SOUTH THAMES CHILDREN S CANCER NETWORK GROUP. REFERRAL PROTOCOLS AND DIAGNOSIS AND STAGING PROTOCOLS October 2014

Transcription

1 SOUTH THAMES CHILDREN S CANCER NETWORK GROUP REFERRAL PROTOCOLS AND DIAGNOSIS AND STAGING PROTOCOLS October 2014

2 Contents 1. Leukaemia Referral, Diagnostic and Staging Guidelines 2. Lymphoma Referral, Diagnostic and Staging Guidelines 3. Carcinoma and Melanoma Referral, Diagnostic and Staging Guidelines 4. Germ Cell and Gonadal Tumour Referral, Diagnostic and Staging Guidelines 5. Embryonal Tumours Referral, Diagnostic and Staging Guidelines 6. Bone Rumour Referral, Diagnostic and Staging Guidelines 7. Brain and CNS Referral, Diagnostic and Staging Guidelines 8. Late Effects Referral Guidelines

3 Suspected Leukaemia pathway (0 to 15 years and 364 days) A&E /other Trust Hospital- Paediatric Unit DIAGNOSIS/ SUSPICION OF LEUKAEMIA Clinical assessment Assess possibility of mediastinal mass, risk of tumour lysis, sepsis and coagulopathy Routine bloods: FBC, blood film, U&Es, Ca, PO4, LFTs, urate, LDH, coagulation screen, Gp&S Imaging: Chest X-ray. Do not do CT if mediastinal mass without prior discussion with RMH. Not required if FBC/Blood film abnormal. Do not sedate if any suspicion of mediastinal mass. After appropriate stabilisation contact Paediatric Oncology Registrar on call at RMH via hospital switchboard. Commence iv fluids and allopurinol prior to transfer. Transfuse as required. Consultant paediatrician on call to discuss possible diagnosis with family If patient unstable discuss with South Thames Retrieval Service Transfer to GOSH Patient 1yr Transfer to RMH Prepare & send appropriate transfer letters/ forms including copy of all investigation results (Imaging to be linked via IEP) Patient acutely unwell, WBC >100x10 9 /l + symptomatic (CNS signs, 02 requirement/active bleeding) or mediastinal mass Discuss with PICU. Transfer SGH Fax RMH leukaemia CNS to inform of Following transfer Diagnostic investigations: Bone marrow, trephine ± Lumbar puncture. Send peripheral blood immunophenotyping if blasts on blood film. Once confirmed, diagnosis, treatment plan and appropriate clinical trial to be discussed with family. Consultant letter to POSCU lead, GP & CCN team RMH Paediatric Leukaemia MDT meeting (weekly Wed) Review all new patient bone marrow morphology, immunophenotyping & cytogenetics. Management planned. Confirm trial registration. MDM proforma will be faxed to GP, Referrer, POSCU lead followed by letter

4 Suspected Lymphoma pathway (0 to 15 years and 364 days) A&E or other Trust Hospital- Paediatric Unit DIAGNOSIS/ SUSPICION OF LYMPHOMA Clinical assessment Routine bloods, Ultrasound, MRI and CT After appropriate stabilisation contact Paediatric Oncology Registrar on call at RMH via hospital switchboard. Consultant Paediatrician to discuss possible diagnosis with family. If patient unstable may require discussion with South Thames Retrieval Service Refer to GOSH Patient 1yr Refer to RMH Prepare & send appropriate transfer letters/ forms including copy of all investigation results ( Imaging to be linked via IEP) Patient acutely unwell or mediastinal mass. This is a medical emergency See Algorithm Transfer to SGH. Discuss with PICU prior to transfer Following transfer Fax RMH Shared Care Sister to inform of Complete staging investigations and confirm diagnosis. CT, PET Scan, MRI, Lumbar Puncture, Bone Marrow. Once confirmed, diagnosis, treatment plan and appropriate clinical trial to be discussed with family. Consultant letter to POSCU lead, GP & CCN team RMH Paediatric Tumour Board MDT meeting (weekly Thurs) Review all new patient imaging, and histology. Management planned. Confirm trial registration. MDM proforma will be faxed to GP, Referrer, POSCU lead followed by letter

