Merseyside and Cheshire Cancer Network HEPATO BILIARY MULTIDISCIPLINIARY
Merseyside and Cheshire Cancer Network HEPATO BILIARY MULTIDISCIPLINIARY TEAM MEETING Referral to Specialist HPB (Liver) MDT, University Hospital, Aintree, with suspected Colorectal Liver Metastases PART 1: TO BE COMPLETED BY THE REFERRING UNIT. N. B. NO PATIENT WILL BE DISCUSSED WITHOUT FULL DETAILS Initial Referral Date / / Date Referred to UHA / / PART 2: TO BE COMPLETED BY UHA Date of 1 st MDT Referring Consultant / / Yes No Number of Days on Pathway Referring Hospital Presenting Consultant Referring Cancer Network SHA Forename UHA Surname DOB 2 week rule / / GP NHS Number GP Tel. No Initial colorectal cancer Date Decision to Treat / / Treatment Start Date / / Operation performed Laparoscopic resection? Yes TNM classification Tumour T 0 T 1 T 2 T 3 T 4 T 5 Colon tumour localisation Right Chemotherapy post colectomy Number of cycles Yes Node N 1 N 2 Metastasis M 0 MX Transverse No N 0 No Left including sigmoid Rectum Drugs 5 FU Yes No Oxaliplatin Yes No Irinotecan Yes No Other Yes No Name product ………………. . Diagnosis of suspected Liver metastases Date Concomitant extra hepatic disease Yes Number Synchronous No Max size …………. mm Yes Localisation: Unilateral Bilateral PLEASE ENCLOSE WITH REFERRAL X-rays Date of last CT/MR. ……………. Contact name and number where Specialist HPB MDT can FAX the MDT decision back to referring team Name X-rays reports Primary cancer histology Details of any co-morbidity CEA Date: ……………. . Tel. No. FAX E-mail SEND PROFORMA WITH CT/MR AND X-RAY REPORTS TO: The Specialist HPB (Liver) UNIT, Room 19, GENERAL SURGERY, UNIVERSITY HOSPITAL AINTREE, LIVERPOOL, L 9 7 AL. TEL: 0151 -529 -8515 REFERRAL CANNOT BE ASSESSED WITHOUT CT/MR AND REPORTS No M 1
PART 3: TO BE COMPLETED BY UHA MDT Decision Potentially Resectable Mass Present Yes Metastases No Immediate Action Planning Ascites No action here Refer Back Vascular Encasement Yes Nodes Consultant Radiologists Dr Smethurst Dr White Dr O’Grady Dr Evans General Summary Further Investigation Date Booked Date Completed CT / / MR / / CEA / / US / / EUS / / Other / / Days on Pathway Reason for Investigation Date of 2 nd MDT / UHA / Reason for Discussion General Summary Confirmed Diagnosis Treatment Outcome Resection OPD Preoperative Chemotherapy Admission Palliative Chemotherapy Microwave RFA Best Supportive / Palliative Care Trials Date of Recurrence / /
Merseyside and Cheshire Cancer Network HEPATO BILIARY MULTIDISCIPLINIARY TEAM Referral to Specialist HPB (Liver) MDT, University Hospital, Aintree, with suspected primary liver cancer, including cholangiocarcinoma, gall bladder cancer PART 1: TO BE COMPLETED BY THE REFERRING UNIT. N. B. NO PATIENT WILL BE DISCUSSED WITHOUT FULL DETAILS Initial Referral Date / / Date Referred to UHA / / PART 2: TO BE COMPLETED BY UHA Date of 1 st MDT Referring Consultant / / Number of Days on Pathway Presenting Consultant Referring Hospital Forename UHA Surname DOB / Inpatient / GP 2 week rule Decision to Treat / / Treatment Start Date / / Yes No Outpatient Presenting Symptoms and Relevant History Bloods CLINICAL QUESTION ALK PHOS ALT CA 19. 9 BILIRUBIN GGT CEA AFP Histology (please include details of any relevant histology e. g. brushings). DO NOT BIOPSY LIVER LESIONS, REFER TO HPB SPECIALIST MDT FIRST ALL RELEVANT IMAGING (INCLUDING ERCP FILM) AND RADIOLOGISTS REPORTS ARE ENCLOSED WITH THIS REFERRAL PART 3: TO BE COMPLETED BY UHA MDT Decision Potentially Resectable SUMMARY OF MDT 1 Mass Present Yes Metastases Immediate Action Planning Ascites No No action here Refer Back Vascular Encasement Yes Discussed by: Nodes Consultant Radiologists Dr Smethurst Dr White Dr O’Grady Dr Evans Contact Details of Referrer where MDT Decision can be faxed: Name: Fax: Tel No. SEND PROFORMA + REFERRAL LETTER WITH CT/MR/ERCP AND X-RAY REPORTS TO: The Specialist HPB (Liver) UNIT, Room 19, GENERAL SURGERY, UNIVERSITY HOSPITAL AINTREE, LIVERPOOL, L 9 7 AL TEL: 0151 -529 -8515 REFERRAL CANNOT BE ASSESSED WITHOUT CT/MR AND REPORTS
Further Investigation Date Booked Date Completed CT / / US / / / / EUS / FNA / / CT Biopsy / / US Biopsy / / / / OPD Admission Days on Pathway Reason for Investigation Date of 2 nd MDT / UHA / Reason for Discussion General Summary Confirmed Diagnosis Treatment Outcome Resection Photodynamic Therapy Neo/Adjuvant Chemotherapy Chemoembolisation Palliative Bypass RFA Palliative Chemotherapy Best Supportive / Palliative Care Trials Date of Recurrence Date of 3 rd MDT / / / UHA / Reason for Discussion General Summary Confirmed Diagnosis Treatment Outcome Resection Trials Neo/Adjuvant Chemotherapy Palliative Bypass Palliative Chemotherapy Date of Recurrence
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