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EM Head and Neck and Thyroid Clinical Guidelines – for review – v1 09.05.16 1

East Midlands Head, Neck and Thyroid Expert Clinical Advisory Group (ECAG)

Guidelines for the Investigation and Treatment of Head, Neck & Thyroid Cancer

Version 2.0


Reviewed by: Ratified by: Endorsed by:

Distributed to: Head, Neck & Thyroid ECAG members

Trust Lead Cancer Clinicians Cancer Centre Managers

Version History:

Date: Version: Review:


TABLE OF CONTENTS PAGE

1. Summary of Operational Arrangements

4

2. Primary Care Referral Arrangements 2.1 Head and Neck Referral Arrangements 2.2 Thyroid Referral Arrangements 2.3 Distribution Process for Primary Care Referral Guidelines

6

6

8

9

3 Referral Guidelines Between Teams 3.1 Network wide Upper Aero-digestive Tract (UAT) Referral Proforma

for Routine Referrals 3.2 Internal Referral Guidelines for Non-Designated Hospital

Clinicians 3.3 Distribution Process for Internal Referral Guidelines 3.4 Designated Hospitals Receiving Referrals of Patients with Thyroid

Lumps 3.5 Referral Guidelines Between Teams

11

11

11

12

13

15

Head and Neck Specific Clinical Guidelines

- Neck - Oral Cavity and Lip Cancer - Oropharyns - Nasopharynx - Laryngeal - Hypopharynx - Noses and sinuses - Ear and Temporal Bone - Salivary Gland - General Principles for Radiotherapy and Chemotherapy

18

Thyroid Cancer Specific Clinical Guidelines

64

Appendix D1 Primary Care Referral Guidelines Schema

71

Appendix D2 Network-wide UAT Referral Pro forma for Routine Referrals

76


1. SUMMARY OF OPERATIONAL ARRANGEMENTS

Head and Neck Cancer is the eighth most common cancer in men and sixteenth in women with several types and sites of cancer, many of which are rare with treatment being complex and difficult for patients. Hence, many disciplines are involved. Skilled assessment, care and rehabilitation are crucial to quality of life outcomes and require good sustained organisation. Robust clinical guidelines are put in place to ensure this happens. The British Association of Endocrine and Thyroid Surgeons (BAETS) is the representative body of British Surgeons who have a specialist interest in surgery of the endocrine glands (thyroid, parathyroid and adrenal). The BAETS is recognised by the Department of Health, the Association of Surgeons of Great Britain and Ireland (ASGBI) and the British Association of Surgical Oncology (BASO) (www.baets.org.uk). The arrangements for diagnosis and treatment of Head and Neck Cancer and Thyroid Cancer are governed by the NICE Improving Outcomes Guidelines published in November 2009. The key principles from this document as followed by the East Midlands Cancer Clinical Network (EM CCN) and Head and Neck Multi-disciplinary Team (MDT) are:

Services for patients with head and neck cancers and again should be commissioned at the EM CCN level. Assessment and treatment services should become increasingly concentrated in Cancer Centres serving populations of over a million patients.

Multi-disciplinary teams with a wide range of specialists will be central to the service, each managing at least 100 new cases of Upper Aero-digestive Tract Cancer per annum. They will be responsible for assessment, treatment, planning and management of every patient. Specialised teams will deal with patients with Thyroid Cancer, and with those with rare or particularly challenging conditions such as salivary glands and skull base tumours.

Arrangements for referral at each stage of the patient’s cancer journey should be streamlined. Diagnostic clinics should be established for patients with neck lumps.

Clinical nurse specialists, speech and language therapists, dieticians and restorative dentists play crucial roles but a variety of other therapists are also required, from the pre-treatment assessment period until rehabilitation is complete.

Co-ordinated local support teams should be established to provide long term support and rehabilitation for patients in the community. These teams will work closely with every level of the service, from primary care teams to the specialist MDT.

MDTs should take responsibility for ensuring that accurate and complete data on disease stage, management and outcomes are recorded. Information collection and audit are crucial to improving services and must be adequately supported.

http://www.baets.org.uk/


Research into the effectiveness of management – including assessment, treatment, delivery of services and rehabilitation – urgently requires development and expansion. Multi-centre clinical trials should be encouraged and supported.


2. PRIMARY CARE REFERRAL ARRANGEMENTS

2.1 Head and Neck Referral Arrangements

The EM CCN Head, Neck and Thyroid ECAG agreed the implementation of referral guidelines for patients where there was a suspicion of Head and Neck/Thyroid Cancer in line with the recommendations of the Manual of Cancer Services. A patient who presents with symptoms suggestive of an Upper Aero-digestive Tract/Head and Neck Cancer should be referred to an appropriate specialist. Any patient with persistent symptoms or signs related to the head and neck in whom a definitive diagnosis of a benign lesion cannot be made should be referred or followed up until the symptoms and signs disappear. If the symptoms and signs have not disappeared after six weeks an urgent referral should be made. Primary healthcare professions should advise all patients, including those with dentures, to have regular dental checkups. The key questions for the primary care practitioner, which then govern the type and destination of the referral of a patient with potential Head and Neck Cancer are:- For patients with neck lumps

Is the lump clinically thyroid or not?

Are there ’urgent’ features to the lump itself?

Are there other ‘urgent’ features, not directly of the lump itself? If so, are they pointing to UAT (Upper Aero-digestive Tract) or to haematological malignancy?

Does the patient have stridor? For patients with no neck lump

Are there ‘urgent’ features or not?

Does the patient have stridor? The answers to these questions determine the two or three steps through the referral schema given in Appendix D1 – 5.


Specific Recommendations In a patient with unexplained red and white patches (including suspected lichen planus) of the oral mucosa an urgent referral should be made. A non-urgent referral should be made in the absence of these features. If oral lichen planus is confirmed the patient should be monitored for Oral Cancer as part of routine dental examination (See: NICE Clinical Guideline No. 19 – www.nice.org.uk/CGO19 / Multi-Disciplinary Guidance.) In patients with unexplained ulceration of the oral mucosa or mass persisting for more than three weeks an urgent referral should be made. In adult patients with unexplained tooth mobility persisting for more than three weeks an urgent referral to a dentist should be made. In any patient with hoarseness persisting for more than three weeks, particularly smokers aged 50 years and older and heavy drinkers, an urgent referral for a chest X-ray should be made. Patients with positive findings should be referred urgently to a team specialising in the management of Lung Cancer. Patients with a negative finding should be urgently referred to a team specialising in Head and Neck Cancer. In patients with an unexplained lump in the neck that has recently appeared or a lump that has not been diagnosed before that has changed over a period of three to six weeks, an urgent referral should be made. In patients with an unexplained persistent swelling in the parotid or submandibular gland, an urgent referral should be made. In patients with an unexplained persistent sore or painful throat, an urgent referral should be made. In patients with unilateral unexplained pain in the head and neck area for more than four weeks, associated with otalgia (ear ache) but with normal otoscopy, an urgent referral should be made. Investigations With the exception of persistent hoarseness, investigations for Head and Neck Cancer in Primary Care are not recommended as they can delay referral. Local Services and Contact Points

Referral Arrangements

Hospital Designated Clinician Contact Details

Lincoln County Hospital Mr D McRae Mr C Young

2ww office Fax 01522 573351 Pilgrim Hospital, Boston

Grantham Hospital

Queens Medical Centre Miss L Sneddon 2ww office

http://www.nice.org.uk/CGO19


Referral Arrangements


City Hospital Mr J McGlashan Mr N Beasley Mr I McVicker Mr P Hollows

Tel:- 0115 8405801 Fax:-0115 8405802

Kings Mill Hospital Mr N Beasley Via Choose & Book 01623 622515

Kettering General Hospital Mr A Tewary 2ww Office 01536 493303

Northampton General Hospital

Mr C Harrop Mr P Gurr

2ww Office 01604 544235

University Hospitals of Leicester

Mr Chris Avery Mr P Convoy Mr J Woodein Mr P Martinese

Cancer Unit Office 0116 2502543

Queens Hospital, Burton Mr A Thompson Mr A Hawrani

Patient Access Centre Direct Fax – 01283 593090

Royal Derby Hospital Mr K Jones Mr M De Mr D Haloame Mr J Stenhouse Dr N Cozens Mr S Mortimer

Via Choose and Book or Direct Fax – 01332 787535

2.2 Thyroid Referral Arrangements In patients presenting with symptoms of tracheal compression, including stridor due to thyroid swelling, immediate referral should be made. In patients presenting with a thyroid swelling associated with any of the following, an urgent referral should be made:

A solitary nodule increasing in size.

A history of neck irradiation.

A family history of an endocrine tumour.

Unexplained hoarseness or voice changes.

Cervical lymphadenopathy.

Very young (pre-pubertal) patients.

Patients aged 65 years and older. In patients with a thyroid swelling without stridor or any of the features indicated in the list above, the primary healthcare professional should request thyroid function tests. Patients with hyper or hypo-thyroidism and an associated goitre are very unlikely to have thyroid cancer and could be referred non-urgently to an Endocrinologist. Those with goitre and normal thyroid function tests who do not have any of the features indicated in the above list should be referred non-urgently.


Initiation of other investigations by the primary healthcare profession, such as ultrasonography or isotope scanning, is likely to result in unnecessary delay and is not recommended. The GP should be informed within 24 hours (by telephone or fax) of the diagnosis being communicated to the patient for the first time and should be made aware of the information which has been given to the patient and of the planned treatment. Subsequent alterations in prognosis, management or drug treatment should be communicated promptly to the GP. The patient should be informed of the diagnosis by a member of the specialist team. Local Services and Contact Points

Referral Arrangements - Thyroid Cancer


Nottingham City Hospital Nottingham Queens Medical Centre

Mr D Chadwick Miss L Sneddon Miss J Nigel

2ww office Tel:- 0115 8405801 Fax:-0115 8405802

Kings Mill Hospital Mr I Akhtar Mr K Nigam

Via Choose & Book 01623 622515

Lincoln County Hospital Grantham and Kesteven Hospital

Mr M McRae Mr C Young

2ww office Fax 01522 573351

Pilgrim Hospital, Boston Mr J Chelladurai

Kettering General Hospital Mr S Al-Hamali 2ww Office 01536 493303


Mr D Ratliff Mr P Gurr

2ww Office 01604 544235

University Hospitals Leicester

Mr P Conboy Mr J Uddin

Cancer Unit Office 0116 2502543

Royal Derby Hospitals Mr M De Mr S Mortimer

Via Choose and Book or Direct Fax – 01332 787535

Queens Hospital, Burton Mr A Thompson Mr A Hawrani

Patient Access Centre Direct Fax – 01283 593090

Referral schema Appendix D1 – Page 66 are included to help through the steps for referral of either Head and Neck or Thyroid Tumours. 2.3 Distribution Process for Primary Care Referral Guidelines The distribution of the Primary Care Referral Guidelines for suspected Head and Neck Cancer including Thyroid Cancer was achieved as follows:


Primary Care Medical Practices:

Email

Fax

Cascade through the CCG cascade system

Post.

Primary Care Dental Practices:

Post

Distribution through the CCGs. Designated and non-designated Hospital Consultants (Ear, Nose and Throat (ENT) Surgeons, Endocrine Surgeons, Oral and Maxillofacial Surgery (OMFS) Surgeons, Oral Medicine Specialists, Endocrinologists, Restorative Dentists:

Through the Cancer managers in each Acute Trust.

Through the relevant directorate managers.

By MDT.

By personal copy through the post/email. It is anticipated that all clinical guidelines for each tumour site in the EM CCN will be available on the Network website.


3. REFERRAL GUIDELINES BETWEEN TEAMS

3.1 Network-wide UAT Referral Proforma for Routine Referrals A referral proforma, the format of which was agreed by the EM CCN Head, Neck and Thyroid ECAG at its meeting on 9th July, will be used for Network-wide referral for routine referrals of patients. This is used for:

Patients with UAT symptoms which are outside the ‘urgent suspicion of cancer’ definition and who have not got neck lumps.

It allows the referrer to categorise a patient by presenting features, so that the hospital can direct the referral to the relevant specialist (e.g. ENT, OMFS).

The network-wide format is made locally specific by identifying a single referral point for each designated hospital to which proformas can be sent for direction to individual specialists.

A copy of the referral proforma is included as Appendix D2 - Page 71. 3.2 Internal Referral Guidelines for Non-Designated Hospital Clinicians The following are the internal guidelines for hospital clinicians for Head and Neck Cancer presenting to non-designated clinicians. These guidelines are based on the scheme proposed by the Manual for Cancer Services.

