Dorset County Hospital Cancer of Unknown Primary CUP

Classification MUO – Malignancy of unknown origin. p. CUP – Provisional Cancer of Unknown

DCH CUP MDT Core Members: Dr Richard Osborne – (MDT Lead) Consultant Medical Oncologist

Accessing the CUP service Fast track referral In-patient referral Inter-MDT referral from other cancer

CUP – Peer Review Cancer of Unknown Primary is now being managed as all

Metastatic site c. CUP 67% (6) Peritoneal (9) Lung 11% (1) Ovarian 22% (2)

Metastatic site c. CUP 71% (10) Liver (14) Small Bowel 7% (1) c. CUP

DCH CUP Patient timeline (W 165445) PRESENTING SYMPTOMS; Referred to Urology by GP with

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Dorset County Hospital Cancer of Unknown Primary (CUP) Service JW. 10/11/15

Classification MUO – Malignancy of unknown origin. p. CUP – Provisional Cancer of Unknown Primary Confirmed c. CUP – No primary site found

DCH CUP MDT Core Members: Dr Richard Osborne – (MDT Lead) Consultant Medical Oncologist Dr Tom Marsh – Consultant Radiologist Dr Teresa Thomas - Consultant Histopathologist Dr Sandra Pepper – Speciality Doctor, Hospital Palliative Care Team Ann Dixon - Palliative Care Specialist Nurse Jane Wraight – CUP (and Upper GI) CNS Ellie Goff – MDT Facilitator

Accessing the CUP service Fast track referral In-patient referral Inter-MDT referral from other cancer sites Referral to members of the MDT e. g. Palliative care team Via radiology reporting

CUP – Peer Review Cancer of Unknown Primary is now being managed as all other site specific cancers. CUP is subject to peer review. This year we had internal validation and were pleased to have very positive feedback. In 2016 we will be externally peer reviewed with a National Team on site on 4 th April 2016.

Metastatic site c. CUP 67% (6) Peritoneal (9) Lung 11% (1) Ovarian 22% (2) c. CUP 63% (5) Lymph Node(s) (8) Ovarian 13% (1) Haem 25% (2)

Metastatic site c. CUP 71% (10) Liver (14) Small Bowel 7% (1) c. CUP 25% (3) Pancreas 21% (3) Lung 25% (3) Pancreas 15% (2) Bone (13) Ovarian 8% (1) Prostate Small Bowel 8% (1) 7% (1) Renal 15% (2)

DCH CUP Patient timeline (W 165445) PRESENTING SYMPTOMS; Referred to Urology by GP with increasing Urinary tract symptoms. Seen in Urology O. P 2. 04. 15 • Previous heavy smoker stopped 3 months ago. • Serum PSA 3. 04. 14 = 6. 04. • Serum PSA 18. 11. 14 = 8. 07 • MRI & Urology MDT planned. • 14/04/15 MRI PELVIS • 15/04/15 Urology MDT: Discuss at following days MDT • 16/04/15 Specialist Urology MDT: MDT MR showed extensive bone mets – for urgent CT (requested) • 21/04/15 CT scan chest abdo pelvis 3/06/15 Urology MDT: MDT TRUS biopsies do not show any malignancy but has metastatic disease. Query origin – CUP MDT tomorrow 14/05/15 CUP MDT Imaging of MRI and CT Remain under Urology team pending bone biopsy 22/04/14 Urology MDT – CT shows bone mets. No primary. For TRUS and biopsies re-discuss at MDT following this. TRUS & biopsy requested • 5/05/15 Prostate biopsy • 13/05/15 Urology MDT: MDT No primary identified. Normal trans rectal biopsies. For CT of right pubic bone. Refer to CUP MDT • 13/06/15 Prostate biopsy reported no malignancy. For bone biopsy right pubic bone. Referred to CUP MDT 04/06/15 CUP MDT - Await bone biopsy. CUP team take over management, For femoral X-Rays to assess fracture risk. Repeat LFTs calcium and U&Es. for Dr Osborne OPA. 11/06/15 CUP MDT - Possible risk of fracture. For urgent Ortho opinion. Biopsy delayed deliberately in case Ortho procedure provided material • 12/06/15 Orth opinion - no immediate fracture risk. For analgesia and observe • 02/07/15 bone biopsy 09/07/15 CUP MDT Histology pubic bone suggests diffuse large Bcell lymphoma – referred to Haematology.