5 Suspected Carcinoma and Melanoma pathway (0 to 15 years and 364 days) A&E or other Hospital- Paediatric Unit DIAGNOSIS/ SUSPICION OF CARCINOMA OR MELANOMA Clinical assessment Routine bloods, MRI and CT. Melanoma skin biopsy After appropriate stabilisation contact Paediatric Oncology Registrar on call at RMH via hospital switchboard. Consultant Paediatrician to discuss possible diagnosis with family. If patient unstable may require discussion with South Thames Retrieval Service Refer to GOSH Patient 1yr Refer to RMH Prepare & send appropriate transfer letters/ forms including copy of all investigation results (CD-ROM of imaging or image link via IEP) Patient acutely unwell Transfer to SGH. Discuss with RMH / PICU prior to transfer Following transfer Complete staging investigations and confirm diagnosis. Chest x-ray, restaging CT and MRI. Fax RMH Shared Care Sister to inform of Once confirmed, diagnosis, treatment plan and appropriate clinical trial to be discussed with family. Consultant letter to POSCU lead, GP & CCN team RMH MDT Discussion Review all new patient imaging, and histology. Management planned. Confirm trial registration. MDT proforma will be faxed to GP, Referrer, POSCU lead followed by letter

6 Suspected Germ Cell and Gonadal Tumours pathway (0 to 15 years and 364 days) A&E or other Trust Hospital- Paediatric Unit DIAGNOSIS/ SUSPICION OF GERM CELL OR GONADAL TUMOUR Clinical assessment Routine bloods, Ultrasound, MRI and CT After appropriate stabilisation contact Paediatric Oncology Registrar on call at RMH via hospital switchboard. Consultant Paediatrician to discuss possible diagnosis with family. If patient unstable may require discussion with South Thames Retrieval Service! Refer to GOSH Patient 1yr Refer to RMH Prepare & send appropriate transfer letters/ forms including copy of all investigation results (Imaging to be linked via IEP) Patient acutely unwell Transfer to SGH. Discuss with rmh / PICU prior to transfer Following transfer Complete staging investigation, tumour markers and confirm diagnosis. CT, MRI Fax RMH Shared Care Sister to inform of Once confirmed, diagnosis, treatment plan and appropriate clinical trial to be discussed with family. Consultant letter to POSCU lead, GP & CCN team RMH MDT meeting Review all new patient imaging, and histology. Management planned. Confirm trial registration. MDM proforma will be faxed to GP, Referrer, POSCU lead followed by letter

7 Suspected extra-cranial embryonal tumour pathway (0 to 15 years and 364 days) A&E / other Trust Hospital- Paediatric Unit DIAGNOSIS/ SUSPICION OF tumour (neuroblastoma, hepatoblastoma, Wilms tumour, germ cell tumours, rhabdomyosarcoma) Clinical assessment Routine bloods: FBC, U&Es, tumour Markers: AFP, B-HCG (for suspected germ cell tumours, liver tumours) urine for catecholamines for suspected neuroblastoma Imaging: Chest X-ray, CT/ MRI Contact Paediatric Oncology Registrar on call at RMH via hospital switchboard (Cordless 1450). Consultant paediatrician on call to discuss possible diagnosis with family If patient unstable discuss with South Thames Retrieval Service Refer to GOSH Patient 1yr Refer to RMH/SGH after discussion with RMH team Prepare & send appropriate transfer letters/ forms including copy of all investigation results Patient acutely unwell Transfer to SGH. Discuss with PICU prior to transfer Following transfer Fax RMH Shared Care Sister to inform of Diagnostic investigations: Biopsies at SGH for all tumours except liver tumours (King s college) Bilateral Bone marrow aspirates and trephine (suspected neuroblastoma, rhabdomyosarcoma) Central venous access Further staging investigations on confirmation of diagnosis RMH Solid Tumour MDT meeting (weekly Thu) Review all new patient imaging, histology and staging investigations. Plan management. Offer clinical trial if appropriate. MDM proforma will be faxed to GP, Referrer, POSCU lead and followed by letter

