Haematological Cancer Suspected (Adults & Children)

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1 Haematological Cancer Suspected (Adults & Children) Link to NICE guidelines: Patient of any age presents with symptoms of possible haematological cancer If 60 years of age with persistent bone pain, particularly back pain, or unexplained fracture Order FBC, blood tests for calcium and plasma viscosity or ESR Malignant spinal cord compression/acute kidney injury or hypercalcaemia = medical emergency If 60 years of age with hypercalcaemia/ anaemia/ leukopenia/ raised ESR Patient <25 years of age with unexplained petechiae Consider possibility of meningococcal sepsis or severe marrow suppression (leukaemia) Patient <25 years of age with unexplained hepatosplenomegaly Unexplained lymphadenopathy or splenomegaly < 25 years of age 25 years of age Very urgent FBC (WITHIN 48 HRS) Other symptoms consistent with haematological cancer/ leukaemia Also order blood tests for calcium and plasma viscosity or ESR Organise immediate paediatric/ medical assessment Call consultant IMMEDIATELY - URGENT referral within 48 hours Assess for associated symptoms and include in referral (regardless of symptoms) Review FBC within 48hrs Myeloma suspected 2WW suspected haematological cancer Acute Leukaemia not suspected - consider other causes including other cancers If blood testing not consistent with acute Leukaemia consider other causes including other cancers and if 60, myeloma Blood film or FBC suggest Acute Leukaemia If the blood film or FBC suggest Acute Leukaemia NICE recommends immediate referral: call consultant and complete 2WW form Offer protein electrophoresis and a Bence-Jones protein urine test (WITHIN 48 HOURS) Myeloma suspected 60 years of age possible myeloma 25 years of age and cancer not ruled out < 25 years of age and cancer not ruled out Emergency assessment: call paediatric or haematology consultant If results abnormal, 2WW referral for suspected haematological cancer Assess for associated symptoms and include in referral (regardless of symptoms) Call consultant IMMEDIATELY - URGENT referral within 48 hours 2WW suspected haematological cancer

2 If 60 years of age with persistent bone pain, particularly back pain, or unexplained fracture Multiple myeloma can present with a wide variety of symptoms including bone pain. Presenting features include: Bone pain, particularly backache Pathological fractures Spinal cord/nerve root compression Lethargy (due to anaemia) Anorexia. Dehydration (due to proximal tubule dysfunction from light-chain precipitation) Recurrent bacterial infection Bleeding and/or bruising Features suggesting amyloidosis (e.g., cardiac failure, nephrotic syndrome) Signs and symptoms of hypercalcaemia (e.g., thirst, constipation, nausea, confusion. Dizziness, confusion, blurred vision, headaches, epistaxis, cerebrovascular event - due to hyperviscosity If there are signs of spinal cord compression, the patient should be admitted to hospital immediately

3 If 60 years of age with hypercalcaemia/ anaemia/ leukopenia/ raised ESR Multiple myeloma can present with a wide variety of symptoms including hypercalcaemia, anaemia and renal impairment. Presenting features include: Signs and symptoms of hypercalcaemia (e.g., thirst, constipation, nausea, confusion) Lethargy (due to anaemia) Anorexia. Dehydration (due to proximal tubule dysfunction from light-chain precipitation) Recurrent bacterial infection Bleeding and/or bruising Features suggesting amyloidosis (e.g., cardiac failure, nephrotic syndrome) Dizziness, confusion, blurred vision, headaches, epistaxis, cerebrovascular event - due to hyperviscosity Bone pain, particularly backache Pathological fractures Spinal cord/nerve root compression Blood testing may be carried out for other reasons and show: Impaired renal function Anaemia: normochromic, normocytic Leukopenia Thrombocytopenia Hypercalcaemia Persistently raised plasma viscosity or erythrocyte sedimentation rate (ESR) If there are signs of acute kidney injury or hypercalcaemia, the patient should be admitted to hospital immediately. If a paraprotein is found on routine testing, the patient should be referred to an haematologist or oncologist. Multidisciplinary care should follow.

4 Patient <25 years of age with unexplained petechiae Meningitis should be ruled out in children and young people with unexplained petechiae. In addition unexplained petechia may indicate severe marrow suppression and are therefore medical emergencies. Therefore children and young adults < 25 years of age should have immediate specialist assessment.

5 Patient <25 years of age with unexplained hepatosplenomegaly NICE recommends that patients <25 years of age with unexplained petechiae or hepatosplenomegaly are referred urgently within 48 hours. GPs should phone specialist haematological or paediatric consultant to arrange urgent assessment.

6 Unexplained lymphadenopathy or splenomegaly NICE recommends that patients with unexplained lymphadenopathy or splenomegaly are considered for urgent referral for suspected cancer. When considering referral, take into account any associated symptoms, particularly: fever night sweats shortness of breath pruritus or weight loss alcohol-induced lymph node pain

7 Other symptoms consistent with haematological cancer/leukaemia NICE recommendations: Adults Consider a very urgent FBC (within 48 hours) to assess for leukaemia in adults with any of the following: pallor persistent fatigue unexplained fever unexplained persistent or recurrent infection generalised lymphadenopathy unexplained bruising unexplained bleeding unexplained petechiae hepatosplenomegaly NB: If < 25 with unexplained petechiae or hepatosplenomegaly, call consultant IMMEDIATELY for consideration of assessment within 48 hours. Children and young people Offer a very urgent FBC (within 48 hours) to assess for leukaemia in children and young people with any of the following: pallor persistent fatigue unexplained fever unexplained persistent infection generalised lymphadenopathy persistent or unexplained bone pain unexplained bruising unexplained bleeding.

8 60 years of age possible myeloma NB: if patient 60 consider myeloma. Blood results consistent with myeloma include: Anaemia: normochromic, normocytic Leukopenia Thrombocytopenia Hypercalcaemia Persistently raised plasma viscosity or erythrocyte sedimentation rate (ESR) Impaired renal function

9 Offer protein electrophoresis and a Bence-Jones protein urine test (WITHIN 48 HOURS) To assess for myeloma in people aged 60 with hypercalcaemia or leukopenia and a presentation that is consistent with possible myeloma. Consider very urgent protein electrophoresis and a Bence-Jones protein urine test (within 48 hours) to assess for myeloma if the plasma viscosity or erythrocyte sedimentation rate and presentation are consistent with possible myeloma.