Head and Neck patient with signs and symptoms suggestive of cancer presents to non-designated clinician

Cancer highly likely

Cancer diagnosis uncertain and biopsy deemed necessary for initial diagnosis of malignancy

▪ URGENT REFERRAL ▪ CORE MEMBER OF MDT ▪ WITHOUT BIOPSY

▪ URGENT REFERRAL ▪ CORE MEMBER OF MDT WITH RESULTS


The locally specific, named, designated clinicians are included in the table below. Table 1: Onward referral to core MDT members without biopsy plus those patients with neck lumps:

Hospital of non-designated clinician

Refer to Core MDT Member

Contact MDT for

discussion

Queens Medical Centre Nottingham

Miss L Sneddon Mr N Beasley Mr J McGlashan Mr D Chadwick

Nicola Hodgkinson 0115 9249924 Ext 65982

Nottingham Head and Neck MDT

City Hospital, Nottingham

Kings Mill Hospital Mr A McVicar Mr N Beasley

Sue Stringer 01623 622515 Ext 2413

Nottingham Head and Neck MDT

Lincoln County Hospital

Mr M McRae Mr M Buah

Wendy Smith 01522 512512 Ext 2659

Lincolnshire Head and Neck MDT

Pilgrim Hospital, Boston

Mr J Chelladurai Lincolnshire Head and Neck MDT

Grantham and Kesteven General Hospital

Mr A McRae Lincolnshire Head and Neck MDT

Queens Hospital, Burton

Mr A Thompson Mr A Hawrani

Brianne Knowles 01332 785034

Royal Derby Hospitals Head and Neck MDT Royal Derby Hospital Mr K Jones

Mr J Sharp Mr M De Mr D Haloame Mr J Stenhouse Mr S Mortimer

Kettering General Hospital

Mr Tewary Mr Harrop Mr Smith

MDT Co-ordinator 01604 544163 H&N Tracker 01536 491563

Northants Head and Neck MDT


Mr C Harrop Mr D Ratliff

MDT Co-ordinator:- 01604 544163

Northants Head and Neck MDT

University Hospitals of Leicester

Mr Avery Mr Hayter Mr Uddin Mr Conboy

MDT Co-ordinator:- 0116 2587624

Leicestershire Head and Neck MDT

3.3 Distribution Process for Internal Referral Guidelines

The Internal Referral Guidelines are distributed to the following using the stated processes: Designated Consultant Clinicians:


Email

Post

Fax.

Non-designated OMFS/ENT/Thyroid Clinicians:

Email

Post

Fax. Endocrine Surgeons:

Email Post

Fax. Oral Medicine Specialists:

Email

Post

Fax. Endocrinologists:

Email

Post

Fax. 3.4 The Designated Hospitals Receiving Referrals of Patients with Thyroid Lumps Please see below the following named CCGs which will refer patients with lumps clinically of thyroid origin to the named, designated hospitals. Name of

MDT/Host

organisation

Type of

MDT/Level of

Care provided

Hospital Contact Referring CCG Catchment

population

Burton Hospitals

NHS Foundation

Trust

LSMDT

Linked to Derby

SSMDT

Level 1,2,3,4

NHS East

Staffordshire

CCG

NHS South East

Staffs & Seisdon

Peninsular

129,929

201,453

Derby Teaching

Hospitals NHS

Foundation Trust

SSMDT

Levels 1,2,3,4,5

NHS Erewash

NHS Southern

Derbyshire

105,068

560,968

Kettering General

Hospitals NHS

Trust

LSMDT

Linked to

NHS Corby

NHS Nene

78,850

See below


Name of

MDT/Host

organisation

Type of

MDT/Level of

Care provided


population

Leicester SSMDT

Levels 1,2,3,4

(shared)

Northampton

General Hospital

NHS Trust

LSMDT

Linked to

Leicester SSMDT

Level 1,2,3,4

NHS Nene

(shared)

636,532

Nottingham

Treatment Centre

and Nottingham

University

Hospitals NHS

Trust

SSMDT

Levels 1,2,3,4,5

NHS Nottingham

North & East

NHS Nottingham

West

NHS Rushcliffe

NHS Nottingham

City

151,219

98,614

115,530

345,438

Sherwood Forest

Hospitals NHS

Foundation Trust

LSMDT

Linked to

Nottingham

SSMDT

Levels 1,2,3,4,5

NHS Newark &

Sherwood

Mansfield and

Ashfield

132,733

208,081

University

Hospitals

Leicester NHS

Trust

SSMDT

Levels 1,2,3,4,5

NHS East

Leicestershire &

Rutland

NHS West

Leicestershire

NHS Leicester

City

307,667

349,738

361,554

United

Lincolnshire

Hospitals NHS

Trust

LSMDT

Linked to

Leicester SSMDT

Levels 1,2,3,4

NHS Lincolnshire

East

NHS Lincolnshire

West

NHS South

Lincolnshire

268,723

228,588

160,744


Name of

MDT/Host

organisation

Type of

MDT/Level of

Care provided


population

NHS South West

Lincolnshire

127,179

3.5 Referral Guidelines between Teams

Tertiary Referral Guidelines Tertiary referrals come from consultants outside the Head, Neck and Thyroid Cancer Teams and other hospitals. Tertiary referrals should be made to a named Consultant and usually after an initial telephone conversation. The required tests that should have been completed prior to a tertiary referral being made are set out below: 1. A biopsy and ulta scan taken and a positive histological diagnosis of cancer

made.

2. Imaging (Computed Tomography (CT) or Magnetic Resonance Imaging (MRI)) if this is a diagnostic test: a) Imaging other than as a diagnostic test is helpful providing no delays to the

patient’s tertiary referral will result. For example, where there are waits for CT or MRI slots. Imaging is often repeated at the tertiary centre even if the patient has previous scans.

3. Clinical information is also required:

a) Previous relevant surgery. b) If previous case notes not available a photocopy of the relevant areas to be

sent with the referral. c) All diagnostic test results.

4. Where a recurrence of a cancer is suspected by the referring unit these patients will be accepted by the tertiary centre without confirmed histology and should be referred urgently.

Childhood Head and Neck Cancer Growing masses in the Head and Neck in children and young people (<18 yrs) should be referred primarily to the Paediatric Oncology Service at Queens Medical Centre, Nottingham for assessment prior to the consideration of surgical intervention. The range of diagnosis in childhood and adolescence is considerably different than that seen in adulthood, the prognosis is also different. The nursing and social needs of the young person or child and their family are just as important as the surgery as this is rarely the sole method of treatment.


The child/young person will be cared for in an age appropriate environment, with specialist nurses, youth workers and social support.

Neurosurgical Procedures

Patients who require complex procedures and an input from neurosurgeons or the use of specialised techniques when treating skull base tumours will be referred to the specialist team at Queens Medical Centre, Nottingham (who involve the Neurosurgical Team). In view of the rarity of such cases, the referring clinicians may participate in the management of such patients and may join the surgical team when surgery is to be performed. The referring clinicians may not undertake such surgical procedures in isolation. This treatment should be performed by the local specialists with involvement from the visiting referring surgeons if required.

Out of Network Referrals

Referral of patients out of the EM CCN for treatment of Head and Neck Cancers is rare but would occur as part of the ongoing care of the patient in the following circumstances:

1. Patients requiring hyperbaric oxygen. 2. Patients requiring photodynamic therapy have been referred.

Pre-treatment Assessment and Management

Careful assessment of each patient’s clinical, nutritional and psychological stage must be carried out to inform MDT decisions on treatment options. Co-morbidity, performance status, psychological state, nutritional status and alcohol dependence should be assessed. The Clinical Nurse Specialist should ensure that all patients and carers receive appropriate support and information, that their non-medical needs are assessed and that there is effective liaison between hospital staff, primary care teams and other agencies as required.

Patients who are dependent on smoking, drinking or other addictive substances that increase the risk of head and neck cancers should be offered interventions to help them stop.

The full range of treatment options should be discussed with the patient with supporting written information if required. These discussions may be held over a number of meetings so that patients have adequate time to consider the MDT’s proposals.

a) Dental Assessment applies to Head & Neck only

Once a treatment plan has been agreed a dental assessment should be carried out on those patients where treatment will affect the mouth or jaws. Any necessary dental extractions should be carried out pre-treatment with sufficient time allowed for healing. The patients should be encouraged to have good oral hygiene and attend


their general dental practitioner if appropriate. Referral to a specialist restorative dentistry consultant should be considered in appropriate patients.

b) Speech and Language Therapist (SLT) and Dietician

SLTs and Dieticians will work together to assess patient swallowing ability and nutritional status at any time during the patients journey. This will include working up patients requiring enteral feeding tubes, liaising with appropriate teams/organisations to ensure optimal care. If a patient is to have treatment that will affect eating or swallowing the team should discuss the method of feeding that will be used and inform the primary care team well in advance if tube feeding is required so that the patient can be supported at home.

c) Anaesthetic Assessment

Patients who are to undergo surgery that will involve the airways should be assessed by the specialist anaesthetist who works with surgeons at the MDT.

d) Treatment Options

Diagnostic Services

Cancer can only be diagnosed in the head and neck by definitive histology. This can be in the form of fine needle aspirate, core biopsy or open biopsy. The specimen should be reported by a head, neck and thyroid pathologist.

Outpatient Arrangements

Oral cavity lesions are most commonly diagnosed by biopsies performed on an outpatient basis under local anaesthesia.

Treatment Options

The patient should have clear explanations and written information of treatments involved and their risks and common side effects and should have the opportunity to discuss likelihood of cure and quality of life after treatment.

The minimum investigations will include:

1. Biopsy. 2. Appropriate imaging. 3. Baseline medical investigations such as full blood count, liver function tests, urea and electrolytes, clotting screen, etc.

All patients require a full medical examination to assess fitness for treatment and assess co-morbidity (sometimes previously undiagnosed).


East Midlands Head, Neck & Thyroid Expert Clinical Advisory Group (ECAG)

Head and Neck Specific Guidelines


Reviewed by: Ratified by: Endorsed by:

Distributed to: Head, Neck & Thyroid ECAG members

Trust Lead Cancer Clinicians Cancer Centre Managers

Version History:

Date: Version: Review:


TABLE OF CONTENTS PAGE

Head and Neck Specific Clinical Guidelines

- Neck

21

- Oral Cavity and Lip Cancer

27

- Oropharynx

33

- Nasopharynx

36

- Laryngeal

39

- Hypopharynx

44

- Nose and sinuses

49

- Ear and Temporal Bone

53

- Salivary Gland

56

- General Principles for Radiotherapy and Chemotherapy

61

Thyroid Specific Clinical Guidelines 64


CLINICAL GUIDELINES FOR HEAD AND NECK

In compliance with Measure 10-1C-105i the ECAG agreed imaging guidelines for UAT Cancer reflect The Royal College of Radiologists “Recommendations for Cross-Sectional Imaging in Cancer Management”. 1. NECK

Key Points

The status of cervical lymph nodes is the single most important prognostic factor.

Single node metastasis at presentation reduces the cure rate by 50%.

Prognosis is dependent on a number of metastases, level in the neck, presence of extra-capsular spread, perineural and /or vascular invasion.

A significant number of malignant nodes will be less that 10mm in diameter.

The incidence of micro-metastases is highly dependent on the site and size of the primary tumour, e.g. glottic tumours (1%), nasopharyngeal tumours (80%).

The majority of tumours metastasise in a predictable manner to certain nodal groups.

Bilateral nodal disease should be considered for tongue base, nasopharyngeal and supraglottic laryngeal tumours.

Standardised reporting of neck dissection specimens according to the Royal College of Pathologists Guidelines is essential.

Assessment of the Neck

Clinical Examination

This is generally inaccurate with sensitivity and specificity 60 – 70%.

CT scanning has a higher sensitivity (69 –93%) than clinical examination.

MRI is slightly better than CT in assessing the clinically negative neck.

Ultrasound guided Fine-Needle Aspiration Cytology (FNAC), although requiring expertise and experience, is a very useful technique for the assessment of neck node metastases. It has a sensitivity of 76% and specificity 100% in necks that are clinically negative.

Staging of the neck

Nx Nodes cannot be assessed

N0 No node metastases

N1 Ipsilateral single node < or equal to 3cms diameter

N2a Ipsilateral single neck node – 3-6cms

N2b Ipsilateral multiple nodes – 3-6cms

N2c Bilateral, contra-lateral nodes 3-6cms

N3 > 6cms node

Staging of neck disease is the single most important factor in the prognosis of the patient.


Final stage is the culmination of clinical examination, imaging, +/- cytological results and histopathological report.

MANAGEMENT OF THE NECK IN HEAD AND NECK CANCER

Nomenclature for Neck Dissection

Classification of Neck Dissection Techniques

Radical neck dissection Is the fundamental procedure by which any other neck dissection is compared. Levels I–V dissected; accessory nerve, internal jugular vein and sternomastoid muscle resected.

Modified radical neck dissection

Denotes preservation of one or more of the accessory nerve, internal jugular vein or sternomastoid muscle (types I, II, III respectively), levels I-V dissected.

Selective neck dissection Denotes preservation of one or more groups of lymph nodes e.g. supraomohyoid (level I – III) Lateral neck dissection (level II,III,IV)

Extended radical neck dissection

Denotes radical neck dissection plus removal of one or more additional lymphatic and/or non-lymphatic structure(s).

Treatment of cervical lymph nodes is either ELECTIVE (clinically negative neck) or THERAPEUTIC (clinically positive neck).

