Greater Manchester Cancer: Referral, Assessment & Management for Suspected Sarcomas
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12
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October 2019
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Increase awareness of MSK tumours
Appropriately manage a patient with a concerning lump
/ suspected bone tumour
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Background
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Symptoms & Signs
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Clinical assessment
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Initial Management
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Referral Criteria
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NICE Sarcoma Guidelines
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Familiarity with 2WW local referral form
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Sarcoma UK
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Bone Cancer Research UK
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A rare type of cancer arising from
mesenchymal/
connective tissue
Soft Tissue, Bone or GIST
1% of all primary cancer
Approx 5300 per year (15/day)
100 different sub-types.
5 year survival rate for sarcoma is 55%
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40-60 years, young adults, children
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No significant aetiology
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Associations: HIV / Kaposis, Neurofibromatosis,
other cancers
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2
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hit hypothesis
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50% extremities: LL > UL
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Other: Retroperitoneal, Chest, Gynae, Breast
World Health Organization classification of
tumours
Tumours are classified by differentiation and biological behaviour.
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Adipocytic tumours
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Fibroblastic/myofibroblastic tumours
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So-called fibrohistiocytic tumours
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Smooth-muscle tumours
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Skeletal muscle tumours
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Vascular tumours
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Chondro-osseous tumours
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Gastrointestinal stromal tumours
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Nerve sheath tumours
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Tumours of uncertain differentiation
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Undifferentiated/unclassified sarcomas.
Common Sarcomas
Soft Tissue
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Leiomyosarcoma
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Fibroblastic Sarcoma
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Liposarcoma
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Rhabdomyosarcoma
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Malignant peripheral nerve
sheath tumour
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Angiosarcoma
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Synovial sarcoma
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GIST
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Kaposi’s
Bone
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Ewings
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Osteosarcoma
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Chondrosarcoma
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Chordoma
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Approach to Patient with a lump
History:
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How long
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Painful
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Increasing in size
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Bigger than 5cm?
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Previous surgery/Rxt
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Discharge or skin changes
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FHx
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other cancers: melanoma, lymphoma, lung
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Ask what has been done: other GP, hospital, private
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Symptoms & Signs
Symptoms
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Pain
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Stiffness
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Local effects
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Non weight bearing
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Vague symptoms
Signs
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Noticeable lump
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Joint swelling
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Skin changes
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Fungating tumour
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Clinical Examination
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Clinical Examination
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Look
: skin changes, naevi, neurofibromas,
multiple lumps
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Feel/Move:
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Location
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limb, trunk, areas of lymph nodes?
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Soft or hard
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Mobile or adherent to deeper structures
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Size >5cm?
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Pain
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Joint function
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Neurological symptoms
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Investigations
Basic Work up:
Ultrasound: Will rule out most benign
MRI (Tumour protocol)
Limb Xray
CXR
Baseline Bloods
Bone Profile/Calcium
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WHOOPS
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Do NOT not biopsy
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Do NOT excise without imaging and discussion
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If in-advertent incision
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biopsy and close
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Lump increasing in size, deep, bigger than 5cm
Painful, fungating, previous surgery, Rxt
Bone changes on Xray
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Sarcoma Service
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Clinical assessment
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Imaging
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Biopsy: Core biospy.
No role for FNA
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Histopathology
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MDT review locally
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Regional MDT
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Management Plan
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Treatment
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Surgical Excision: Marginal, Wide, Amputation
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Pre or Post op Radiotherapy
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Chemotherapy
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Palliative treatment
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Pitfalls in patient pathway
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Delayed referral
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biggest cause of litigation
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Patients referred to non-tumour specialists
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Poor knowledge of tumours and clinical skills
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WHOOPS
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Where are the scans? Urgent? 2WW?
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Beware the persistent haematoma
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Not taking a history
Sarcoma
Clinic
GP
Referral
Specialist
Referral
Soft Tissue
Mass/Bone
lesion
Diagnostic
Clinic
USS + Bx
GMOSS
MDT
MRI / CT
Return to
referrer
Refer to
other
specialty
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Arrange
Surgery
Sarcoma
Diagnostic
Triage/MDM
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Clinic and/or MDT < 2 weeks
Biopsy < 2 weeks
Results and MDT 2-3 weeks
Back to C
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Total = Min 6 weeks
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Doctor, I have got a lump, what do I
do with it?
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History: how long, is it getting bigger and painful
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Examine to see is it soft, hard, mobile and deep;
joint swelling
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Xrays?
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Refer to local sarcoma service if meets criteria
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Discuss/refer if concerned
Its not a pathway for: Unknown malignancy, get seen quicker, small benign proven
lumps
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This content provides comprehensive information on Greater Manchester Cancer referral and assessment for suspected soft tissue and bone sarcomas. It covers objectives, background, symptoms, signs, clinical assessment, initial management, and referral criteria. Essential guidelines and key points on sarcoma classification, common types, and WHO tumor classification are outlined. The document emphasizes the importance of early detection, familiarity with referral forms, and awareness of different subtypes of sarcomas, aiming to improve patient outcomes and increase survival rates.
