SOUTH WEST LONDON CANCER NETWORK

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					This guidance is current as of 15th May 2008

SOUTH WEST LONDON CANCER NETWORK

PET REFERRAL FORM - GUIDANCE
It is very important that ALL of the information requested for is completed on the PET/CT referral form. It is also important that the most recent version of the PET referral form is being used. Whilst announcements will be made through the TWGs and WGs when a new form is available, please ensure that you visit the radiology pages on the Royal Marsden website regularly to check for new versions of the form. http://www.royalmarsden.nhs.uk/RMH/healthcare/services/clinserviceradiology.htm Please forward results of recent relevant imaging as a CD with the referral. Lack of previous imaging may delay the issuing of the PET/CT scan report. Forms, with the most recent imaging and report on CD, should be posted to: Department of Nuclear Medicine and PET, The Royal Marsden Hospital NHS Foundation Trust, Downs Road, Sutton, Surrey, SM2 5PT If you wish to fax the referral form at the same time as posting a copy with the most recent imaging, you can do so on 020 8643 6761. If you have any questions, please call 020 8661 3286/7, and someone will be pleased to help. PET referrals forms are used to determine if: (a) there is clinical justification for the PET scan (b) if the PET scan would be covered by the South West London contract, under agreed indications. Some patients from outside the network may also be referred and therefore the appropriate PCTs activity contract would apply. All sections must be completed. Failure to do this and to send previous imaging will result in delays. GP details It is important that full GP details are included. This is essential information that identifies those PET scans which will come under the SWL contract. It is also important for us to know the number of scans that we are undertaking to enable us to plan for future activity levels. Currently the PET team, for each referral form they have, have to call the service planning desk in order to establish the location of the GP practice. This task is made more onerous when only the GP name is given and no address details for the practice are provided. Chemotherapy and radiotherapy history It is also important that details of the patient’s chemotherapy and radiotherapy history are provided, as both can affect the appearance on the PET scan. Patient diagnosis and clinical details It is essential that before allocating an indication code, the relevant patient diagnosis and clinical details are included. Failure to do so may result in a delay to your patient receiving their PET scan. Indications The indications that are applicable for funding are outlined below. These have recently been updated and are current as of the May 2008. This is one of the reasons why it is essential to be using the correct version of the PET referral form. In the past, patients have been turned down for a PET scan

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This guidance is current as of 15th May 2008

as the referrer filled in an old form and the indication that was ticked was no longer applicable as a reason for funding. You should complete the box by adding the appropriate code. For example, if a patient was being sent for a PET scan with clinical stage 1 lymphoma where the CT was indeterminate, the code you write in the box would be 2b. For a breast cancer patient for the detection of metastases where other clinical and imaging signs are equivocal, you would write 6. And so on.

Full indications are as follows: 1. Lung cancer – a. Patients who are candidates for surgery on CT to look for mediastinal lymph nodes and distant metastases. b. Patients who are candidates for radical radiotherapy. c. Solitary pulmonary nodule1 cm or more when an FNA is impossible or has failed. 2. Lymphoma – a. Characterisation of residual masses after treatment. b. Lymphoma clinical stage 1 where CT indeterminate. c. Baseline staging of High grade lymphoma and Hodgkins and staging and follow up in childhood Hodgkins. 3. Colorectal cancer– a. Staging of patients being considered for resection of metastases as part of their treatment for primary or recurrent colorectal cancer. b. When conventional imaging has failed to show the cause of rising tumour markers. 4. Oesophageal cancer pre- radical surgery or radiotherapy 5. Nasopharyngeal/ hypopharangeal cancer looking for occult primary or to detect recurrence where clinical or imaging findings are equivocal 6. Breast cancer – detection of metastases in selected cases where other clinical and imaging signs are equivocal. 7. Thyroid cancer – Rising serum thyroglobulin with a negative radio iodine scan. 8. (8a) Sarcoma, (8b) Melanoma, and (8c) Gynae malignancy prior to radical treatment where conventional imaging is equivocal or unhelpful. 9. Testis – characterisation of residual masses post treatment. 10. Other indications – It is recognised that occasionally PETCT will be required for other cancers in exceptional circumstances requested by the MDT where: • Where major treatment with curative intent which entails a risk of mortality or major morbidity (such as pelvic exenteration, pancreatectomy or other major surgery) would not be considered in the presence of clinically occult disease elsewhere which has not been demonstrated on conventional imaging e.g. CT. Where the early diagnosis of malignancy in the context of rising tumour markers or equivocal conventional imaging would result in proven better therapeutic outcomes. Alternatively in the case of disease recurrence further treatment with curative potential or known therapeutic benefit would be carried out.

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May 2008

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