-operative baseline MRI scan approximately three months following their surgery.
• Specific rehabilitation resources, dependent on patient choice and treatment outcome, are insertion of bone anchored hearing aid and facial reanimation (eyelid gold weight, static oral sling, cross-facial nerve graft).
• NF2 patients are managed as per National Commissioning Group recommendations, including in a local periodic multidisciplinary NF clinic.
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Slide 8
17/03/2011 Skull Base Patient Pathway
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Care Pathway: Skull Base Meningiomas/Incidental
Interval imaging(or patient choice re surgery/radiosurgery)
‘Incidental’/asymptomatic skull base meningiomas
Surgical Resection(with preservation of neurovascular structures)
• >3cm maximal diameter• Associated secondary brain oedema• Orbitosphenoid
Radiosurgery
Clival/petroclival <3cm maximal diameter
<3cm maximal diameter(other than orbitosphenoid & petroclival)
Radiological progression
Interval imaging
In general, patient choice re surgery/radiosurgery (occasional exceptions, e.g., radiosurgery for cavernous sinus meningiomas)
Radiosurgery to any growing remnant
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Slide 9
17/03/2011 Skull Base Patient Pathway
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Care Pathway: Skull Base Meningiomas/Symptomatic
Meningioma location†
Suprasellar (visual loss)Orbital roof osteotomyOrbital roof osteotomy or transcranial endoscopicor transcranial endoscopic
Anterior clinoidOrbito-zygomaticOrbito-zygomatic
Planum sphenoidaleSubfrontal osteotomySubfrontal osteotomy
Sphenoid wingFronto-temporalFronto-temporal
Clival/petroclivalStaged/combined approachesStaged/combined approaches
Venous/CP-angleRetromastoidRetromastoid
Tumour clearance not at expense of neurovascular structures
Interval imaging for tumour remnant progression or for tumour recurrence
Radiosurgery for recurrence or growing remnant
Radiosurgery to post-op tumour remnant if:• WHO grade 1 and residual tumour component can be demonstrated to have shown radiological progression• WHO grade 2• WHO grade 3
Radiotherapy if:• WHO grade 2, tumour remnant is demonstrated, and is not suitable for radiosurgery• WHO grade 3 irrespective of whether tumour remnant is demonstrated or not
Baseline post-op MRI scan at three months post-surgery
Skull base-specific rehabilitatory issues• Superficial temporal fossa fat injection• Paralytic squint (prisms, squint surgery)• Facial nerve (lubricants, eyelid gold weight, static oral sling, cross-facial nerve graft)• Lower cranial nerve (swallow assessment, tracheostomy, PEG, vocal cord injection)
OrbitosphenoidOrbital margin osteotomyOrbital margin osteotomy with lateral orbital wallwith lateral orbital wall reconstructionreconstruction
†Tumour locationSurgical approachSurgical approach
Slide 10
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17/03/2011 Skull Base Patient Pathway
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Care Pathway: Skull Base CSF Fistula
Β2 transferrin positive discharge
Encephalocoele demonstrated on imaging
History of meningitis or other intracranial sepsis
CT skull base/MRI
CT cisternogram if defect not clear
Trans-nasal endoscopic repair Trans-cranial repair
Ethmoids/cribriform plate/sphenoid/clivus Frontal sinus/petrous temporal bone
Defect location
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Slide 11
17/03/2011 Skull Base Patient Pathway
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Care Pathway: Chordoma & Chondrosarcoma
Skull base petroclival or clival bony-involving tumour
Blood prolactin level to exclude atypical prolactinoma
Consider biopsy if accessible through sphenoid sinus
Skull base endoscopic resection
Endoscopic-assisted with appropriate trans-cranial approach(depending on extent/location of intracranial disease)
Chondrosarcoma Chordoma
Remnant/recurrence Remnant/recurrence
Radiosurgery Radiosurgery +/- proton therapy
Baseline post-op MRI at two months followed by interval MR imaging
Or
Or
Skull base-specific rehabilitatory issues• Paralytic squint (prisms, squint surgery)• Facial nerve (lubricants, eyelid gold weight, static oral sling, cross-facial nerve graft)• Lower cranial nerve (swallow assessment, tracheostomy, PEG, vocal cord injection)
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Slide 12
17/03/2011 Skull Base Patient Pathway
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Additional General Principals of Care• Patient/Carer access to information. All patients are copied into clinic letters and discharge
summaries, with objective of any operation and associated risks clearly stated. Information sheets are provided where appropriate (e.g., Craniotomy Information Sheet, Large Acoustic Neuroma Information Sheet, Small Acoustic Neuroma Information Sheet).
• Communication of interval scan results. Patients can request to have interval imaging reports posted or emailed to them or their GP in advance of any clinician-dictated letter or clinic appointment detailing results. Their imaging results and the significance of their results are communicated in either a clinician-dictated letter if there are no specific concerns or at an early clinic appointment (next relevant specialist clinic appointment) if there are concerns.
• Option for non-clinic attendance during interval imaging follow-up. Where there is no specific concerns, patients are given the option of next interval scan without the requirement for clinic attendance.