CLINICALLY NEGATIVE NECK (N0)

Treatment should be prescribed:

i. Where there is a high incidence of occult nodal metastases (over 20%). Most

sites and stages of squamous cell carcinoma in the neck and head fall into this category, except lip, early glottic cancer and lower alveolus. All other tumours qualify for elective treatment of the neck because the incidence of occult node metastases is over 20% (although this is accepted practice, it is not supported by strong evidence).

ii. Where the neck needs to be entered for surgical access to the primary tumour and/or micro-vascular anastomoses.

iii. When the patient is an irregular attender. iv. Where the status of lymph nodes cannot be adequately assessed e.g. obesity.

Elective radiotherapy to the neck is as effective as elective surgical treatment and the choice of treatment is heavily influenced by the mode of treatment for the primary tumour.

Choice of Neck Dissection

Oral cavity and oropharyngeal tumours are managed with selective neck dissections involving levels I–IV.


Laryngeal and hypo-pharyngeal tumours require a selective neck dissection of levels II – IV.

Classical radical neck dissection has no role to play in the management of the N0 neck.

Selective neck dissection is as effective as modified radical neck dissection type II.

Sentinel node biopsy is still a research tool.

RADIOTHERAPY FOR THE CLINICALLY NEGATIVE NECK

Primary Treatment

This should be considered in situations as follows:

If the primary tumour is treated with radiotherapy, the ‘at risk’ lymph node regions harbouring occult disease should be included in the treatment field.

Elective radiotherapy is preferred when both sides of the neck are treated electively such as e.g. nasopharyngeal tumours.

Postoperative Radiotherapy

This is indicated where the histopathological report reveals:

Multiple nodal level involvement.

Presence of extra capsular spread.

THE CLINICALLY POSITIVE NECK (N1 – 3)

Treatment of the clinically positive neck involves a combination of surgery and radiotherapy.

Single modality treatment may be sufficient for N1 disease.

Combined modality treatment (surgery plus post operative radiotherapy) is generally indicated for N2 and N3. The dose should be tailored to the bulk of the disease.

Modified radical neck dissection is as oncologically effective as classic radical neck dissection even in advanced disease when combined with post-operative radiotherapy.

MRND type 1 is recommended for the management of node positive necks where possible.

Level V involvement is uncommon such that the need for comprehensive i.e. level V neck dissection even in node positive necks has been questioned.

Conversion to radical neck dissection from modified radical neck dissection is required where there is involvement of non-lymphatic structures (accessory nerve, jugular vein, etc).

Post operative radiotherapy to the neck is indicated when there are bad prognostic features:

a) Multiple nodal level involvement


b) extra-capsular spread c) perineural invasion d) perivascular invasion e) involvement of nonlymphatic structures f) involvement of skin of the neck g) bilateral positive nodes h) Positron Emission Tomography (PET) scans at three months for all patients to

assess treatment.

THE OCCULT PRIMARY TUMOUR – MANAGEMENT OF THE NECK

5% of patients with Head and Neck Cancer fall into this category as the primary site can nearly always be identified. Metastatic lymph nodes containing Squamous-Cell Carcinoma (SCC) with the exception of supraclavicular fossa nodes should be considered as metastases from the upper aero-digestive tract. Supraclavicular fossa nodes usually arise from regions outside the head and neck, e.g. oesophagus, stomach.

Management and Diagnosis

Full examination of the upper aero-digestive tract is essential. Endoscopy should

be performed under general anaesthetic with biopsy if the tumour is obvious.

If no tumour is obvious then biopsy should be taken of the nasopharynx, ipsilateral tonsillectomy and tongue base. Bi-lateral tonsillectomy has been advocated as there is a 10% incidence of contra lateral nodes from occult tonsil primary.

RADIOLOGY: chest x-ray, CT scan or MRI scan of the head and neck should be performed preferably prior to biopsy. The CT of the chest is useful where there are respiratory symptoms or clinical suspicion of tumours of the lower aero-digestive tract e.g. bronchus.

CYTOLOGY: FNAC is mandatory. A repeat FNAC should be considered if the initial aspiration is negative. Tru-cut biopsy may be considered if FNAC equivocal.

GENERAL EXAMINATION: examination of the breasts, chest, abdomen should be performed.

Management of the Neck in the Occult Primary

Evidence for management is retrospective and of variable quality. It is, however, apparent that surgical salvage after failed radiotherapy is not effective in terms of survival. Management is highly dependent on the outcome of the FNAC.

If the FNAC is positive, a neck dissection should be performed.

If the neck is N1 stage, postoperative radiotherapy should be given where poor prognostic factors exist (see above).

For N2, N3 necks, combined modality treatment is indicated. Consideration should be given to chemo radiotherapy.


If the FNAC is negative, an excisional biopsy is performed under frozen section control. If positive for SCC, proceed immediately to neck dissection (radical neck dissection or preferably modified radical neck dissection).

Postoperative radiotherapy should be given where there are bad prognostic features on histological examination.

Management after Incisional Biopsy/“Lumpectomy”

a) For N1/NX disease – neck dissection. b) N2, N3 disease, a neck dissection should be performed with post-

operative radiotherapy. Chemo-radiotherapy should only be performed within a clinical trial.

Management of the likely Primary Sites

Elective Mucosal Irradiation (EMI) should be individualised for each patient,

bearing in mind the potential severe morbidity and many patients may be treated unnecessarily.

Elective Mucosal Irradiation does not improve survival. Ipsilateral Mucosal Radiation is advocated, as it is an alternative with less morbidity.

Recurrence after Combined Treatment

This carries a very poor prognosis and often associated with distant metatastes. Re-excision maybe considered to control neck recurrence and the associated distressing symptoms. Those with an existing or predicted complex needs should be referred early to local specialist palliative care teams.

Radiotherapy Techniques

Radiotherapy should only be delivered under the remit of an accredited

department.

Modern methods will utilise mega voltage photons from a linear accelerator (typical energies 4 – 6 MV). In early cancer of oral cavity, oropharynx, hypopharynx and larynx, the first station/echelon nodes are treated in continuity with the primary tumour.

Number of fields and energy of photons/electrons used are dependent on the exact geometry of the tumour and patient. This information is, best obtained by the means of a CT scan. CT scan to be obtained for all patients undergoing radiotherapy planning to determine patients and tumour geometry.

Intensity Modulated Radiotherapy (IMRT) may be of value in reducing the side effects in the unexplored neck. This is still experimental and is the subject of clinical trials. IMRT is standard care for head and neck.

Concomitant chemo radiotherapy may improve progression free survival if patients are medically suitable.

Altered fractionation techniques and adjuvant treatment do have improved outcomes and should be considered for patients who are medically fit and well and able to tolerate this intensive treatment.


Indications for post-operative radiotherapy are derived from careful pathological examination. Where indicated chemotherapy is considered as well. Decision will be based on MDT discussion.

Indications for post-operative radiotherapy are: a. Multiple nodal involvements b. Extracapsular spread c. Perineural invasion d. Perivascular invasion e. Involvement of the overlying skin.

It is important to complete post-operative radiotherapy within 11 weeks of surgery, particularly in patients who are at high risk of recurrence (see above).

All patients Head and Neck PET scan three months.

Palliative Treatment

Incurable nodal disease may be managed with palliative chemotherapy or radiotherapy.

Chemotherapy including cisplatin, 5FU and methotrexate.

Palliative radiotherapy should be delivered in a simple field arrangement, by a lateral parallel pair or single anterior field doses.


2. GUIDELINES FOR ORAL CAVITY AND LIP CANCER

ORAL CAVITY

Diagnosis

This is based on:

Physical examination of the oral cavity and oropharynx.

Examination under anaesthetic – indicated when clinical assessment difficult.

Panendoscopy for those at high risk of a second primary tumour.

Clinical diagram to outline the extent of tumour. Careful documentation with a standard tumour map.

Biopsy report should include the differentiation, tumour thickness, evidence of vascular and peri–neural invasion.

Imaging

All malignant tumours of the upper aero-digestive tract require radiological imaging. A variety of techniques including MRI, CT, plain radiography and isotope scanning maybe necessary.

An orthopantomogram is required on all patients.

MRI scan remains the preferred modality for imaging of the oral cavity primary tumour.

Ideally, MRI should be performed BEFORE biopsy of the primary tumour.

Consultation

All patients with a diagnosis of Head and Neck Cancer must be seen in a multi-

disciplinary team setting.

Staging

Primary Tumour

All patients must be staged prior to treatment planning:

TX Primary tumour cannot be assessed

T0 No evidence of primary tumour

T1s Carcinoma in situ

T1 <or equal to 2cms diameter

T2 >2-4 cms diameter

T3 > 4cms diameter

T4 Tumour of any size invading adjacent structures e.g. bone, skin, extrinsic muscles

Staging of the primary tumour is based on:

Clinical examination including visualisation and palpation.


Imaging.

Histological diagnosis.

MANAGEMENT OF ORAL CANCER

Early Oral Cancer

T1/T2 – this may be treated by a single modality therapy either surgery or primary

radiotherapy.

Surgery is the preferred modality of treatment unless the patient is medically unfit.

Larger T2 lesions (greater than 3cm) usually require combination therapy.

Surgery is preferred for tumours of anterior oral tongue, floor of mouth and buccal mucosa.

Radiotherapy is preferred if the oral commissure is involved.

Gingival/palatal lesions are treated surgically.

SURGERY

Consideration must be given to:

Insertion of feeding gastrostomy – preferably prior to definitive surgery.

Tracheostomy when required.

Dental extractions if necessary (preferably performed under anaesthetic, and at the time of Examination Under Anaesthetic (EUA) and biopsy).

Excision of neck dissection specimens and primary tumour in continuity.

Frozen section evaluations iagrammatical.

Orientation of primary and neck dissection specimen for the pathologist by the surgeon.

RADIOTHERAPY

Radiotherapy may be appropriate especially in the very elderly in whom anaesthesia is a particular risk.

Equivalent survival rates can be achieved either with primary radiotherapy or surgery to T1 and low volume to T2 tumours of the oral cavity. Disadvantages of external beam radiotherapy: o Cannot be used a second time. o Salvage surgery following radiotherapy is often associated with low survival

and high morbidity. Side effects include:

- Xerostomia, mucositis and osteo-radionecrosis of the mandible.

Patients may require multiple dental extractions prior to and after treatment.

Late Oral Cancer (T3, T4 tumours)

These should be treated by a combination of surgery/post operative radiotherapy.


Special Surgical Considerations

Mandible

A segmental mandibulectomy (full thickness resection of bone) is carried out where invasion of the bone is evident.

Primary reconstruction of the jaw is preferable over delayed mandibular reconstruction.

A full range of reconstructive techniques including composite flaps must be readily available.

A suitable mandibular reconstruction plating system should be available.

Vascularised fibula or vascularised iliac crest remains the gold standard for mandibular reconstruction.

Soft Tissue Defects

The fasciocutaneous radial forearm flap is the standard versatile, reliable and robust flap for oral and oropharyngeal soft tissue defects. More bulky reconstructions require rectus abdominus flap.

Pedicle flaps e.g. pectoralis major should only be contemplated for salvage procedures.

A two-team approach to surgery is mandatory to shorten operative time and to reduce post-operative complications.

TREATMENT OF THE NECK IN ORAL CAVITY TUMOURS

The Clinically Negative Neck (N0)

In Oral Cavity and Oropharyngeal Cancer the incidence of occult metastases is

approximately 34%. Expectant management of N0 of the clinically negative neck is not recommended, i.e. a policy of ‘wait and see’ is to be avoided.

If surgery to the primary tumour is contemplated, simultaneous neck dissection should be considered.

If radiotherapy is planned for the primary tumour then elective radiotherapy may be used to manage the clinically negative neck.

Anterior Oral Cavity Lesions

Because of lymphatic crossover in anterior oral cavity lesions or those located at

or near the mid-line, consideration should be given to bilateral treatment of the neck – radiotherapy or bilateral neck dissection.

Oral Tongue Lesions

These have a high incidence of metastases to levels I – IV. Selective neck

dissection in oral tongue tumours should include levels I – IV.


The Clinically Positive Neck (N1 – N3)

With palpable neck node involvement or conclusive evidence following imaging of

the neck, surgical treatment is preferred.

Selective neck dissection for N1 neck can be contemplated for oral cavity tumours with isolated/single nodal metastases.

Modified radical neck dissection/radical neck dissection or even extended radical neck dissection maybe be required for more extensive disease.

Most patients will require post-operative radiotherapy.

CRITERIA FOR POST-OPERATIVE RADIOTHERAPY

Primary Site

Positive margins.

Large T2, all T3 and T4, irrespective of nodal status.

Peri-neural or intra-vascular invasion on definitive histological assessment.

Poorly differentiated squamous cell carcinoma.

Radiotherapy should begin as soon as possible and after surgery. Radiotherapy should commence no later than six weeks after surgery.

Neck

More than one positive node.

Presence of extra capsular spread.

Perivascular invasion.

Perineural invasion.

Involvement of the overlying skin.

