. Renal Cancer Pathway Network Meeting

Monday 4th November 2013 17.30pm – 18.30pm Hubworking, 5 Wormwood Street, London, EC2M 1RQ

Action

1. Apologies ( see Appendix 1)

2 Introduction and Agenda (Tom Powles, Chair)

Navin Ramachandaran , Lead Renal Cancer Radiologist, presented a set of papers on the Diagnostic Pathway for Renal Cancer following the previous meeting on 9th September to discuss this pathway. (Notes for that meeting can be viewed on the London Cancer website as minutes)

These included :

 Renal Cancer MDT referral

 Renal Cancer referral notes

 Renal Cancer MDT Imaging Outcomes

 Biopsy guidelines

3 Renal Cancer MDT referral

It was agreed that as most renal tumours are asymptomatic, these need to be assessed thoroughly via a Triple phase CT scan. The only time this should not take place was if the patient is too young (<40), they are pregnant or have a contrast allergy.

It was noted that a definition of renal failure was outstanding from the nephrologists. Action: GA to chase John Connolly and Robin Woolfson. GA

The route to the Renal Cancer MDT – this was discussed at the last meeting. It was noted that some local centres still want the referral to go via local MDT first in order to reduce the number of possible inappropriate referrals. The meeting was informed that all BCF referrals go directly to the SMDT at RFL. It was proposed that some pre-screening needs to take place to reduce the number of potential referrals to the SMDT.

TP commented that he had reviewed the patients seen at the last SMDT and 70% of the patients should not have been reviewed at that forum.

It was agreed that if an ultrasound abnormality is identified the MDT co-ordinator should request a CT scan locally and then add them to the SMDT list. Patients without a CT scan would not be discussed unless there was a very good reason. ‘Suspicious’ lesions have been defined in the pathway as a solid lesion or a cyst that are 2F or above, these are to be referred to the SMDT.

Benign lesions that are graded as Bosniak 1 or 2 or ‘column of Bertin’ do not require fol- low up. The Uroradiologist should review and record the comments to stop it going to the MDT.

It was suggested that the local centre Uroradiologist is a part of the SMDT as when they grade it locally they need to take part in the SMDT to explain the report.

It was agreed that patients who have suspicious renal mass (Bosniak 3 /4 or solid lesions) need to have a CT chest carried out ideally before the MDT clinic.

It was noted that a recent paper indicated that after following up Bosniak 2F and 3 cystic renal lesions over 3 years, none had metastases. It was discussed and agreed that to be- gin with all Bosniak 3 patients should have a CT chest and this would be reviewed at a later date.

There was discussion that cases would not be reviewed centrally without all relevant im- ages and reports in order to ensure that the SMDT could work effectively. There were concerns expressed that this would cause delays but it was deemed to be achievable and the MDT co-ordinator should ensure all information is received before the meeting.

A checklist is to be created for the MDT co-ordinators to ensure all the relevant informa- NR/TP tion is sent over with each case.

Renal Cancer MDT review – imaging outcomes

Following SMDT review the possible definitions and outcomes for the patient are:

 Tumour, Bosniak 3 or 4 : remove surgically or treat

 Bosniak 2F : referral to renal SMDT and enter follow up pathway of 5 year imaging plan with nurse led clinic telephone follow up. Any change in ima- ging ( at local centre) goes back to SMDT.

 Equivocal enhancement : ultrasound to determine if cystic, if not then MRI or contrast US if available.

NR to contact local centre radiologists to discuss local CT and MRI protocols. NR

Renal mass biopsy guidelines

A discussion was held around the need to biopsy for ablation procedures. NR commented that he had added in that there was a recommendation that the surveil- lance population should have a biopsy for the purposes of research, but believed that it was patients choice. He informed the meeting that there were new cytogenic panels that looked at the muta- tion to grade rather than looking via a microscope, and this could change the way they would be graded in the future. It was noted that there were no firm guidelines on anticoagulation so a plan would need to be developed each time.

It was noted that Histology have confirmed that they can support the pathway for biopsy and discussions have started with the Radiology team to cover the MDT.

6 AOB None

7. Date/Time and Venue of Next Meeting:

Monday 9th December 2013 17.30 – 18.30pm Hubworking, 5 Wormwood Street, London, EC2M 1RQ

Future meetings are as follows:

Thursday 7th January 5.30 – 6.30pm Monday 3rd February 5.30 – 6.30pm Thursday 6th March 5.30 – 6.30pm Monday 7th April 5.30 – 6.30pm

All at Hubworking, 5 Wormwood Street, London, EC2M 1RQ Appendix 1 Attendees 04/07/13 Name Initials Role Base David Cullen DC Lead Renal Nurse RFL Tom Powles TP Chair Network Pathway group, Barts Health Interim Clinical Lead Renal Cancer Consultant Oncologist Geraldine Alder GA Project Manager RCC RFL

Navin Ramachandran NR Interventional Oncology / Ablation UCLH Zaid Aldin ZA Consultant Radiologist PAH Rowland Illing RI Interventional Oncology / Ablation UCLH

Shelley Coombs SC CNS RFL

Apologies received Name Initials Role Base Faiz Mumtaz FM Consultant Surgeon / Interim Surgical BCF / RFL Lead, NC London Sue Lyons SL Divisional Operations Director,, RFL Transplant & Immunology services Frank Chinegwundoh FC Consultant Urologist Barts / Newham Angela Lee AL CNS BHRUT Guy Webster GW Consultant surgeon BCF / RFL Antony Goode AG Consultant radiologist RFL Barry Maraj BM Consultant surgeon Whittington Rateb Samman RS Consultant surgeon PAH Gillian Smith GS Consultant Surgeon & Service Line RFL Lead