The diagnosis of a head and neck malignancy can cause a devastating emotional, financial and functional impact upon patients’ lives, their family and the wider support services. This disadvantaged socioeconomic group of cancer patients are disproportionally represented and an early diagnosis with definitive treatment can offer the greatest hope of cure.
An adult patient presenting with an unexplained neck lump will often initially consult a primary care physician and, although a diverse range of pathologies can be ultimately responsible, an attending current or recent non-smoker with elevated alcohol consumption should certainly magnify clinical concerns. The presence of co-existent elicited symptoms of a “sore throat”, dysphagia, voice change or otalgia is worrying and a non-tender, hard lump should be referred urgently. Non-dental related persistent oral ulceration and non-intentioned weight loss needs thorough investigation. In the last decade, a younger patient group with fewer typical high risk behaviours has seen a marked increased incidence of oro-pharyngeal cancers that are thought secondary to particular strains of HPV infection. As non-smokers with fewer co-morbidities, this group is often more curable when managed well.
In Australia, the most common cause of malignant cervical lymph nodes are either from an aero-digestive squamous cell carcinoma or a cutaneous skin primary. Occult tongue, tonsillar carcinomas or malignant scalp lesions may first present with enlarged cervical nodes.
Following a focused history and a preliminary examination, if a malignant process cannot be confidently excluded in primary care, the patient should be expedited onto a responsive, specialist tertiary assessment pathway if available.
In 2004, NICE guidelines for improving cancer outcomes recommended specialist neck lump clinics with same-day cytology for patients with a suspected malignancy. Here, a specialist surgical opinion is synchronously offered alongside all essential diagnostic tests including an FNA tissue biopsy. On site “live” cytology services is the gold standard. The time taken from presentation to multi-disciplinary team decisions on definitive treatment should be minimized.
The tertiary services at Fiona Stanley Hospital offer a Rapid Access Neck Lump Clinic; a one-stop clinic with ultrasound, FNA/core and computer tomography on the same day as the urgent outpatient ENT appointment. The nuclear medicine department has weekly reserved slots when necessary. A specially designed form is utilised to expedite the patient journey, minimise anxiety and communicate quickly between all involved onsite specialists. Repeat patient trips to healthcare facilities are also minimised and unnecessary costly investigations are not performed. There are no out of pocket costs to the patient and the findings are rapidly made available to allow definitive treatment planning at a weekly meeting with regional combined multi-disciplinary oncological, surgical and radiological teams.
Following a single clinic attendance, a specialist summary letter to the referrer will detail symptoms and findings. This includes the flexible nasendoscopy, ultrasound and FNA biopsy results. In most instances a definite benign or malignant diagnosis will be made and onward idealised guidance will be provided following discussion with the patient and their relatives. When a case is TNM staged against the AJCC manual and proven as malignant, it can be significantly expedited into the next MDT meeting alongside parallel provisions for surgical planning and operating theatre requirements.
For more information on assessment and management of adult patients with neck lumps including referral pathways and eligibility criteria for the Fiona Stanley Hospital Rapid Access Neck Lump Clinic please see the ‘Neck Lumps in Adults health pathway.
Rapid Access Neck Lump Clinic at Fiona Stanley Hospital
Dr.Daren Gibson. FRANZCR
Consultant Head & Neck Radiologist. Department co-lead FSH
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National Institute for Clinical Excellence. Guidance on Cancer Services: Improving outcomes in Head & Neck Cancers. November 2004.
Read this and more the May edition of GP Connect.