LIP CANCER

Cancer of the lower lip is common. Cancer of the upper lip and commissures is rare. DIAGNOSIS

Clinical Assessment

Complete history including history of sun exposure and tobacco usage.

Clinical examination remains the mainstay for diagnosis.

Careful examination of the oral cavity and oropharynx under direct vision is recommended.

Incisional biopsy need only be considered if the clinical appearance is equivocal.

Imaging

An orthopantomogram is indicated for assessment of the anterior mandible and

dentition prior to radiotherapy.

Dental Assessment – consideration for pre-radiation extractions, restoration or prophylactic treatment.


TREATMENT

Primary Lip Cancer

Surgical excision is generally preferred as the initial treatment.

Frozen sections are helpful.

Small lesions can be excised under local anaesthetic +/- intravenous sedation.

Superficial early lesions of the vermillion may be treated by laser or lip shaves. Full thickness lip lesions require immediate repair/reconstruction.

Reconstruction of the Defect

< 1/3 of the lip removed - V or W closure.

>1/3 – 2/3 of the lower lip – local flap reconstruction e.g. Johannson Step reconstruction.

>2/3 of the lower lip – usually requires micro-vascular free tissue transfer method – fasciocutaneous forearm flap.

Invasion to adjacent tissues e.g. lip e.g. mandible is extremely rare.

Radiotherapy and Chemo Radiotherapy

Radiation therapy is satisfactory particularly for patients who are medically unfit to

undergo surgery.

Treatment by external beam radiotherapy.

Brachytherapy will require gingival shielding to reduce mucositis.

Large lip tumours require surgery as the primary treatment with appropriate reconstruction.

Management of the Neck in Lip Cancer

Occult lymph node metastasis in lip cancer is low. The policy of Lip Cancer

behaves differently from Oral Cavity and Oropharyngeal Cavity Cancer.

CLINICALLY NEGATIVE NECK

A policy of “watch and wait” is recommended.

T2 tumours of the lip – 15 – 35% of occult lymph node metastasis. No firm evidence to prescribe routine selective neck dissection. A policy of watch and wait is recommended for this lesion.

T3 –T4 lesions +/- poorly differentiated – bilateral selective neck dissection – (I – III) is contemplated where patients are medically fit.

CLINICALLY POSITIVE NECK

N1

Ipsilateral selective neck dissection or modified radical neck dissection is

recommended. Consider contra-lateral supra-omohyoid neck dissection.


N2/N3

Consider bilateral neck dissection. Tracheostomy maybe required.

Indications for Post-Operative Radiotherapy

As for the management of the neck in Oral Cavity Cancer.

Recurrence

This is uncommon but is best managed with aggressive surgical resection with

frozen section control.


3. CLINICAL GUIDELINES FOR OROPHARYNX

GENERAL CONSIDERATIONS

Tumours in this head and neck subsite can be further subdivided into four anatomical areas. They are:

a. Tonsil b. Base of tongue c. Soft palate d. Pharyngeal wall.

Many tumours in this sub site are large with considerable overlap of the above sub sites.

Assessment

Examination under anaesthetic and biopsy is mandatory for all cases to:

a. Establish histological diagnosis b. Stage the tumour c. Exclude synchronous head and neck tumours d. Assess extent of possible surgical resection e. Indicate type of required reconstruction f. Assess and manage the dentition.

Investigations

a. MRI is required for all cases b. CT thorax should be considered in advanced disease (high incidence of

distant metastases in Oropharyngeal Cancer) c. FNAC of enlarged lymph nodes d. Orthopantomogram to assess dentition.

Pre-Treatment Consultations

a. Dietary Assessment

Patients require a basic nutritional assessment pre-treatment. Most patients require enteral feeding preferably by feeding gastrostomy, as surgery, radiotherapy and chemo radiotherapy interfere with swallowing in both the short term and long term.

b. Speech and language assessment Treatment of oropharyngeal tumours, especially surgery, has an enormous impact on communication and swallowing.

c. Oral surgical assessment This is required two-fold:

i. to assess and treat any existing dental disease ii. to assess suitability for mandibulotomy procedures.


TONSIL

All patients should have a Hepatobiliary (HPB) status by PCR (Polymerase Chain Reaction). Many tonsillar carcinomas present with an enlarged lymph node as a primary symptom.

T1/T2 Lesions

These are uncommon but can be managed by:

a. trans-oral surgery in the form of laser or robotic technology should be

considered b. radical radiotherapy or chemo radiotherapy

T3/T4 Lesions

These require combined treatment in the form of:

Management of T3 and T4 tonsil lesions does not require extensive surgery and reconstruction followed by adjuvant radiotherapy – primary chemo radiotherapy is widely used and should be included in the guideline as a primary treatment option. Similarly for base of tongue tumours. Radiotherapy as a primary treatment and major salvage surgery for recurrences.

Reconstruction

Defects of the tonsillar bed can be preferably managed with microvascular radial artery forearm flaps or pectoralis major myocutaneous flap. If the primary tumour involves the retromolar trigone, rim resection of mandible or segmental resection is appropriate. Full thickness resection requires mandibular reconstruction with either microvascular fibula or iliac crest graft.

BASE OF TONGUE

General Principles

Treatment options include:

1. Primary radiotherapy. Chemo radiotherapy treatment of choice. 2. Patients with early/small tumour can undergo transoral resection using a

robotic/laser technique. 3. Neck dissection + mandibulotomy + incontinuity resection of tongue base

with immediate reconstruction with microvascular radial forearm flap. 4. Salvage surgery with reconstruction for recurrences.

PRIMARY TUMOUR

T1 lesion and selected group of T2 patients can be treated by surgery e.g. transhyoid approach OR chemotherapy/salvage.


T2, T3 and T4 lesions require combined treatment and will require chemo radiotherapy.

Recurrence of base of tongue tumour after primary chemo-radiotherapy often requires management by total glossectomy with laryngectomy and bilateral neck dissection. This has a high morbidity requiring careful counselling and extensive rehabilitation.

SOFT PALATE

Tumours in this area usually appear on the edge of the soft palate or uvula.

T1 and selected group of T2 tumours may be managed by trans-oral resection or laser excision.

T2, T3, T4 tumours require management as outlined for tonsillar tumours.

POSTERIOR PHARYNGEAL WALL

T1 and selected group of T2 tumours can be managed either by endoscopic resection or radical radiotherapy.

T2, T3, T4 tumours require combined treatment as outlined for tonsillar tumours.

MANAGEMENT OF THE NECK IN OROPHARYNGEAL CANCER

Base of tongue, posterior pharyngeal wall and palatal lesions frequently encroach across the midline. This can result in bilateral lymph node metastases. This concept needs consideration when planning treatment.

N0 Neck

This should be managed electively either by radical radiotherapy or selective neck dissection.

If the primary tumour is managed by surgery, selective neck dissection (levels I-III) should be carried out in continuity with the primary tumour.

N1-N3 Neck

This is managed either by selective or type I modified radical neck dissection. When the neck is managed surgically, the primary tumour should also be managed similarly. Chemo radiotherapy or selected T1.

Post-operative radical radiotherapy is indicated if more than one node is involved or if extra-capsular spread is identified / modified.


4. CLINICAL GUIDELINES FOR NASOPHARYNX

INTRODUCTION

Tumours of the nasopharynx present with a variety of symptoms and include:

a) Nasal obstruction b) Conductive unilateral hearing loss c) Cranial nerve palsy secondary to skull base invasion d) Unexplained cervical lymphadenopathy.

SIGNS

Nasopharyngeal tumours may either be obvious or undetectable on initial examination. Examination under anaesthetic and biopsy is essential to confirm the diagnosis.

Unlike many other anatomical sites in the upper aero-digestive tract, tumours of the nasopharynx need distinguishing between squamous cell carcinoma and lymphoma (other rare tumours also occur at this site).

ASSESSMENT

Cervical lymphadenopathy is the frequently presenting feature of nasopharyngeal

carcinoma. Blind biopsies should be taken from the nasopharynx (as well as tongue base and ipsilateral tonsil) to detect occult primary tumour.

CT scanning and MRI are complementary in the assessment of nasopharyngeal tumour.

Chest x-ray.

Blood test including LFT.

Liver ultrasound if LFT abnormal.

Bone scan.

CT thorax.

FNAC of cervical lymphadenopathy.

Dental examination (see later).

Dietetic and Speech & Language Therapy (SLT) assessment.

Patients with a nasopharyngeal carcinoma have a high incidence of distant metastases compared with other tumours of the aero-digestive tract.

TREATMENT OPTIONS

Localised Disease

a) Radiotherapy b) Chemotherapy c) Surgery.


Radiotherapy +/- Chemotherapy

High dose radiation therapy +/- chemotherapy is the primary treatment for nasopharyngeal carcinoma, even in patients with palpable neck disease. External beam irradiation is the method of delivery, occasionally boosted by interstitial implants.

Platinum-based chemo-radiotherapy produces better results than radiotherapy alone, albeit at the cost of increased toxicity.

Surgery

There are few indications for surgery in the initial management of nasopharyngeal carcinoma.

METASTATIC DISEASE

Patients with distant metastases are incurable.

High dose radiotherapy to the primary site and neck may be indicated to provide symptom control.

RECURRENT NASOPHARYNGEAL CANCER

Treatment Options

Patients with failed primary treatment or recurrent disease may be treated either by: a) Further external beam radiotherapy b) Interstitial radiotherapy c) Surgical resection.

Radiotherapy The surgical implantation of gold grains into the nasopharynx via a palatal split approach under direct vision has reported up to 80% control for residual disease and 54% for recurrent disease. Patients with disease outside the nasopharynx have lower control rates.

Surgery

This may be indicated with disease that has spread into the paranasopharyngeal space but not involving the internal carotid artery and skill base. A trans-maxillary/ trans-nasal/ trans-nasal approach is the preferred access procedure.

Modified radical neck dissection is indicated for nodal recurrence.

Morbidity

Strong consideration should be given to the provision of a feeding gastrostomy prior to either radiotherapy or surgery. Dental assessment prior to treatment is mandatory


as radiotherapy for nasopharyngeal carcinoma often produces severe xerostomia and acceleration of dental disease. Regular dental hygienist appointments are important and extraction of carious teeth should be carried out prior to radiotherapy. Regular monitoring of thyroid function to detect primary hypothyroidism is important following neck irradiation.

Survival

Small localised cancers of the nasopharynx are rare but curable with primary radiotherapy. Survival approaches 80% - 90% in this group.

Moderately advanced disease with no evidence of lymph node metastases carries survival rates of 50% - 70%.

Patients with advanced disease and cervical node metastases carry a very poor prognosis even when local control is achieved.

Most recurrences occur within five years of diagnosis.


5. CLINICAL GUIDELINES – LARYNGEAL TUMOURS

An Overview

Management of cancer of the larynx involves:

a) Diagnosis and appropriate staging b) Treatment of:

o Glottic cancer – early/late o Supraglottic tumours –early/late/advanced o Subglottic tumours

c) Management of the neck d) The use of chemotherapy in Laryngeal Cancer.

Diagnosis of Laryngeal Cancer

Diagnosis of Laryngeal Cancer involves formal examination under anaesthetic after

provisional diagnosis by direct or indirect laryngoscopy. All patients require a histological confirmation by biopsy.

Photo documentation is preferred.

It is preferable that all patients with a provisional diagnosis of Laryngeal Cancer should undergo formal examination under anaesthetic by surgeons involved in subsequent management.

An accurate anatomical description of the tumour extent is essential to ensure accurate staging of the disease both clinically and radiologically.

Glottic, supraglottic and subglottic tumours differ significantly in their patterns of behaviour and modes of spread. Separate consideration should be given to each anatomical site.

In general, radiotherapy and conservative surgery alone are options for early disease.

Combined radiotherapy and surgery are used for advanced disease and those patients with cervical node metastases.

It is no longer acceptable for surgeons to manage patients with Laryngeal Cancer on the basis of one surgical option (total laryngectomy). The surgeon’s repertoire must include conservative methods: laser, partial laryngectomy, selective neck dissection and surgical voice restoration.

All patients subjected to laryngectomy must be offered modern methods of voice restoration including valve speech. GLOTTIC TUMOURS Early Glottic Cancer

Early Glottic Cancer is potentially curable with either modality.

Single modality is usually the preferred choice.

Standard UK practice for treating T1 and T2 Laryngeal Cancer is radiotherapy.


Surgical modality may be by either endoscopic or open resection (partial laryngectomy). Endoscopic laser techniques are increasingly popular in some centres.

STAGE FOR GLOTTIC TUMOURS

Tx Primary tumour cannot be assessed T0 No evidence of primary tumour T1s Carcinoma in situ T1a Limited/mobile (one cord) T1b Limited/mobile (both cords) T2 Extends to supra or subglottis (impaired mobility) T3 Cord fixation T4 Extends beyond larynx Stage T1s

Carcinoma in situ can be reversed by the cessation of smoking. Excisional biopsy

by laser provides excellent control. Excision with preservation of the vocal ligament is probably the best option. Stage T1a

Endoscopic laser resection or radiotherapy provides equal control rates. The surgical access may define method of treatment. Partial laryngectomy may be required, but voice results are better with radiotherapy and/or endoscopic laser resection. Endolaryngeal laser surgery is more cost effective than radiotherapy.

