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1. Fast Track Referrals Richard Sim
Consultant ENT Surgeon
2. Background Referral guidelines for suspected cancer published by the Department of Health in 2000.
NICE updated 2005
4. Timeline 2/52 Referral to appointment.
31/7 Referral to investigation.
62/7 Referral to treatment.
5. Problems Who is going to benefit:
Some patients clearly have cancer and early diagnosis is not going to change outcome.
Some 2/52 wait patients clearly do not have cancer.
Number (majority?) of patients with cancer do not come through fast track system.
Can be difficult to remove from fast track some patients will need multiple investigations.
6. Problems Knock on effect
To see patients without a waiting list the capacity must exceed mean demand by an amount proportional to the square root of the mean.
Thomas SJ, Williams MV, Burnet NG, Baker CR. How much surplus capacity is required to maintain low waiting times? Clin Oncol. 2001;13:2428.
7. Size of problem Incidence of head and neck cancer
7.7-15.3 / 100,000 / year.
ENT population 440,000 = 34-67 cancers.
Estimated 1 cancer for every 7.5 appointments.
Need 255 502 appointments to pick up these cases.
9. Whats important Age
(PMH / DH)
10. Whats important Does it all fit?
Unlikely to present with first quinsey in middle age.
Unlikely to present with branchial cyst for first time in middle age.
Supraclavicular lymph nodes are not normal.
11. Voice Change Voice Change Persistent Does it ever come back to normal
Need CXR prior to referral to exclude lung pathology (mobile patients with investigations in multiple centres).
12. Dysphagia Dysphagia Does food actually stick; Describe an episode; What types of food not pills / fruit skin.
13. Whats important Voice Change Persistent Does it ever come back to normal- Need CXR
Dysphagia Does food actually stick; Describe an episode; What types of food not pills / fruit skin.
Haemoptysis but often more appropriate to respiratory.
Weight Loss untoward / without effort.
14. Diagnostic Approach Adults - Full ENT examination including nasendoscopy, FNAC, imaging as appropriate clinical suspicion, anatomical site etc.
Children may have clear diagnosis eg branchial cyst but more commonly seen with lymphadenopathy.
Thyroids more didactic pathway.
15. Cervical Lymphadenopathy - Children Palpable lymphadenopathy is common 55% of children aged 6-12/12 and 41% of children aged 2-5 years.
16. Cervical Lymphadenopathy - Children Worrying Features
Palpable liver or spleen
Larger size and progressive (>3cm)
However - Majority of nodes will be benign
17. Cervical Lymphadenopathy - Children Investigation
Consider USS - most useful non-invasive?
Viral titres may help in 10% of cases
18. Cervical Lymphadenopathy - Children If investigations unhelpful and nodes persistent or enlarging - consider need for excision biopsy.
19. Thyroid lumps Common Palpable nodules in 5% of women and 1% of men worldwide.
Ultrasound can detect nodules in 19-67% of randomly selected individuals more common in women and the elderly.
How do we select for further investigation / treatment?
20. Thyroid lumps Differentiated Thyroid cancer 90%.
Incidence of papillary thyroid cancer increasing 49% of increase <1cm and 87% <2cm.
Due to increased detection and early diagnosis with USS?
21. Thyroid lumps Prognostic factors:
Family Hx, Radiation to neck, thyroiditis.
Age - <10 - >40.
Size >4cm / enlarging on serial scanning.
Vocal cord palsy.
Sex Male > Female.
Histology generally papillary better than follicular but roughly equal when other confounding effects removed.
Tumour extent / metastases.
22. Thyroid lumps BTA guidelines Patients with thyroid nodules who may be managed in primary care (IV, C):
Patients with a history of a nodule or goitre which has not changed for years and who have no other worrying features (ie adult patient, no history of neck irradiation, no family history of thyroid cancer, no palpable cervical lymphadenopathy).T
Patients with a non-palpable asymptomatic nodule <1 cm in diameter discovered coincidentally by imaging of the neck without other worrying features.
Patients who should be referred non-urgently (IV, C):
Patients with nodules who have abnormal thyroid function tests (TFTs). These patients should be referred to an endocrinologist; thyroid cancer is very rare in this group.
Patients with a history of sudden onset of pain in a thyroid lump (likely to have bled into a benign thyroid cyst).
Patients with a thyroid lump which is newly presenting or increasing in size over months.
Symptoms needing urgent referral (2-week rule)50 (IV, C):
Unexplained hoarseness or voice changes associated with a goitre.
Thyroid nodule in a child.
Cervical lymphadenopathy associated with a thyroid lump (usually deep cervical or supraclavicular region).
A rapidly enlarging painless thyroid mass over a period of weeks (a rare presentation of thyroid cancer and usually associated with anaplastic thyroid cancer or thyroid lymphoma).
Symptoms needing immediate (same day) referral (IV, C):
Stridor associated with a thyroid lump.
23. Thyroid lumps Investigations:
Ultrasound Scan (USS)
Fine needle aspiration cytology under USS guidance where appropriate.
24. Thyroid lumps ATA guidelines
25. Thyroid lumps FNA Results
Thy3 - Follicular lesion
Thy3a Atypia of undetermined significance
Thy3f Follicular neoplasm
Thy4 Suspicious for malignancy.
Thy5 Diagnostic for malignancy.
26. Thyroid lumps Thy1 Repeat USS guidance.
Thy2 Consider interval USS and repeat.
Thy3a MDT - Repeat biopsy / surgery
Thy3f MDT - Surgery
Thy4 MDT - Surgery
Thy5 MDT - Surgery
27. DCH Neck Lump Clinic Wednesday afternooon.
Consultant ENT, consultant radiologist, cytological assessment in clinic.
One stop service where possible allows reassurance for majority of patients and prompt treatment where necessary.
28. Summary Happy to see any neck lump in ENT.
Facial lesions (not eye lids)
Easier to upgrade to fast track than downgrade from fast track (particularly thyroid).
Neck lump clinic available with USS and cytology.