PATHWAY FOR INVESTIGATION OF ADULTS PRESENTING WITH ASCITES U/S Abdo/pelvis shows ascites without obvious evidence of 1 liver disease Refer back to original requester with this paperwork and review previous imaging Comprehensive history and examination and appropriate blood tests (Appendix 1) Including performance status (Appendix 2) (If status 3 or 4 consider direct oncology referral or palliative care for symptom control) Primary site suspected Refer to appropriate Rapid Access clinic Primary site unknown (GP to request) CT chest/abdomen/pelvis FEMALES MALES No primary identified No primary identified Refer Gynae MDT Refer Colo-Rectal MDT Primary identified Refer to appropriate MDT 1 MUO/CUP Presenting symptoms Pathways 2017_DP
Appendix 1 COMPREHENSIVE HISTORY AND EXAMINATION OF PATIENT PRESENTING WITH ASCITES, INCLUDING: Family history of ovarian or breast cancer Change in bowel habit Rectal examination abnormal Breast examination abnormal Symptoms/signs of lung cancer (including haemoptysis) Dyspeptic symptoms or epigastric pain suggestive of upper GI cancer Haematuria Testicular examination abnormal Thyroid examination abnormal Enlarged lymph nodes If the answer to any of the above is yes the patient should be referred to the appropriate Multidisciplinary Team using a 2-week wait form. Blood tests prior to referral FBC Full biochemistry CEA CA125 (women only) Appendix 2 0 Normal activity 1 Strenuous activity restricted, can do light work 2 Up and about > 50% of waking hours. Capable of self care 3 Confined to bed > 50% of waking hours. Limited self care 4 Confined to bed or chair. No self care. Completely disabled 2 MUO/CUP Presenting symptoms Pathways 2017_DP
PATHWAY FOR INVESTIGATION OF ADULTS PRESENTING WITH RADIOLOGICAL SUSPICION OF A BONE TUMOUR X-ray (or other imaging), shows a suspicious bony lesion Refer back to original requester with letter and this paperwork and review previous imaging Comprehensive history and examination (Appendix 1) Including performance status (Appendix 2) (3 or 4 consider direct oncology referral or palliative care for symptom control) Appropriate blood tests (Appendix 1) Primary site suspected Refer to appropriate Rapid Access clinic Primary site unknown (GP to request) CT chest/abdomen/pelvis Lung metastases on CT Liver metastases on CT Refer Chest MDT Refer Colo-Rectal MDT No primary site identified, no lung or liver mets and no additional bone secondaries (GP to request) Bone scan Multiple lesions Solitary lesion Female Male Refer Mr Sjolin Mr Nicolai or Breast MDT Mr Wood or Urology MDT 3 MUO/CUP Presenting symptoms Pathways 2017_DP
Appendix 1 COMPREHENSIVE HISTORY AND EXAMINATION OF PATIENT PRESENTING WITH SUSPICION OF A BONE TUMOUR, INCLUDING: Change in bowel habit Rectal examination abnormal Breast examination abnormal Symptoms/signs of lung cancer (including haemoptysis) Dyspeptic symptoms or epigastric pain suggestive of upper GI cancer Haematuria Testicular examination abnormal Thyroid examination abnormal Enlarged lymph nodes If the answer to any of the above is yes the patient should be referred to the appropriate Multidisciplinary Team using a 2-week wait form. Blood tests prior to referral FBC EC LFTs Calcium PSA in men (if > 10 refer to Urology Team) Immunoglobulins Appendix 2 0 Normal activity 1 Strenuous activity restricted, can do light work 2 Up and about > 50% of waking hours. Capable of self care 3 Confined to bed > 50% of waking hours. Limited self care 4 Confined to bed or chair. No self care. Completely disabled 4 MUO/CUP Presenting symptoms Pathways 2017_DP