Stage T1b

Treatment options are the same as T1a.

Stage T2

T2a (no cord restriction) radiotherapy may be preferable for superficial tumours can

be treated by Transoral Surgery and chemo radiotherapy depending on local expertise.

T2b (tumours impairing cord movement) can be treated either with partial laryngectomy or radiotherapy. Advanced Glottic Cancer

Stage T3

Treatment needs to be individualised.

A review of prognostic factors is relevant. Better prognosis is seen in glottic lesions, female patients and N0 necks.


Many advanced glottic cancers are under staged and are upgraded to T4 due to unsuspected cartilaginous involvement.

Options for treatment include surgery, radiotherapy, combined therapy, chemo radiotherapy or surgery.

Loco-regional control may be better in the surgically treated patient.

Salvage surgery usually requires total laryngectomy but salvage partial laryngectomy has been reported with good outcomes. Stage T4 Tumours Primary surgery with postoperative radiotherapy can be managed by either chemo radiotherapy or surgery. Patients who are not fit for or refuse surgery can be offered chemo radiotherapy since this may provide better overall survival compared to radiotherapy alone. SUPRAGLOTTIC TUMOURS

There is a high incidence of overt and occult metastases in Supraglottic Cancer.

Early disease is treated with single modality, advanced disease with combined surgery and radiotherapy.

Early Supraglottic Cancer

Early supraglottic tumours (T1-2) can be treated either with surgery (including

endolaryngeal resection) or radiotherapy. Consideration should be given to bilateral elective management of the neck either by primary radiotherapy or bilateral selective neck dissection. Advanced Supraglottic Cancer (T3-4) Chemo Radiotherapy

Total laryngectomy with postoperative radiotherapy has been the treatment. No survival advantage has been demonstrated compared to chemo radiotherapy and salvage laryngectomy if necessary.

Primary laryngectomy with follow up with postoperative radiotherapy confers significant survival advantage compared to radical radiotherapy alone followed by salvage surgery.

Patients undergoing conservative laryngeal surgery should be medically fit and with adequate pulmonary function prior to surgery. SUBGLOTTIC TUMOURS

Most of these tumours are indistinguishable from glottic tumours.

Most present late with stridor and require total laryngectomy with postoperative radiotherapy. MANAGEMENT OF THE NECK IN LARYNGEAL CANCER The management of the neck is highly dependent on the site of the primary tumour.


The Clinically Negative Neck (N0)

Early Glottic Cancer (T1-T2) does not require elective neck treatment since the risk of occult neck metastases is low.

Neck irradiation is as effective as elective neck dissection. Elective neck treatment is recommended for:

a) Advanced Glottic Cancer b) Transglottic Cancer c) All T stages of Supraglottic Cancer d) Subglottic Cancer.

The treatment of the neck should follow wherever feasible the same modality as treatment of the primary.

If the primary site is treated with radiotherapy then elective neck radiation should be performed.

If the primary site is treated by surgery then appropriate elective neck dissection should be performed:

a) Glottic Cancer – ipsilateral neck dissection (Levels II,III,IV) b) Supraglottic Cancer – bilateral selective neck dissection (Levels II, III, IV) c) Subglottic extension of Glottic Cancers/Subglottic Cancer – bilateral neck

dissection (Levels II, III, IV and VI) d) If the paratracheal nodes are histologically positive then postoperative

radiotherapy should be considered for the mediastinum. Indications for Postoperative Radiotherapy:

a) Multiple node metastases b) Extra capsular spread c) Positive paratracheal nodes (Level VI) – mediastinal irradiation.

In salvage surgery after failed primary radiotherapy neck dissection should be considered even if the neck is negative. The clinically positive neck (N+)

If radiotherapy/chemo radiotherapy is used to treat the primary tumour both sides of

the neck should be included in the irradiation fields.

If post radiotherapy assessment at six weeks demonstrates Residual Neck Disease then Modified Radical Neck Dissection (MRND) or Radical Neck Dissection (RND) should be prescribed.

If the primary tumour is treated by surgery then MRND is performed.

Ipsilateral neck dissection is indicated for Glottic Cancer.

Bilateral neck dissection is indicated for Supraglottic Cancer.

Indications for postoperative radiotherapy are:


a) Multiple positive nodes b) Extra capsular spread c) Positive paratracheal nodes d) Involvement of adjacent structures e) Skin involvement.

Special Circumstances

Stridor

This presents a difficult problem; most have advanced disease that dictates combined treatment:

Endoscopic debulking is carried out where this is feasible.

Tracheostomy although not desirable may be necessary.

Emergency laryngectomy should only be used in exceptional circumstances.

Recurrent/residual disease

Further management is dependent on the primary treatment.

Recurrence after radiotherapy is managed by salvage surgery.

Total laryngectomy is the most commonly performed salvage surgery.

Conservative laryngeal procedures may be considered in selected cases.

Unresectable recurrences are treated with radiotherapy with or without chemotherapy.

Stomal recurrence particularly if arising superiorly may be respectable and requires mediastinal resection and possible pharyngectomy with reconstruction.


6. CLINICAL GUIDELINES - HYPOPHARYNX

ASSESSMENT Thorough assessment of a patient with hypo-pharyngeal carcinoma includes:

a) Endoscopy b) Chest x-ray c) CT and MRI d) Pulmonary function testing.

Endoscopy Tumour site and extent of disease should be recorded iagrammatically and biopsy taken for histological examination. At the same assessment, oesophagoscopy and bronchoscopy are used to eliminate synchronous primary tumours and tracheal invasion respectively. Percutaneous endoscopic gastrostomy may be appropriate at this assessment. Chest X-Ray This is better than bronchoscopy in identifying a second primary tumour. Chest CT is preferable. CT/MRI Cross sectional imaging should be performed in all cases. CT has the advantage of assessing the presence of thyroid cartilage invasion. MRI scan offers a better soft tissue image. Chest CT should be performed for most tumours. Most patients with hypo-pharyngeal carcinoma should undergo both MRI and CT scanning. Pulmonary Function Tests These are useful where a tumour is amenable to surgical treatment. TREATMENT General Considerations

1. Physical state 2. Mental state 3. Patient’s wishes (in light of extent of surgery and morbidity) 4. Nutritional status/swallowing ability.


Combined surgery and radiotherapy is the optimal treatment for all except the earlier stage tumours. Local control is improved with a combination of surgery and radiotherapy. Conservative surgical techniques are preferable for early stage disease. Resection should be wide to provide clear margins as positive margins have a poor prognostic factor. Submucosal spread of tumour is common and more extensive especially in piriform sinus carcinoma. The patient should be advised to stop smoking. Neoadjuvant chemotherapy should only be prescribed within a setting of a clinical trial. SURGERY T1 and T2 Tumours Early tumours are infrequent. Single modality treatment of the primary tumour can be either:

a) radiotherapy b) partial pharyngolaryngectomy c) endoscopic resection.

Insufficient evidence exists to identify one method as superior to all others. Radiotherapy appears to be less effective in tumours that are bulky or involve the piriform sinus apex. T3 and T4 Tumours T3 requires primary radiotherapy combined with radical surgery with post-operative radiotherapy. T4 requires combined radiotherapy post op. The type of surgery depends on the site and extent of the tumour. Most tumours require total laryngectomy with partial pharyngectomy or total pharyngolaryngectomy. Resection and reconstruction No clear guidelines exist and each situation demands individual techniques. Endoscopic resection is suited for early posterior wall and piriform fossa tumours. Partial pharyngectomy with or without partial laryngectomy is useful for advanced tumours.


Reconstruction Several options exist dependent on the extent of the defect: Partial Pharyngectomy Defects

a) Primary closure – small posterior wall defects b) Radial forearm free flap c) Myocutaneous pectoralis major flap d) Jejunal patch flaps are useful.

Total Pharyngolaryngectomy

a) Free jejunal transfer is the technique that provides the most optimal outcome b) Tubed free radial forearm flap is an alternative c) gastric transposition may be required for extensive defects.

RADIOTHERAPY Primary radiotherapy with salvage surgery is commonly prescribed in many UK centres. Primary radiotherapy is appropriate for:

a) Small hypo-pharyngeal tumours b) Patients medically unfit for extensive surgery c) Patients who refuse extensive surgery e.g. pharyngolaryngectomy.

Dose of primary radical radiotherapy varies from 55 Gy to 70 Gy over a period of 4-7 weeks. Post-Operative Radiotherapy This is indicated for:

a) T3-T4, N0-N3 tumours b) T1-T2, N0 tumours if histology shows:

I. positive margins II. vascular invasion

III. perineural invasion IV. extra-capsular spread V. if neck dissection is not being carried out.

Radiotherapy should be commenced within six weeks of diagnosis. Lymph Node Metastases Two-thirds of patients have positive lymph node metastases at the time of presentation and diagnosis.


Occult metastases are found in 40% of patients with hypo-pharyngeal tumours with an N0 stage neck. Occult spread occurs commonly to levels II – IV (rare for levels I or V to be involved in an N0 neck). Spread is bilateral in midline and bilateral tumours. Management of Lymph Node Metastases N0 Neck Little scientific evidence on the best mode of management. The management of the N0 neck is highly dependent on the management of primary tumour i.e.

a) Primary radiotherapy to the neck if primary radiotherapy to the tumour site. b) Neck dissection if surgery is prescribed for the primary tumour. c) Selective neck dissection of levels II, III and IV is recommended with inclusion

of level IV in tumours that extend to the post cricoid region or apex of piriform fossa.

d) Oro-pharyngeal extension demands, in addition, level I dissection. Clinically Positive Neck (N1 – N3) Modified radical neck dissection is indicated. Levels II, III, IV are adequate for N1 disease. Surgery should be used for recurrent disease if it is resectable followed by post-operative radiotherapy if it has not already been prescribed. Chemotherapy has a palliative role. REHABILITATION Involvement of the Speech Therapist as early as possible is the cornerstone of rehabilitation. All patients to be seen by a Speech Therapist prior to commencement of treatment. Surgical voice restoration should be considered either primarily or as a secondary procedure. Low-pressure valves are necessary when free tissue transfer has been used for reconstruction. Long-term use of feeding gastrostomy is frequently required. All patients should be seen by Dietitian.


PALLIATIVE CARE One-third of patients are incurable on presentation. Pain control and the use of percutaneous endoscopic feeding gastrostomy helps to maintain the quality of life. Palliative radiotherapy can produce tumour shrinkage and provide relief of symptoms. Comprehensive holistic multidisciplinary assessment and plan is vital at an early stage to maximise the individual’s quality of life. This suggests all should have Percutaneous Endoscopic Gastronomy (PEG) for quality of Life. Communication with all colleagues involved in the individuals care is vital to ensure continuity. Primary Care have a vital role in co-ordinating that care. Referral to specialists in palliative care at an early stage should be made for existing or predicted complex problems. Members of the multidisciplinary team should initiate end of life discussions with patients and carers to introduce Advance Care Planning in order to facilitate patient’s choices.


7. CLINICAL GUIDELINES – NOSE & SINUSES

INTRODUCTION

Tumours in the sinonasal region are rare.

Instance < 1/100,000 people per year.

Squamous cell carcinoma commonest tumour.

Other tumours include: o adenocarcinoma o olfactory neuroblastoma o adenoid cystic carcinoma o malignant melanoma o sarcomas.

Anatomical Site

All areas of the nasal cavity and paranasal sinuses can be affected. Common sites include maxillary sinus, lateral wall of the nose and ethmoidal air cells. Frontal and sphenoidal sinus tumours are very rare. Assessment and Diagnosis Symptoms include:

o Unilateral nasal obstruction o Unexplained epistaxis o Cheek/facial swelling o Visual disturbances.

Imaging

CT - coronal and axial cuts with intravenous contrast enhancement

MRI - three planar T1 pre and post gadolinium DPTA +/- T2 fat suppression.

Biopsy - usually under a general anaesthetic. An endoscopic approach is preferred to avoid transgression of normal tissue planes.

Related consultations

Patients with sinonasal tumours may also require the input of:

a) oral and orbital prosthetic rehabilitation b) neurosurgical input c) Medical oncology.

Treatment Options Most patients require combined modality treatment. Radiotherapy may be given before or after surgery. Usual dose of 60-66 Gy in 30-33 fractions over 6 weeks.


Neck nodes do not require prophylactic treatment. Concomitant chemotherapy – this is increasingly indicated with radiotherapy in both the pre and post-operative situation for patients with SCC and other tumours such as rhabdomyosarcoma and advanced lymphoma. Radiotherapy alone is required for lymphoma or for palliative treatment. Surgical Management a. Maxillectomy

SCC is the commonest indication for this operation.

Midfacial degloving, lateral rhinotomy or Weber-Fergusson incisions may be combined with orbital exenteration or extended to craniofacial resection.

