SCC MDT Service Evaluation

1. SCC MDT Service Evaluation Dr Alistair Brown

2. Purpose • To assess whether all squamous cell carcinomas with one or more high risk features were discussed at MDT. • To evaluate consistency of MDT decisions. • To evaluate five year outcomes for patients discussed at MDT.

3. Method • All cutaneous SCCs reviewed by pathology at the Royal Devon and Exeter NHS FT identified by cancer services for the year of 2013. • Patient notes including MDT proforma reviewed on CDM and Medway • 5 years of followup assessed.

4. 459 patients, had 514 histologically confirmed SCCs in 2013 • 211 patients were discussed at MDT • Mean age 80 years • Clinical size was inconsistently recorded (32%) but correlated closely with histology size (15mm vs 16mm)

6. Immunosuppressed

7. High risk features • 274/514 had 1 or more high risk feature (further 35 curetted lesions w/o other feature) • 17 perineural/vascular invasion • Involved margins 40 (8%) cases & narrow (<1mm) in 71 (14%) cases. (Margins not recorded (either missing from report or curettings) in 46 cases) • 108 Size >20mm • 140 Thickness >4mm • 278 Differentiation/grade • 141 with high risk features not discussed at MDT (if curetted lesions inc n=11)

8. MDT decisions • 211 cases were discussed at MDT and outcomes were as follows: • 56 were deemed adequately treated • 63 recommended for observation • 54 for WLE • 7 for radiotherapy • 29 were offered varying combinations of the above. • Following MDT: • 58 had WLE • 10 patients were referred for adjuvant radiotherapy. • 11 patients not discussed at MDT had a WLE

9. Outcomes • 173 (38%) patients died of non-SCC related causes during the 5 year follow up period • 12 patients developed local recurrence of which 2 subsequently developed metastases. • Overall 9 (2%) patients developed metastatic SCC, of which 8 died (average 2.1 years following original diagnosis).

10. Metastasis • All high-risk at diagnosis, with average size of 28mm, 8mm thickness and 8/9 were moderately or poorly differentiated. 4 had been incompletely excised and 2 had narrow margin excisions. • 7/9 were discussed at MDT. • 2 not discussed (97yo, PD, 35mm & 78yo, PD, 20mm – both well excised, no further treatment) • 4 had WLE+/- adjuvant radiotherapy, 1 had palliative radiotherapy. and 4 had no further treatment. • 2 cases that metastasised had narrow margins but no further treatment (92yo, MD chest, 5mm thick, 22mm, deep 0.7 & 85yo, PD temple, 30mm, 6mm thick, deep 0.4 – MDT recommended WLE or RT)

11. Conclusion • In 2013 not all high risk SCCs were discussed at MDT, including 2 that subsequently metastasised (although this would probably not have influenced outcome) • Size of tumour and margins were not uniformly reported either clinically or histologically although when size was reported clinically it correlated well with histology. • Size, thickness, and narrowness of excision were all features of SCCs that metastasised, in addition to differentiation. • Immunosuppression was difficult to capture retrospectively but is likely to be another important factor. • Our evaluation supports WLE of any tumour narrowly or incompletely excised with any additional risk factor. • There was not enough data to inform use of radiotherapy.