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Presentation Transcript
Greater Manchester Cancer Referral & Assessment for Suspected Soft Tissue & Bone Sarcomas Amit Kumar 12thOctober 2019
Greater Manchester Cancer Aims Increase awareness of MSK tumours Appropriately manage a patient with a concerning lump / suspected bone tumour
Greater Manchester Cancer Objectives Background Symptoms & Signs Clinical assessment Initial Management Referral Criteria
Greater Manchester Cancer Must Read NICE Sarcoma Guidelines Familiarity with 2WW local referral form Sarcoma UK Bone Cancer Research UK
Greater Manchester Cancer Introduction A rare type of cancer arising from mesenchymal/connective tissue Soft Tissue, Bone or GIST 1% of all primary cancer Approx 5300 per year (15/day) 100 different sub-types. 5 year survival rate for sarcoma is 55%
Greater Manchester Cancer Sarcoma 40-60 years, young adults, children No significant aetiology Associations: HIV / Kaposis, Neurofibromatosis, other cancers 2nd hit hypothesis 50% extremities: LL > UL Other: Retroperitoneal, Chest, Gynae, Breast
World Health Organization classification of tumours Tumours are classified by differentiation and biological behaviour. Adipocytic tumours Fibroblastic/myofibroblastic tumours So-called fibrohistiocytic tumours Smooth-muscle tumours Skeletal muscle tumours Vascular tumours Chondro-osseous tumours Gastrointestinal stromal tumours Nerve sheath tumours Tumours of uncertain differentiation Undifferentiated/unclassified sarcomas.
Greater Manchester Cancer Common Sarcomas Soft Tissue Leiomyosarcoma Fibroblastic Sarcoma Liposarcoma Rhabdomyosarcoma Malignant peripheral nerve sheath tumour Angiosarcoma Synovial sarcoma GIST Kaposi s Bone Ewings Osteosarcoma Chondrosarcoma Chordoma
Greater Manchester Cancer Approach to Patient with a lump History: How long Painful Increasing in size Bigger than 5cm? Previous surgery/Rxt Discharge or skin changes FHx other cancers: melanoma, lymphoma, lung Ask what has been done: other GP, hospital, private
Greater Manchester Cancer Symptoms & Signs Symptoms Pain Stiffness Local effects Non weight bearing Vague symptoms Signs Noticeable lump Joint swelling Skin changes Fungating tumour
Greater Manchester Cancer Clinical Examination Look: skin changes, naevi, neurofibromas, multiple lumps Feel/Move: Location limb, trunk, areas of lymph nodes? Soft or hard Mobile or adherent to deeper structures Size >5cm? Pain Joint function Neurological symptoms
Greater Manchester Cancer Investigations Basic Work up: Ultrasound: Will rule out most benign MRI (Tumour protocol) Limb Xray CXR Baseline Bloods Bone Profile/Calcium
Greater Manchester Cancer WHOOPS Do NOT not biopsy Do NOT excise without imaging and discussion If in-advertent incision biopsy and close
Greater Manchester Cancer 2WW Referral Criteria Lump increasing in size, deep, bigger than 5cm Painful, fungating, previous surgery, Rxt Bone changes on Xray
Greater Manchester Cancer 2WW Referral Form
Greater Manchester Cancer Sarcoma Service Clinical assessment Imaging Biopsy: Core biospy. No role for FNA Histopathology MDT review locally Regional MDT Management Plan
Greater Manchester Cancer Treatment Surgical Excision: Marginal, Wide, Amputation Pre or Post op Radiotherapy Chemotherapy Palliative treatment
Greater Manchester Cancer Pitfalls in patient pathway Delayed referral biggest cause of litigation Patients referred to non-tumour specialists Poor knowledge of tumours and clinical skills WHOOPS Where are the scans? Urgent? 2WW? Beware the persistent haematoma Not taking a history
GMOSS Greater Manchester & Oswestry Sarcoma Service Soft Tissue & Bone Guidelines GP Specialist Referral Referral Return to referrer Soft Tissue Mass/Bone lesion Diagnostic Clinic USS + Bx Sarcoma Diagnostic Triage/MDM Refer to other specialty Arrange Surgery Sarcoma Clinic MRI / CT GMOSS MDT
Greater Manchester Cancer Current Patient Pathway Clinic and/or MDT < 2 weeks Biopsy < 2 weeks Results and MDT 2-3 weeks Back to Clinic Total = Min 6 weeks
Greater Manchester Cancer NHS England
Greater Manchester Cancer Doctor, I have got a lump, what do I do with it? History: how long, is it getting bigger and painful Examine to see is it soft, hard, mobile and deep; joint swelling Xrays? Refer to local sarcoma service if meets criteria Discuss/refer if concerned Its not a pathway for: Unknown malignancy, get seen quicker, small benign proven lumps
Greater Manchester Cancer Thank you