Immediate prosthetic rehabilitation is optimal.

Modern approach of immediate reconstruction of the maxillectomy defect involves the use of microvascular free tissue transfer including the use of composite flaps e.g. iliac crest: DCIA/scapula/fibula flaps.

Modified denture/prosthetic obturator provision is an alternative but considered only in the medically compromised patient.

b. Partial or Medial Maxillectomy (Lateral Rhinotomy)

Indicated for:

Localised tumours of the nasal mucosa, nasal septum and lateral wall.

Rapid access with reasonable cosmesis e.g. elderly patients. c. Midfacial Degloving

This procedure is an access procedure to maxilla, ethmoids and nasal cavity.

Often combined with bicoronal incision for skull base/craniofacial resection. d. Rhinectomy

Required for extensive tumours of the anterior cartilaginous septum and nasal dorsum.

Usually SCC.

Local skin flap or prosthetic reconstruction.

Multiple reconstructive procedures are required but delayed until pathological clearance established.

Prosthetic rehabilitation (adhesive or implant retained) is a well-tried reconstructive alternative.

e. Endoscopical Endonasal Approaches

Suitable for relatively benign neoplastic e.g. inverted papilloma and small tumours.


f. Neck Dissection

Indications for neck dissection for sinonasal malignant disease are:

a) Clinical evidence of cervical node enlargement b) Imaging evidence of cervical node enlargement c) Access for microvascular anastomosis.

HISTOPATHOLOGY Frozen sectional control is usually required for extensive resection. Second opinion pathology may be indicated for individual tumours. MANAGEMENT OF SPECIFIC TUMOURS Squamous Cell Carcinoma Combined surgery and radiotherapy usually required with the exception of small localised tumours.

Adenocarcinoma associated with hard wood exposure but not exclusive. Commonly involve the antero-ethmoidal air cells. Surgical excision e.g. craniofacial +/- maxillectomy +/- post-op radiotherapy is the mainstay of treatment. Adenoidcystic Carcinoma Widespread local dissemination by perineural lymphatic and embolic dissemination. Pulmonary metastases common. Wide excision and post-operative radiotherapy mainstay of treatment (radiotherapy delays local recurrence but does not affect overall survival). Late recurrence is common. 10-20 year follow-up recommended.

Olfactory Neuroblastoma Arises from olfactory epithelium e.g. superior nasal cavity. Craniofacial resection usually required. Referral to supra-regional centre.


Inverted Papilloma Arises commonly in middle meatus involving the maxillary, ethmoid and frontal sinuses. Local invasion of bone but potential for malignant transformation (1-2%). Surgical excision mainstay of treatment.

Angiofibroma

Arises within the sphenoplalatine region with extension into nasopharynx, sphenoid and infratemporal fossa. Surgery is the mainstay of treatment with radiotherapy for recurrence. Endoscopic excision combined with embolisation also possible. FOLLOW-UP MANAGEMENT

Baseline post-operative imaging at three months.

EUA and debridement of cavity may be required on a regular basis.


8. CLINICAL GUIDELINES FOR EAR AND TEMPORAL BONE

INTRODUCTION Cancers arising in the temporal bone are extremely rare. Tumours may involve the ear in the following way:

a) Primary cancer involving the ear from auricle, external auditory canal or middle ear and temporal bone. 70% of ear cancer originates in the skin of the pinna.

b) Tumours from adjacent sites extending into the temporal bone. These include malignancies from the parotid gland, Temproromandibular Joint Disorders (TMJ), skin of the pre-auricular and post-auricular sulcus.

c) Metastases from tumours arising in breast, kidney, lung, prostate and other sites.

DIAGNOSIS Diagnosis is usually required before planning definitive treatment (small lesions of the pinna may be suitable for excisional biopsy). Associated enlarged lymph nodes should undergo FNAC assessment prior to definitive treatment. IMAGING High resolution CT is the investigation of choice for assessing bony anatomy of the temporal bone. MRI is useful to define a tumour that may arise from the brain or involve or arise from surrounding anatomical sites e.g. parotid gland. Carotid angiography may be indicated to establish unequivocally the involvement of the carotid artery. If involvement of the internal carotid artery is suspected, then its sacrifice (or reconstruction) may be considered by some surgeons as part of the resection. Under these circumstances, assessment of the effect of occlusion of the ICA is required. This usually involves a test balloon occlusion under local anaesthetic to assess the neurological sequelae. STAGING There is no staging system for malignancies of the ear accepted by either the American Joint Committee on Cancer (AJCC) or Union for International Cancer Control (UICC).


TREATMENT Cutaneous Carcinoma of the Pinna Surgical resection remains the mainstay of treatment, either by traditional methods or Mohs micrographic technique. Where lymphadenopathy exists, surgery in the form of extended neck dissection involving parotidectomy is required (to eliminate the parotid/preauricular lymph nodes). Patients who require resection of carcinoma of the pinna need the input of surgeons who are trained in a repertoire of reconstructive techniques. Radiotherapy can offer a high cure rate for small carcinomas of the pinna. Carcinomas involving the External Auditory Canal/Temporal Bone With a lack of accepted staging system, clinical experience dictates management. Complete surgical resection with clear microscopic margins is the preferred initial primary treatment where the tumour is resectable. A number of surgical approaches are available and include:

a) Mastoidectomy – includes all types of modified radical and radical mastoidectomy.

b) Lateral temporal bone resection (TBR) – removal of the osseous and cartilaginous external auditory canal, tympanic membrane, malleus and incus.

c) Subtotal TBC – includes the additional removal of the otic capsule.

Total TBR – involves the additional removal of the petrous apex.

The above procedures may be combined with parotidectomy and neck dissection depending on the extent of the local disease and associated lymphadenopathy.

Surgical resection and reconstruction that involves the internal carotid artery is controversial. No studies are available to show improved survival with the aggressive approach. The role of pre-operative or post-operative radiotherapy is unknown. Indications for post-operative radiotherapy, however, include:

a) Close resection margins (less than 5mms), when proximity of tumour to important structures such as internal carotid artery precludes wide margins.

b) Positive resection margins. Perineural invasion. These conditions apply to the majority of temporal bone resections – post-operative radiotherapy is indicated in most cases. PROGNOSIS Cutaneous carcinoma of the pinna has been described by several authors as having a higher rate of recurrence and worse prognosis than other skin cancers. Patients


with carcinoma of the pinna should only be managed by surgeons who are regularly involved in Head and Neck Cancer Surgery. Squamous cell carcinoma of the ear has a reported recurrence rate of 14% with death in 2.5% of patients from local failure. The prognosis for carcinoma of the external auditory canal/temporal bone where disease is confined to the canal is approximately 50% with 5 year’s survival but falls to approximately 29% with middle ear involvement. SUMMARY Carcinoma of the temporal bone is rare. No studies are available to evaluate treatment options. Clinical experience dictates the management. Complete surgical resection with clear margins is the preferred initial treatment. The precise role of pre and post-operative radiotherapy is unclear although post-operative radiotherapy is indicated in most cases.


9. CLINICAL GUIDELINES FOR SALIVARY GLAND TUMOURS

INTRODUCTION

Salivary gland tumours are a diverse range of histology and clinical behaviour.

Benign tumours are relatively common.

Malignant tumours are relatively rare.

Carcinomas are classified as:

a) High grade b) Low grade c) Mixed behaviour.

The 1991 World Health Organisation (WHO) histological classification is as follows:

a) Adenomas b) Carcinomas c) Non-epithelial tumours. d) Malignant lymphomas e) Secondary tumours f) Unclassified tumours g) Miscellaneous/tumour-like disorders.

Clinical pathology correlation has proved unreliable and overall clinical behaviour rather than histology provides a better guide for treatment and prognosis. Malignant salivary gland tumours are more common in the submandibular, sublingual and minor salivary glands than the parotid gland. The parotid gland is the commonest site of salivary gland tumours, most of which are benign.

Adenomas Pleomorphic adenoma Myoepithelial adenoma Basal cell adenoma Warthin’s tumour – Adenolymphoma Ductal papilloma Cystadenoma

Carcinomas Acinic cell carcinoma Mucoepidermoid carcinoma Adenoid cystic carcinoma Polymorphous low-grade (terminal

duct) Papillary cystadenocarcinoma Mucinous adenocarcinoma Adenocarcinoma Carcinoma in pleomorphic adenoma (malignant mixed tumour) Squamous cell carcinoma Undifferentiated carcinoma


Assessment and Investigations

Many malignant tumours, particularly low grade, are indistinguishable from benign lesions. Definitive histology is usually available after surgical resection. Diagnosis of high grade malignant tumour is based on:

a) Clinical features – pain, rapid growth, fixation to adjacent tissues, facial nerve involvement or neck node metastases.

b) MRI scanning – non-homogenicity, muscle infiltration and enlarged lymph nodes all suggest malignancy.

c) FNAC – useful for major salivary gland tumours where malignancy is suspected (the role of FNAC in overtly benign disease is questionable). Expert cytopathology should distinguish malignant from benign disease in 90% of cases.

d) Open biopsy – this should be avoided as tumour spillage has an adverse affect on survival.

e) Frozen section – often more difficult than in SCC of the upper aero-digestive tract. False negative rates are high and frozen sections are not as reliable in salivary gland malignancy.

Management

Surgery remains the mainstay of treatment for malignant tumours of the salivary glands. This may or may not be followed by post-operative radiotherapy.

SUBMANDIBULAR GLAND

Primary Tumour

Total excision of the gland is appropriate – extra capsular excision or supra-hyoid or

supra-omohyoid neck dissection is deemed appropriate. The argument for wide resection for adenocystic carcinoma including sacrifice of lingual, hypoglossal and marginal mandibular nerve is equivocal. High grade malignancy in younger patients should be treated aggressively with excision of the gland involving a 2cm margin of healthy tissue.

Large tumours with bone involvement i.e. mandible, require composite resection of soft tissue and rim or segmental mandibular resection. Management of the Neck

High grade tumour with no node metastases (N0) should undergo elective supra-

omohyoid dissection.

Patients with positive neck metastases should have modified radical neck or full radical neck dissection.


RADIOTHERAPY

Indications include: o High grade or bulky disease o Residual neck disease o Microscopical extra-capsular spread within adjacent lymph nodes o Adenoid cystic carcinoma.

Inoperable tumours are best managed with palliative radiotherapy. PAROTID GLAND Primary Tumour

Conservative parotidectomy should be performed with preservation of the facial

nerve provided there is no microscopic invasion.

Deep lobe tumours will require total parotidectomy.

Facial nerve preservation is recommended unless tumour infiltration is obvious per-operatively.

Primary nerve grafting should be considered if clearance of the main facial nerve trunk has been achieved.

Adenoid cystic carcinoma requires total parotidectomy sacrificing any part of the facial nerve involved with tumour. Neck

Neck dissection should be performed where there is evidence of nodal disease

either on clinical assessment or MRI scan.

Prophylactic neck dissection should be considered for patients with high grade tumours e.g. adeno-carcinoma, SCC, high grade muco-epidermoid carcinoma. RADIOTHERAPY Postoperative

As for submandibular gland.

Palliative

As for submandibular gland. MINOR SALIVARY GLANDS

Confirmation of diagnosis usually requires open biopsy e.g. palatal swelling.

The prognosis is more closely related to the stage of disease rather than histology i.e. larger tumours do worse than smaller tumours.


Treatment

Surgery remains the mainstay of treatment.

On bloc resection with wide adequate resection margins is the cornerstone of treatment.

Ablative defects require reconstruction e.g. temporalis muscle flap for posterior maxillectomy defects. Management of the Neck

Clinically positive neck requires:

Modified radical or radical neck dissection where there is evidence of lymph node involvement on clinical examination or MRI scan.

Clinically negative neck: Prophylactic neck dissection is only indicated for high grade tumours e.g. adeno-carcinoma, carcinoma in pleomorphic adenoma or undifferentiated carcinomas.

Indications for Radiotherapy

Microscopic residual disease.

Adenoid cystic tumours.

Aggressive undifferentiated tumours.

THE NATURAL HISTORY OF COMMON SALIVARY GLAND TUMOURS

Acinic Cell Carcinoma

3% of parotid tumours. Peak incidence 5th decade.

Demonstrates variable histological pattern – multifocal and occasionally bilateral.

Survival 90% at 5 years and 55% at 20 years.

Lymph node metastases in 10%.

Total parotidectomy, wide local excision with preservation of uninvolved nerves is the mainstay of treatment.

Prophylactic neck dissection not indicated. Mucoepidermoid Tumour

Variable malignancy with low and high grade lesions.

Low grade lesions show a benign nature.

Commonest major malignant salivary gland tumour (4-9%). >90% in the parotid – almost always in the superficial lobe.

Commonest malignant salivary gland tumour in children.

Highest incidence 3rd – 5th decade. M=F.

Histologically divided into low, intermediate and high grade lesions. These divisions correlate directly with the prognosis.

5 years survival with low grade is 86%.

5 years survival for high grade 22%.

40% incidence of lymph node metastases for intermediate and high grade tumours.


