Skull Base (SB) Multidisciplinary Team Operational Policy Base MDT...1.2 Skull base disorders include meningiomas arising from the meninges over the base of skull, acoustic neuromas,

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


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


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.


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


http://www.sth.nhs.uk/neurosciences/neurosurgery/sheffield-skull-base-group

http://www.northtrentcancernetwork.nhs.uk/Network-Cancer-Services-Directory/sheffield%20directory%20of%20cancer%20services%20-%20july%202009.pdf



http://sthnet/STHcontDocs/STH_SCS/DirectoryOfCancerServices.doc

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.


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


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


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)


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.


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:



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.


mailto:[email protected]

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)’.


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)


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


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


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)




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.


http://www.nbtr.nhs.uk/

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.


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.


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.


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.


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


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


Appendix 1 Skull Base Patient Pathway (measures 11-2K-234, 11-2K-235, 11-2K-236)


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


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


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


X

LeafletSmall Vestibular Schwannoma Information Sheet

STHFT Skull Base MDT

By handBy post

At diagnosisKey Worker / Mr Carroll

X X

LeafletLarge Vestibular SchwannomaInformation Sheet


By handBy post


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


2

http://www.gammaknife.org.uk/




Specialist SB MDT Information Pathway – Information about the services offering psychological, social & spiritual/cultural support



How disseminated

Whendisseminated

By whomDisseminated

For Whom


Website www.macmillan.org.ukMacmillan Cancer Support

On an individual patient basis

Diagnosis & Treatment stage

Key WorkerX X

Generic Information – General Patient Advice



How disseminated

Whendisseminated

By whomDisseminated

For Whom


Business CardMr Thomas Carroll, Consultant Neurosurgeon, Contact DetailsPD 6044v1

STHFT By HandAt clinic appointment as required


X X

Websitewww.cancerhelp.cancerresearchuk.org

Cancer Research UK



Key WorkerX X

Website www.macmillan.org.uk Macmillan Cancer Support



Key WorkerX X


2

http://www.macmillan.org.uk/

http://www.cancerhelp.cancerresearchuk.org/

http://www.cancerhelp.cancerresearchuk.org/

Specialist SB MDT Information Pathway – Self help groups



How disseminated

Whendisseminated

By whomDisseminated

For Whom


Websitewww.brainandspine.org.uk

Brain and Spine Foundation

On craniotomy information PDF pamphlet


Key WorkerX X

Websitewww.braintumouruk.org.uk Brain Tumour UK



Key WorkerX X

Websitewww.mengintiomauk.org Meningioma UK



Key WorkerX X

Websitehttp://www.bana-uk.com/

British Acoustic Neuroma Association

In Lateral Skull Base Clinic


Key WorkerX X

Websitehttp://www.accoi.org

Adenoid Cystic Carcinoma Organization International



Key WorkerX X


3

http://www.accoi.org/

http://www.accoi.org/

http://www.bana-uk.com/

http://www.bana-uk.com/

http://www.mengintiomauk.org/

http://www.mengintiomauk.org/

http://www.braintumouruk.org.uk/

http://www.braintumouruk.org.uk/

http://www.brainandspine.org.uk/

http://www.brainandspine.org.uk/

Specialist SB MDT Information Pathway – Information specific to SB tumours about the disease & its treatment options



How disseminated

Whendisseminated

By whomDisseminated

For Whom


Website www.gammaknife.org.ukNational Centre for Radiosurgery, Sheffield

On referral to radiosurgery


Key Worker

X X

Pamphlet (PDF)

CraniotomyPD5339-PIL1722 v1Issue date: July 2009Review date: July 2011

STHFTBy hand By post

Treatment stage


X

LeafletSmall Vestibular Schwannoma Information Sheet


By handBy post


X X

LeafletLarge Vestibular SchwannomaInformation Sheet


By handBy post


X X


3

http://www.gammaknife.org.uk/

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


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


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


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


3

Slide 2


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:


3

Slide 3


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.


3

Slide 4


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.


3

Slide 5


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

+/-


3

Slide 6


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.


4

Slide 7


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.


4

Slide 8


1

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


4

Slide 9


1

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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1

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


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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


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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] /

[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:

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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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