INVESTIGATION PATHWAY FOR PATIENTS PRESENTING WITH BRAIN SECONDARIES, UNKNOWN PRIMARY SITE CT shows probable brain metastases Refer back to original requester with this paperwork and review previous imaging Assess performance status 3 or 4 Refer to GP & Consider palliative care/ counselling (appendix 1) (appendix 2) 0, 1 or 2 Exceptional circumstances Abnormal Careful history and examination Specialist referral and further investigations as appropriate via Rapid Access route Normal No pointers to primary site CT chest/abdomen/pelvis Primary site identified No primary site identified Discuss at appropriate MDT +/ tissue biopsy Refer to oncologist 5 MUO/CUP Presenting symptoms Pathways 2017_DP
INVESTIGATION PATHWAY FOR PATIENTS PRESENTING WITH HEPATIC SECONDARIES, UNKNOWN PRIMARY Ultrasound shows hepatic secondaries CXR whilst patient in dept Normal CXR or lung secondaries Probable lung primary Refer back to original requester Refer chest physicians CACXR 3 or 4 1. Confirm performance status [Refer back to GP]; consider palliative care if symptoms indicate need or consider counselling 0, 1, 2 Exceptional circumstances Abnormal 2. And retake history and examination Refer via Rapid Access to appropriate Clinical Team (Appendix 3) Normal No pointers to primary site GP to request CT (and confirm normal U&E, FBC) CT confirms colorectal Ca CABE CT shows no evidence of colorectal Ca 6 MUO/CUP Presenting symptoms Pathways 2017_DP
Review colorectal MDT Review C-R MDT Image guided liver Bx under Enema/ care of colorectal surgeons Colonoscopy) (Ba Histology directs oncologist/mdt referral 7 MUO/CUP Presenting symptoms Pathways 2017_DP
INVESTIGATION PATHWAY FOR PATIENTS PRESENTING WITH LUNG SECONDARIES, UNKNOWN PRIMARY SITE CXR or CT shows probable lung metastases Refer back to original requester with this paperwork and review previous imaging Assess performance status 3 or 4 Refer to GP & consider palliative care/counselling circumstances Exceptional (appendix 1) 0, 1 or 2 Abnormal Careful history and examination (appendix 2) Specialist referral and further investigations as appropriate Normal No pointers to primary site Review at Lung MDT CT scan thorax/abdomen/pelvis Tumour markers Histological sampling as appropriate 8 MUO/CUP Presenting symptoms Pathways 2017_DP
Appendix 1 COMPREHENSIVE HISTORY AND EXAMINATION OF PATIENT PRESENTING WITH PULMONARY METASTASES, INCLUDING : Head and neck examination for obvious primary including thyroid or lymphadenopathy. Haematuria/palpable renal mass Symptoms/signs of primary lung carcinoma (including haemoptysis) Skin inspection for melanoma or other skin cancer Signs/symptoms of bone/soft tissue sarcoma Breast examination Testes Signs and symptoms of other primary site, eg : Colorectal Upper GI Prostate Ovary Pancreas Will usually spread to other sites, especially liver and peritoneum before lung If the answer to any of the above is yes the patient should be referred to the appropriate team using a two-week wait form. Appendix 2 0 Normal activity 1 Strenuous activity restricted, can do light work 2 Up and about > 50% of waking hours. Capable of self care 3 Confined to bed > 50% of waking hours. Limited self care 4 Confined to bed or chair. No self care. Completely disabled 9 MUO/CUP Presenting symptoms Pathways 2017_DP
INVESTIGATION PATHWAY FOR PATIENTS PRESENTING WITH A SOLITARY BRAIN TUMOUR? SOLITARY SECONDARY CT shows solitary brain tumour Refer back to original requester with this paperwork and review previous imaging Assess performance status 3 or 4 Refer to GP & consider palliative care/ counselling (appendix 1) 0, 1 or 2 Careful history and examination (appendix 2) Exceptional circumstances Abnormal Specialist referral and further investigations as appropriate via Rapid Access route Normal No pointers to possible primary site Probable primary identified CT chest/abdomen/pelvis MRI brain Normal Refer Neuro-Oncology MDT or d/w Addenbrooke s CNS 10 MUO/CUP Presenting symptoms Pathways 2017_DP