Low grade tumours require local resection by parotidectomy with adjuvant radiotherapy for the high grade lesion. Adenoid Cystic Carcinoma

Common salivary gland malignancy – mucosal sites more frequent than major salivary glands.

2-6% of parotid malignant tumours – 15% of submandibular tumours.

Low pervasive growth – high incidence of perineural infiltration.

Variable histological appearance.

High rate of morbidity due to local recurrence and distant metastases particularly to lung. NB: 20% of patients with primary metastases survive more than 5 years.

5 years survival of 60% with 20 years survival of 20%.

Treatment by wide local resection with preservation of uninvolved major nerves.

Post-operative radiotherapy indicated. Adenocarcinoma

Uncommon tumour usually in the parotid gland.

M=F – any age affected.

Histological appearance variable.

Low grade well-differentiated papillary vs mucinous high grade undifferentiated lesions.

Distant metastases in 40% for high grade tumours.

5 years survival: 75% for low grade tumours, 19% for high grade tumours.

Treatment is by wide local resection with elective neck dissection and post-operative radiotherapy. Malignant Mixed Tumour (Carcinoma within PSA)

99% arise from pleomorphic adenoma after a period of 10-15 years.

Frequency between 2-5%.

The most aggressive of all malignant neoplasms with incidence of blood borne metastases.

5, 10 and 15 years cure rates of 40%, 24% and 19% respectively.

Treatment involves radical resection plus neck dissection with post-operative radiotherapy. Squamous Cell Carcinoma

M:F = 2:1.

A very rare tumour in the salivary glands – difficult to differentiate from high grade muco-epidermoid lesion or secondary deposit from a distant site.

Elderly patients >60 years old very bad prognosis.

Treatment with radical surgery and post-operative radiotherapy.


10. GENERAL PRINCIPLES FOR RADIOTHERAPY AND CHEMOTHERAPY TREATMENT FOR MANAGEMENT OF CARCINOMAS OF THE HEAD AND NECK

Pre-treatment assessment of the patient in a multi-disciplinary team setting is essential for radiotherapy treatment. At the consultation full staging information should be available; this should include details of any examination under anaesthetic carried out, with appropriate histology results and appropriate radiological investigations. Where cases have not been seen pre-operatively photographs and surgical mapping are essential. These should be read in conjunction with the pathology report to delineate areas of higher risk where extra radiation dose may be necessary. Where significant areas of the oral cavity and oropharynx will be irradiated patients will require dental assessment prior to radiotherapy and should know the importance of continued dental hygiene following their treatment. Nutritional Support Consideration should be given to insertion of a PEG feeding tube prior to intensive chemo-radiation where significant parts of the oral cavity and oropharyngeal mucosa will be irradiated. Many of these patients require tube feeding and insertion of a tube prior to treatment can reduce treatment interruptions. Immobilisation Shell Patients undergoing radical treatment will require an immobilisation shell. To reduce anxiety adequate preparation with explanation of how the shell is made including diagrams and leaflets in the clinic is helpful. Dose and Fractionation Stage 1 and 2 Disease T1 to T2 Larynx Only Patients with stage T1 or T2 Laryngeal Cancer can be treated with a hypo-fractionated regime of 55 Gy in 20 daily fractions over four weeks. The same treatment regime can be used for small volume tumours at other sites as clinically appropriate although has a less robust evident base than for treatment of carcinoma of the larynx. It may be preferred to use standard fractionation of 60 to 66 Gy in daily 2 Gy fractions over 6 to 6½ weeks. Stage 3 and 4 Disease Any Node Positive Ts/T4 N0 Fit patients with stage 3 or 4 Head and Neck Cancer treated with a definitive radiotherapy should not be treated with conventional fractionation alone (10 Gy per week). Treatment should be with either modified fractionation or synchronous chemo-radiotherapy. The moderately accelerated regime e.g. DAHANCA 66-66 Gy in 5½ weeks or concomitant boost 72 Gy in six weeks seem most attractive. The radiotherapy regimes used with Platinum based chemotherapy are usually delivered over 6 to 7 weeks, but there is also considerable experience in using chemo-radiotherapy over four weeks. The following regimes are recommended:


Moderately accelerated radiotherapy 66-68 Gy in 2 Gy fractions 6 times a week over 5½ weeks or 66-70 Gy in 6½ to 7 weeks with synchronous chemotherapy. A recent study has shown that Cetuximab concurrently with radiotherapy has equivalent efficacy to chemo radiotherapy with less toxicity. Cetuximab is now NICE approved for use concurrently with radiotherapy in patients where platinum-based chemotherapy use may be undesirable because of the specific toxicity. Medical Co-Morbidity Patients with extensive medical co-morbidity may be treated with definitive radiotherapy alone in conventional or short regimes. Prophylactic Nodal Doses 50 Gy in 2 Gy fraction should be delivered to uninvolved nodal areas where risk of involvement is >20%. Post Operative Radiotherapy Post operative radiotherapy should be offered to patients with the following:

1. Incomplete excision margin (*= denotes high risk of recurrence). 2. If there is extra-capsular nodal spread (*+ denotes high risk of recurrence). 3. When a nodal disease is found in more than one surgical level. 4. If there are any nodes more than 3cm in size. 5. More than two nodes pathologically involved. 6. Advanced T disease.

The suggested dose is 60 Gy in daily 2 Gy fractions over six weeks with a boost of up to 6 Gy in three fractions. Two recent publications have shown a benefit to adding single agent Cisplatin to this radiotherapy regime and it should be considered for patients with one or more very high-risk factors as defined about. Patients over the age of 70 were not treated in these trials and particular caution should be used in patients with significant co-morbidity when using Cisplatin as toxic deaths occurred. Treatment interruptions should be avoided (see departmental policies on avoiding interruptions in radical radiotherapy). Palliative Radiotherapy Suggested regimes: 27 Gy in 6 fractions in 2-3 weeks 20 Gy in 5 fractions 30 Gy in 10 fractions. Supportive Care on Radiotherapy and Chemotherapy Patients should be advised to stop smoking and moderate alcohol intake. Patients should be assessed regularly during their radiotherapy and chemotherapy with particular regard to the extent of mucositis, pain control and nutritional status.


Prophylactic anti-fungals and mouthwashes have been shown to reduce the severity of mucositis and should be prescribed to all patients along with soluble analgesia at the start of treatment. Opiate analgesics will be required for significant numbers of patients towards the end of their treatment. It is essential to ensure that ongoing care of radiotherapy reaction is organised and patients and carers should be given appropriate contact numbers for advice in the post-radiotherapy period.


11. GUIDELINES FOR THE MANAGEMENT OF THYROID CANCER

Pathways and guidelines for referral are as detailed above, Section 2. The East Midlands Cancer Network Thyroid Services endorse the following guidelines for management of suspected or confirmed thyroid cancer: British Thyroid Association Guidelines for the Management of Thyroid Cancer 2014 (available at www.british-thyroid-association.org/Guidelines/) Royal College of Pathologists: Standards and datasets for reporting cancer: Dataset for thyroid cancer histopathology reports 2014 (available at www.rcpath.org) Specific recommendations at each stage of the patient's pathway are summarized below: 11.1 INVESTIGATIONS IN SECONDARY CARE TSH: all patients (ideally already performed by GP). A combination of ultrasound scan and a needle biopsy, usually Fine Needle Aspiration Cytology (FNAC) (freehand or with ultrasound scan guidance) is recommended for diagnosis. Excisional/incisional biopsy is rarely indicated and when tissue diagnosis prior to intervention is difficult to obtain by FNAC, and would alter patient management (typically when lymphoma is suspected), core biopsy (under ultrasound guidance or freehand) is recommended. Suspicious lymph nodes should likewise be sampled by FNA, and if this is unsatisfactory, ultrasound core biopsy should be used in preference to excisional biopsy. If thyroid incisional biopsy proves necessary, it should be performed via a lateral approach. Ultrasound scans should be reported as in the BTA guidelines, including the provision of an overall category U1-5. FNAC may be omitted if ultrasound appearances are considered definitively benign (U2). Thyroid FNA may be performed by a cytopathologist, endocrinologist, surgeon, nuclear medicine physician, oncologist or radiologist, with expertise and interest in thyroid disease. He/she should be trained in good practice and should perform sufficient aspirates to maintain expertise. All requests should include full clinical details and details of the aspiration procedure, including the site of the abnormality and the site of sampling. Where cysts are aspirated the pathologist should be informed whether or not there was complete resolution of the mass after aspiration. All the material aspirated (not just a sample) should be sent to the laboratory without fixation (and therefore without delay) as tumours may present as cysts. Any residual mass should be immediately re-aspirated and the specimens identified separately.


Thyroid FNAC samples should be reported as in the RCPath Guidelines, including the provision of an overall category Thy1-5. Thyroid cytology should be reported by a cyto-pathologist who is either a member of the MDT or at least is regularly engaged in reporting thyroid disease. FNAC can also be used in the diagnosis of suspicious lymph nodes (with the same requirements for assessing adequacy as for thyroid). Needle core biopsy (usually ultrasound guided) is also useful in diagnosis of lymphadenopathy, and is particularly recommended when initial FNAC is non-diagnostic. Excisional biopsy may rarely be required for diagnosis, and if so should be limited in extent i.e. a single index node, in order to avoid excessive scarring within a potential future nodal dissection field. FNAC Diagnostic Categories and anticipated actions Thy 1 -Non-diagnostic Usual Action -FNAC should be repeated. Ultrasound guidance may permit more targeted sampling where the initial FNAC has been undertaken by palpation. Cysts containing colloid or histiocytes only, in the absence of epithelial cells, should be classified as Thy1 but should be clearly described as cysts. If the cyst has been aspirated to dryness with no residual mass, clinical/ultrasound follow up alone may be sufficient. Thy2 -Non-neoplastic Usual Action - Correlate with clinical and ultrasound appearances. If these are benign, conservative treatment/follow-up is appropriate. If clinically concerning or U3+, repeat FNAC is advised. Diagnostic surgery may occasionally be required if clinical/radiological suspicion is high, despite benign cytology. Thy3 (a) Atypia Usual Action- Repeat FNAC. MDT discussion if Thy3a on repeat sample. Thy3 (f) Follicular lesion / suspected follicular neoplasm Usual Action- Surgical removal of the lobe containing the nodule (total ipsilateral lobectomy + isthmusectomy, or isthmusectomy alone if lesion confined to the isthmus). MDT discussion pre-op all cases? Thy4 -Suspicious of malignancy Usual Action - These cases should be discussed at the MDT before deciding on management, usually diagnostic hemithyroidectomy. Intra-operative frozen section of lobectomy/lymph node specimen may allow one-stage procedure in some cases of suspected PTC/MTC. Where Thy4 assessment has been given because of the absence of material for immunocytochemistry (medullary carcinoma) or flow cytometry (lymphoma), the aspirate should be repeated. Thy5 -Diagnostic of malignancy Usual Action -The diagnosis should be discussed at the MDT meeting where further management should be agreed. Surgical intervention indicated for differentiated thyroid cancer and MTC, depending on clinical features. Indication for appropriate


further investigation and treatment for anaplastic thyroid carcinoma, lymphoma, or metastatic tumour. Pre-operative MR or CT scanning are indicated to assess nodal disease for proven differentiated thyroid cancer, particularly cases presenting with palpable nodal disease, when the limits of the goitre cannot be determined clinically, for fixed tumours, poorly differentiated/anaplastic tumours, or in patients with haemoptysis or vocal cord paralysis. Iodine-containing contrast media should be avoided if there is an anticipated need for radio-iodine therapy within 8 weeks of imaging. The responsibility for organisation/performance of diagnostic imaging studies is the responsibility of the diagnostic and assessment service, unless otherwise agreed at the MDT. Other investigations (not routinely indicated)

Basal plasma calcitonin may be useful if MTC is suspected but is not recommended routinely for all thyroid nodules at present. Measurement of serum thyroglobulin before thyroidectomy has no diagnostic value and is not recommended. 11.2 MDT/PATHOLOGY REVIEW Any diagnostic biopsy sample that shows, or is thought to show, thyroid cancer should be sent for review by a histopathologist core member of the MDT. Cases recommended to be Referred to Thyroid MDT after Initial Assessment (prior to any surgery) All suspected/confirmed neoplastic FNA’s (Thy4/5) or core biopsies. All Equivocal FNA’s (Thy3f)?? Proven Metastatic disease (biopsy of lymph node, distant sites) or where clinical/radiological suspicion of metastatic thyroid cancer. All FNA’s in children Cases where there is discrepancy between clinical/radiological findings and cytology 11.3. SURGERY Therapeutic surgery for patients with thyroid cancer should be performed by a surgeon who is a core member of the MDT, with specific training and experience of thyroid oncology. Their case load of thyroid surgery should be sufficient to maintain expertise, and their outcomes should be prospectively audited and entered into the national registry. Patients should undergo pre-operative examination of vocal cord function, preferably by fibre-optic laryngoscopy, in all cases with suspected or proven thyroid cancer, before re-operative thyroid surgery, and in patients reporting voice changes.