8 Suspected bone tumour pathway (0 to 24 years) A&E / other Trust Hospital- Paediatric / Adult Unit DIAGNOSIS / SUSPICION OF bone tumour Contact made with London Sarcoma Service (Royal National Orthopaedic Hospital). Tertiary s form sent to MDT co-ordinator. RNOH to request diagnostic tests required. Abnormal Breaking news. Consultant discuss with family Normal Communication from hospital to referrer. FUP regime is communicated if required Refer to GOSH Refer to Diagnostic Centre (Royal National Orthopaedic Hospital). Patient referred directly to RNOH. Trust transfer forms (if referred from Trust hospital). Send full letter and copy of notes. If imaging has been carried out, send imaging including plain films before transfer of patient. If biopsy has been performed, send pathology slides and blocks for review before transfer. Pre diagnostic Sarcoma MDT discussion (UCLH / RNOH). Sarcoma MDT held weekly, Friday morning. No joint MDT discussion with POSCU / referring Trust hospital. MDT report sent to the referring clinician at the Trust hospital and GP after MDT discussion. Arrival at diagnostic centre (Royal National Orthopaedic Hospital). DIAGNOSIS. Diagnostic investigations CT / MRI / US/ biopsy. Allocate key worker. Initial treatment inpatient clinical guidelines.

9 Suspected Brain or spinal cord tumour pathway (0 to 15 years and 364 days) A&E / other Trust Hospital- Paediatric Unit DIAGNOSIS/ SUSPICION OF BRAIN OR SPINAL CORD TUMOUR Clinical assessment (ABC plus neurology) Assess possibility of raised intracranial pressure (ICP) & G.C.S. Routine bloods: FBC, U&Es, Glucose, Coagulation Neuro-imaging: do not sedate patient if any concerns over raised ICP (An awake CT + contrast will demonstrate hydrocephalus/ most mass lesions if not possible to perform urgent awake MRI- if in doubt ask paediatric neurosurgery unit first) After appropriate stabilisation early discussion with regional paediatric neurosurgical unit via on-call neurosurgical registrar (switchboard- SGH/ Kings) for further advice/. If unstable may require discussion with South Thames Retrieval Service and/or time critical neurotransfer If possible ImageLink neuro-imaging via IEP. Exclusion of Brain/ spinal cord tumour! Arrange appropriate local follow up and communication. Confirmation (suspicion remains) of Brain/ spinal cord tumour! Consultant to discuss with patient/ family (Also inform local POSCU lead) Fax RMH Shared care coordinator to inform of Transfer to Regional Paediatric Neurosurgical Unit Mode of transfer will be based on patient s stability after discussion with neurosurgery and South Thames Retrieval Team if appropriate. Prepare & send appropriate transfer letters/ forms including copy of all investigation results (Image link via IEP) South Thames Paediatric Neuro-oncology MDM (weekly Friday) All new patients are discussed and management planned ( investigations and treatment may take place prior to MDM) MDM proforma will be sent to GP, Referrer, POSCU lead followed by letter

10 Long term follow-up clinic pathway RMH oncology-fu clinic Other sec/ tertiary centres A&E / other. Send treatment summary with details of chemotherapy, radiotherapy, surgery and adverse events during treatment. Note post bone marrow transplant patients need to be transferred 1 yr from end of treatment. Brain tumour patients may need earlier input by endocrinologist. All others are referred 5 years after end of treatment. Triage to Levels 1-3 Appropriate long term follow-up clinic Formulate care plan for follow-up. Brain Tumour - BTclinic seen by multi disciplinary team (MDT) Post Bone marrow transplant BMT follow up clinic seen by MDT All other patients seen in oncology late effects FU clinic & by MDT as required Brighton level 1-2 patients followed at late effects clinic at Brighton All patients are discussed at the once a month MDT meeting (2 nd Tues of the month) at the time of transfer to the oncology follow up clinic and again at transfer to adult clinic/ or transfer to Brighton. Prior to transfer to adult clinic a planned transition should take place over a number of years during which the patient is informed of his/her diagnosis, side effects and follow-up. A written summary and care plan should also be given to patient and adult follow up physician When patient is 18 years of age and has been off treatment for 5 years or more they should be transferred to the young adult clinic with a detailed follow-up care plan. Brighton patients should be transferred to the adult clinic at Brighton.