PATHWAY FOR INVESTIGATION OF ADULTS PRESENTING WITH A SYMPTOMATIC MALIGNANT PLEURAL EFFUSION Pathological confirmation of malignant pleural effusion Comprehensive history and examination and appropriate blood tests (Appendix 1) Including performance status (Appendix 2) (If status 3 or 4 consider direct oncology referral or palliative care for symptom control) CXR suggestive of lung primary Refer to chest MDT Other primary site suspected (Clinically or on immunohistochemistry) Refer to appropriate Rapid Access clinic /team Primary site unknown CT chest/abdomen/pelvis FEMALES MALES No primary identified No primary identified Refer Breast MDT Refer Chest MDT Primary identified Refer to appropriate MDT 11 MUO/CUP Presenting symptoms Pathways 2017_DP
Appendix 1 COMPREHENSIVE HISTORY AND EXAMINATION OF PATIENT PRESENTING WITH PLEURAL EFFUSUION, INCLUDING: Symptoms/signs of primary lung carcinoma (including haemoptysis) Asbestos exposure (Mesothelioma/lung cancer) Dyspeptic symptoms or epigastric pain suggestive of upper GI cancer Skin inspection for melanoma or other skin cancer Breast examination Enlarged lymph nodes Testes Signs and symptoms of other primary site, eg: Lower GI Prostate Ovary Will usually spread to other sites, especially liver and peritoneum before pleura If the answer to any of the above is yes the patient should be referred to the appropriate team using a two-week wait form. Blood tests prior to referral: FBC Full biochemistry AFP & βhcg (men only) Appendix 2 0 Normal activity 1 Strenuous activity restricted, can do light work 2 Up and about > 50% of waking hours. Capable of self care 3 Confined to bed > 50% of waking hours. Limited self care 4 Confined to bed or chair. No self care. Completely disabled 12 MUO/CUP Presenting symptoms Pathways 2017_DP
PATHWAY FOR INVESTIGATION OF ADULTS PRESENTING WITH A SYMPTOMATIC MALIGNANT PERICARDIAL EFFUSION Pericardial effusion confirmed on echocardiogram (effusion managed appropriately by cardiology) Comprehensive history and examination and appropriate blood tests (Appendix 1) Including performance status (Appendix 2) (If status 3 or 4 consider direct oncology referral or palliative care for symptom control) CXR suggestive of lung primary Refer to chest MDT Other primary site suspected Refer to appropriate Rapid Access clinic /team Primary site unknown CT chest/abdomen/pelvis FEMALES MALES No primary identified No primary identified Refer Breast MDT Refer Chest MDT Primary identified Refer to appropriate MDT 13 MUO/CUP Presenting symptoms Pathways 2017_DP
Appendix 1 COMPREHENSIVE HISTORY AND EXAMINATION OF PATIENT PRESENTING WITH PERICARDIAL EFFUSUION, INCLUDING: Symptoms/signs of primary lung carcinoma (including haemoptysis) Asbestos exposure (Mesothelioma/lung cancer) Dyspeptic symptoms or epigastric pain suggestive of upper GI cancer Skin inspection for melanoma or other skin cancer Breast examination Enlarged lymph nodes Testes Signs and symptoms of other primary site, eg : Colorectal Prostate Ovary Will usually spread to other sites, especially liver and peritoneum before pericardium If the answer to any of the above is yes the patient should be referred to the appropriate team using a two-week wait form. Blood tests prior to referral: FBC Full biochemistry AFP & βhcg (men only) Appendix 2 0 Normal activity 1 Strenuous activity restricted, can do light work 2 Up and about > 50% of waking hours. Capable of self care 3 Confined to bed > 50% of waking hours. Limited self care 4 Confined to bed or chair. No self care. Completely disabled 14 MUO/CUP Presenting symptoms Pathways 2017_DP