In patients diagnosed with thyroid cancer there should be documented evidence of a key worker/CNS being present at the consultation where the diagnosis of cancer is given, and of any written information supplied to the patient. Urgent notification of the patient's GP, and the offer to the patient of a written record of the consultation/copy of the GP letter, should also be documented. The extent of surgery with respect to the thyroid and regional lymph nodes should be ratified and documented at the pre-treatment MDT, based upon tumour stage and clinical factors, as per BTA guidance. Palpable disease in level VI nodes (ie clinical N1 disease) discovered at surgery: in the absence of pre-operative confirmation of nodal disease by cytology/core biopsy, intra-operative frozen section biopsy of a lymph node is recommended, prior to proceeding with level VI dissection if metastatic disease is confirmed. Lymphadenectomy for thyroid cancer should only be performed by those surgeons formally authorised by the MDT to do so (List of names removed, as will change over time and is the remit of each MDT to decide + include in their Operational Policy). Individual units should have written protocols in place for the management of immediate post-operative complications (particularly neck haematoma and hypocalcaemia). Routine assessment of post-operative vocal cord function by fibre-optic laryngoscopy is recommended in all cases. Medullary Thyroid Cancer All surgery for proven MTC should be carried out in the Cancer Centre. Pre-operative investigations should also include:

Baseline calcitonin

At least one 24 hour urine sample for catecholamines and metanephrines to exclude phaeochromocytoma, and a serum calcium to exclude hyperparathyroidism.

RET mutation analysis (even in the absence of a positive family history) Patients with distant metastases at presentation often have prolonged survival. Even in the presence of disseminated disease, surgery (eg total thyroidectomy and central compartment node dissection) should be considered to prevent subsequent compromise of the trachea, oesophagus and recurrent laryngeal nerves. These structures should be preserved whenever possible. Patients with established MTC should undergo a minimum of total thyroidectomy and central compartment node dissection (and lateral neck dissection for proven pathological nodes in the lateral compartment). The need or otherwise for prophylactic lateral node dissection should be discussed on an individual basis at the MDT, dependent on tumour size, imaging and basal calcitonin.


Prophylactic surgery should be offered to disease-free carriers of germ line RET mutations, identified by genetic screening programmes, recommended timings as per BTA guidelines. The possibility of future surgery should be discussed with parents before testing children. 11.4 POST-OPERATIVE THYROID MDT All thyroid cancers should be discussed at post-operative MDT, including incidental micro-carcinomas. Tumour stage (TNMv7), R-stage and performance status should be recorded, and plans for further treatment and follow-up ratified. All neoplasms should have central pathology review, though confirmed benign lesions will not require discussion at MDT. 11.5 RADIOIODINE REMNANT ABLATION AND THERAPY FOR DIFFERENTIATED THYROID CANCER Indications for RAI therapy should be discussed at the planning MDT. 'Definite' indications include tumours >4cm diameter, gross extra-thyroidal disease and distant metastases. For patients without definite indications, the relative risks and benefits of RAI should be weighed at the MDT. Consideration should be given to enrolment into clinical trials (eg IoN) where doubt exists. The patient should be seen by an appropriate core member of the MDT (ARSAC Certificate holder) for full discussion about therapy. Pregnancy must be excluded before RAI therapy in women of reproductive age. rhTSH is the recommended method of preparation for RRA in patients who have the following characteristics: pT1 to T3, pN0 or NX or N1, and M0 and R0 (no microscopic residual disease). A post-ablation scan should be performed after 131I when residual activity levels permit satisfactory imaging (usually 2– 10 days). External beam radiotherapy The main indications for adjuvant radiotherapy are: Gross evidence of local tumour invasion at surgery with significant macroscopic residual disease, or residual tumour that fails to concentrate radioiodine. High dose external beam radiotherapy as part of primary treatment may be indicated for unresectable tumours (including anaplastic cancer).


11.6 POST-TREATMENT FOLLOW-UP (DTC) Following initial treatment with total thyroidectomy and radioiodine remnant ablation (RRA), and before evaluation of the patient’s response to treatment after 9-12 months, TSH should be suppressed to below 0.1 mU/l in all patients. A stimulated Tg and neck US should be performed in preference to a diagnostic 131I WBS between 9 and 12 months from RRA. (The principal indications for a diagnostic WBS after RRA are cases where measurement of serum Tg is unreliable, and where 131I uptake was visualised beyond the thyroid bed and neck in the post-ablation scan). After total thyroidectomy with R0 resection and RRA, the 9– 12 months post-RRA stimulated thyroglobulin, neck ultrasound (and whole body scan (WBS), if performed) should be used in Dynamic Risk Stratification, assessing response to initial therapy (Excellent, Indeterminate or Incomplete responses), as per BTA 2014 Guidelines. Further follow-up, imaging or treatment should be based on the outcome of dynamic risk assessment, which should ideally be discussed at the MDT. Patients with excellent response should be considered for relaxation of TSH suppression and increase in the interval of follow-up. Low-risk cases who have completed their treatment, are shown to be free of disease at five years, and no longer judged to require TSH suppression, may be followed up in settings other than the multidisciplinary thyroid cancer clinic. This may include a nurse-led clinic or primary care following agreement of well-defined protocols and re-referral pathways. For historical patients who have not undergone Dynamic Risk Stratification, it is recommended that serum TSH should be suppressed below 0.1 mU/l for 5-10 years. This suppression can then be relaxed as appropriate, based on clinical, radiological or biochemical assessment of response. 11.7 RECURRENT/METASTATIC DISEASE (DTC) The preferred hierarchy of treatment for recurrent/metastatic disease is:

Surgical excision of loco-regional disease in potentially curable patients

131I therapy for RAI-responsive disease

External beam radiation or other directed treatment modalities such as thermal/radio-frequency ablation

TSH-suppressive thyroid hormone therapy for patients with stable or slowly progressive asymptomatic disease

Systemic therapy with kinase inhibitors, especially for patients with significantly progressive macroscopic refractory disease.

Management of elevated thyroglobulin A single elevated serum Tg should usually be confirmed by repeating the test before proceeding to additional investigations.


A persistently elevated serum Tg should lead to a detailed neck USS in the first instance. For patients with negative neck ultrasound and low concentrations of Tg that are not rising, the decision to proceed to further investigations needs to be balanced against the low probability of detecting the site of disease for which treatment would be beneficial to the patient. The choice of imaging should be guided in the first instance by the symptoms and clinical assessment of the patient, which may point to a particular anatomical area, bearing in mind that the commonest sites of recurrent disease are cervical/mediastinal lymph nodes, lungs and bones. As first line, any of the following imaging modalities may be used: chest CT without contrast, rhTSH-stimulated FDG- PET-CT, neck MRI, spine MRI, bone scan. If diagnostic imaging fails to identify the source of raised Tg, empirical 131I treatment may be given. Factors that influence this decision include the risk category of the patient and the rate of rise of the serum Tg.


APPENDIX D1 - PRIMARY CARE REFERRAL GUIDELINES FIGURE 1 – SCHEMA – Numbers refer to numbered footnotes below

NECK LUMP? THYROID? FEATURES SUSPICIOUS

OF

MALIGNANCY?

STRIDOR? REFERRAL

GUIDELINE

NECK LUMP

Clinically thyroid

See Figure 2

Clinically non-thyroid

Features suspicious of thyroid cancer

+/- stridor

1A

No features

suspicious of thyroid cancer

STRIDOR

NO STRIDOR

> Same-day referral >Designated clinician or A&E > Management then diagnosis

> Fast-track appointment >Designated clinician for thyroid > Neck Lump or thyroid clinic

2

>Routine

appointment > Designated clinician for thyroid > Neck lump or thyroid clinic

2


FIGURE 2: SCHEMA – Numbers refer to numbered footnotes


OF

MALIGNANCY?

STRIDOR? REFERRAL

GUIDELINE

NECK LUMP Clinically non-

thyroid

Clinically thyroid

See Figure 1 > Lump persists after 3 weeks despite antibiotics > Inf. Mono. Excluded > No associated (non-lump) features of malignancy

1B

> Lump has associated (non-lump) features of UAT malignancy+/- stridor

4

> Lump has associated (non-lump features of haematological malignancy +/- stridor

7

> Lump disappears within 3 weeks +/- antibiotics or positive for Inf Mono > No associated (non-lump) features of malignancy

STRIDOR

NO STRIDOR

NO STRIDOR

> Fast-track appointment > Designated clinical for UAT or Cons Haem-Onc > Neck Lump Clinic

3

> Fast-track appointment > Designated clinician for UAT > Direct or at neck lump clinic

5

> Same-day referral > Designated clinician or A&E > Management then diagnosis

> Fast-track appointment > Cons Haem-Onc > Direct or at neck lump clinic

5

Not applicable


FIGURE 3: SCHEMA – Numbers refer to numbered footnotes– see pages 3-4


OF

MALIGNANCY?

STRIDOR? REFERRAL

GUIDELINE

NECK LUMP

> Lump has associated (non-lump) features of UAT malignancy+/- stridor

4

> Lump has associated (non-lump features of haematological malignancy +/- stridor

7

NO STRIDOR

STRIDOR

> Fast-track appointment > Designated clinician for UAT > Direct

> Same-day referral > Designated clinician or A&E > Management then diagnosis

> Routine appointment > Central contact point of designated hospital referral proforma


Notes to Numbered Points on Figures 1-3 1A Features suspicious of cancer associated with a thyroid lump (reference: guidelines for the management of Thyroid Cancer in adults, 2002. British Thyroid Association and Royal College of Physicians):

Solitary nodules increasing in size.

Patient has history of neck irradiation or family history of Thyroid Cancer.

Patient over 65.

Unexplained hoarseness or voice change associated with a goitre.

Associated cervical lymphadenopathy. 1B Features suspicious of cancer associated with the non-thyroid neck lump itself (reference: Department of Health Referral Guidelines for the Diagnosis of Cancer, reviewed 2005):

Persists for three weeks despite antibiotics.

Infectious Mononucleosis excluded. 2 Depending on network-agreed local arrangements, designated clinicians for UAT assessment may also be designated for thyroid assessment and the services may be provided in one common neck lump clinic; or endocrinologists/endocrine surgeons may be designated for assessment of Thyroid Cancer only and work in a specific Thyroid Clinic. 3 See measure 1D-112 regarding the requirements for common working between designated clinicians for UAT cancer assessment and Consultant Haemato-oncologists. 4 Features suspicious of UAT cancer which are not features of the lump itself (reference: Department of Health Referral Guidelines for the Diagnosis of Cancer, revised 2005):

Hoarseness for more than six weeks.

Oral mucosal ulcer persisting for more than three weeks.

Oral swelling persisting for more than three weeks.

Red or red and white patches of the oral mucosa.

Dysphagia for more than three weeks.

Unilateral nasal obstruction, especially with purulent discharge.

Unexplained tooth mobility, not associated with periodontal disease.

Cranial neuropathies.

Orbital masses.


5 Referral to a neck lump clinic or direct to a designated clinician is at the discretion of the referrer depending on the nature of the presenting features. 6

In the absence of a thyroid lump, there are unlikely to be any other head and neck features which would discriminate towards Thyroid Cancer compared to UAT Cancer. Stridor is dealt with independently.

Features of haematological malignancy, without neck lumps, are not relevant to head and neck specific guidelines.

The very rare cases of UAT and Thyroid Cancer presenting only with features due to distant metastases are not covered by these guidelines. They are better dealt with as part of guidelines on the diagnosis and management of a separate entity “carcinoma of unknown origin”.

7 Features suspicious of haematological malignancy (reference: Department of Health Referral Guidelines for Suspected Cancer).


APPENDIX D2 - NETWORK-WIDE UAT REFERRAL PROFORMA FOR ROUTINE REFERRALS

PATIENT INFORMATION: GP/HOSPITAL INFORMATION:

Patient Surname: Referring GP:

Patient First Name(s): Referring Practice:

Title: GP Practice Code:

Sex: DOB: Practice Tel No:

Address: Post Code:

Practice Fax No:

Hospital Number:

NHS Number:

Date of Referral:

Home Tel No:

Work Tel No:

Mobile:

Has the patient been told they may have cancer? YES/NO Is an interpreter required? YES/NO If YES, what language? Referral to: (please tick one box): ENT MAXILLOFACIAL

REFERRAL INFORMATION (please tick boxes against relevant symptoms. Tick at least one box)

Anatomical Site: Oral Cavity (Maxillofacial only) Neck Larynx Larynx (ENT only) Salivary Gland

Clinical Features: Hoarseness< 2 weeks Unilateral painful salivary gland swelling Oral Ulcer< 2 weeks Painful lump in neck >3 weeks Tonsillar enlargement Unusual oral swelling >3 weeks Unexplained generalised sore throat Suspicious white patches of oral mucosa Painful swallowing < 4 weeks

Risk Factors: Non-Smoker Smoker Alcohol consumption

Comments: (e.g. current symptoms, past history, social history, allergies, current medication)

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