• Contact points for patients undergoing skull base surgery. All skull base surgery patients to receive consultant neurosurgeon mobile phone contact prior to discharge. All skull base surgery patients to receive neurosurgery ward contact details prior to discharge. All skull base surgery patients will have also received appropriate specialist nurse contact details.
• Initial imaging work-up to generally include skull base CT and post-contrast MRI (+/- fat suppression). In particular, the specific question should be asked of any probable benign skull base pathology (e.g., meningioma, schwannoma), to what extent does the tumour extend outside the cranial compartment.
• Angiography and embolisation may be required pre-operatively for some skull base pathologies (juvenile angiofibromas, glomus tumours, some meningiomas).
• Specific neuroendocrine assessment should be performed for parasellar/sphenoid/clival tumours (prolactin, pituitary function) depending on clinical circumstances, e.g., post-op, and for all jugular foramen tumours presumed to be neuro-endocrine in origin, i.e., glomus (urinary cathecholamines).
• Surgical dissection to be avoided for benign tumours in cavernous sinus and jugular foramen. Radiosurgery is treatment of choice in these areas.
• Reconstruction of the CSF cranial compartment is done using vascularised tissue (e.g., pericranium, mucosa, temporalis, free flaps). Dural substitutes are not used.
• Craniofacial skeleton reconstruction may a consideration for some skull base operations. Stereolithographic model generation from volume CT scans with custom-made titanium prostheses by anaplastology may be required to surgically complete the craniofacial skeleton.
• Role of adjuvant radiotherapy is not clear for benign spectrum tumours of skull base.– MDT consensus is that radiotherapy is not to be used at all for WHO grade 1/benign
meningiomas.– MDT consensus is that radiotherapy is not to be routinely used in WHO grade 2/atypical
meningiomas. For grossly resected WHO grade 2/atypical meningiomas, radiosurgery only for any imaging-demonstrated local tumour recurrences. For subtotally resected WHO grade 2/atypical meningiomas, radiosurgery to tumour remnant, then radiosurgery to any further imaging-demonstrated local tumour recurrences (radiotherapy only if post-op remnant is unsuitable for radiosurgery).
– Radiotherapy may have a role in optic nerve sheath meningiomas and large glomus tumours not amenable to radiosurgery.
• Role of proton therapy is as per national guidance (see http://www.specialisedservices.nhs.uk/document/guidance-referral-patients-abroad-nhs-proton), i.e., for chordoma and paediatric rhabdomyosarcoma and Ewing’s sarcoma.
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Appendix 7 – Anonymised copies of patient permanent consultation records (measure 11-2K-224)
a) Cancer patient new patient letter
Sheffield Skull Base GroupDepartment of NeurosurgeryRoyal Hallamshire HospitalGlossop RoadSheffieldS10 2JFDirect line: 0114 2712192Fax: 0114 2268509E-Mail: [email protected]: www.sth.nhs.uk/neurosciences/neurosurgery
Anterior Skull Base Clinic
Mr T CarrollConsultant Neurosurgeon Mr T WestinConsultant ENT SurgeonMr S MirzaConsultant in Otorhinolaryngology-Head & Neck SurgeryMiss Z CurrieConsultant Ophthalmologist
Mr A FitzgeraldConsultant Plastic/Reconstructive SurgeonMr A YousefpourConsultant Maxillofacial SurgeonMr F JohnsonMaxillofacial Prosthetist
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b) Clinic follow up letter
Sheffield Skull Base GroupDepartment of NeurosurgeryRoyal Hallamshire HospitalGlossop RoadSheffieldS10 2JFDirect line: 0114 2712192Fax: 0114 2268509e-mail: [email protected]: www.sth.nhs.uk/neurosciences/neurosurgery
Lateral Skull Base/Acoustic Clinic
Mr T A CarrollConsultant Neurosurgeon and Lead Clinician in Neurosurgery
Mr M YardleyConsultant ENT Surgeon
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A ppendix 8 – Fax back to GP after MDT discussion (measure 11-2K-219)
FaxSheffield Skull Base MDT
Mr T Carroll – Consultant NeurosurgeonCaroline Allsop – Skull Base MDT Co-ordinator
Department of Neurological Surgery N Floor, Royal Hallamshire Hospital, Glossop Road,
Sheffield, S10 2JFWebsite: www.sheffieldneurosurgery.nhs.uk
Email: [email protected] /
To: Referrer From: Caroline AllsopSkull Base MDT Co-ordinatorNeurosurgeryRoyal Hallamshire Hospital
Fax: Fax: 0114 22 68795 Phone: Phone: 0114 27 12010
Date: No.of Pages:
3
Subject: SKULL BASE MDT DISCUSSIONRE: d.o.b. NHS No:
Please see attached the transcript following the Skull Base MDT meeting held on:
Many thanks
Caroline AllsopSkull Base MDT Co-ordinator
Please confirm receipt by faxing back to 0114 22 68795
Received by: ………………………………………………………………………..
Signed: ………………………………….. ……. Date: ………………….
Designation: …………………………………………………………………………
Organisation:………………………………………………………………………...
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