Skin Cancer Clinical Advisory Group – Information for CAG Members

COVID-19 Management Plans
Skin Cancer Management Guidance in Response to COVID
Dermatology COVID 19 surgery procedures v3
http://www.bad.org.uk/shared/get-file.ashx?itemtype=document&id=6658

Skin Cancer CAG Key Documents:
These are living documents that will be continually reviewed and updated.
Please refer to the version control table to see the current status.
SWAG_Skin_Cancer_Clinical_Guidelines_2022 (review underway)
SWAG_Skin_Cancer_Constitution_2022
Management_of_Palpable_Node_in_ Skin_Cancer
Transplant_Skin__Clinic_Surveillance_Visit
Renal_Transplant_Baseline_Dermatology_Risk_ Assessment

Bristol Mohs Micrographic Surgery Service:
SWAG Bristol Mohs referral contact details v1.2
SWAG Bristol Mohs Guidelines text v1.2
SWAG Bristol BCC and Mohs Guidelines flowchart v1.2
Bristol_Mohs_Patient_Information_Leaflet v1.5

Update on Bristol and SWAG Mohs Micrographic Surgery service – March 2023

Dear Colleagues,

I am afraid the Mohs service will be coming under increasing pressure in the near future, but for happy reasons. I am delighted to be able to share the news that both my Mohs colleagues, Dr Kimberlee Lim and Dr Nina Natafji, will be taking maternity leave starting in the next few months.

Whilst obviously we will take steps to try to provide some cover, this will lead to a temporary reduction in capacity. The current waiting list for standard Mohs cases is around 6 months from review in the Mohs clinic (sooner for a minority of more urgent cases). I am concerned this may soon extend towards one year.

Some patients may lose the tissue sparing benefits of Mohs from an extended wait, and would be better served by standard excision sooner (see examples below, under ‘Also consider Mohs..’). In order to maintain the benefits of Mohs surgery for the most necessary cases, we must try to keep the wait under control. I’m afraid this will mean re-considering the current criteria you use in your MDTs, and your threshold for referral, for the time-being.

Yours faithfully,

Adam Bray

Dr Adam Bray MBChB FRCP(UK) Derm

Consultant Dermatologist

Dermatological & Mohs Surgeon

Southmead Hospital, North Bristol Trust

Bristol Dermatology Centre, University Hospitals Bristol & Weston NHS Foundation Trust

Strongest indications for Mohs:

Primary BCC threatening important anatomy (or position limits reconstruction options)
Poorly defined edges/infiltrative BCC in H zone of face

Any incompletely excised BCC in H zone of face
Any head/neck BCC incompletely excised more than once (including once by experienced skin cancer surgeon)
Re-excision with wide margins will be excessively disfiguring or force unsatisfactory reconstruction/delayed repair
Rarer aggressive infiltrating tumours in the H zone e.g. MAC

Also consider Mohs for:

Any BCC where delayed repair is considered

Well-defined primary nodular BCC on lower third of nose
Well-defined primary nodular BCC on lower eyelid but away from lacrimal punctum
Primary infiltrative BCC on face/scalp but away from H zone and well-defined edges

Other tumours

Many follicular/appendageal tumours can be treated with normal fresh frozen Mohs (if meeting the same sorts of indications as BCCs)

We do not currently treat DFSP with Mohs in Bristol (neither fresh frozen or paraffin fixed). However colleagues in other centres do (e.g. London -St John’s) so do consider it. Some colleagues have asked us to look into developing a Bristol service, so if you feel this may be useful please let me know, or if you refer elsewhere and are happy that would also be helpful to know)

We do not currently treat Lentigo Maligna with Mohs, but we can offer peripheral margin-controlled excision of Lentigo maligna (or LMM) with paraffin fixed tissue (similar to Mohs i.e. ‘spaghetti technique’) where tissue sparing or clearance is important and delayed repair is being considered.

Best email for advice: adam.bray@nbt.nhs.uk

Archived updates are available on request: helen.dunderdale@uhbw.nhs.uk

Useful Links:
The West of England Clinical Research Network
http://www.crn.nihr.ac.uk/west-of-england/

The Somerset Cancer Register (SCR)
http://nww.cancerreg.somersethis.nhs.uk/default.aspx

The National Cancer Research Institute Clinical Studies Group (NCRI) – Portfolio Maps
http://csg.ncri.org.uk/portfolio-maps/