FAQ for GP CT Referral for Cancer Pathway (Guidelines)

The person requesting the scan/completing the form must be a doctor (as required by IRMER regulations). GPs in training should discuss this with their trainer to ensure this pathway is appropriate for this patient.

No. The bloods that are required are stated in the referral guide. In spite of the CT being done for a suspicion of cancer tumour markers should not be requested at this stage.

No. See standard pathways for GP referrals to secondary care. http://www.cancerreferral.scot.nhs.uk/

If the patient is under active follow up then discuss with the parent team. If the patient had an in situ malignancy or cancer more than 5 years ago and is not under active follow up this pathway is appropriate.

Yes, the service will be available in Raigmore, Caithness General, Belford and Lorn and the Isles Hospitals.

We aim to provide a scan within 2 weeks of the request. A report should be available within 2 weeks of the scan. If the patient has had an ultrasound the report is likely to be available on the same day.

The result will be available on SCI store. If a radiologist deems a finding 'urgent', the radiology department / teleradiology companies have a process to pass this on to the referrer. This is usually to a practice email address as is already done with x-ray reports. This will take between 1 and 2 working days. GP practices need to have a robust system to deal with this result if the referring clinician is not available on that day.

The referring GP.

The responsibility for onward referral also lies with the referring GP and will not be done by radiology.

The patient is counted against the USC Standard once the GP makes the referral to a Secondary Care clinician as would be the case for a standard USC referral without a CT diagnosis.

If the report is unclear in style or content, the referrer can contact the administrative team by email to: nhsh.reportingqueries@nhs.scot  The query will then be directed to the reporting radiologist or teleradiology company.

The Raigmore Radiology department are not routinely available to discuss the implications of reports. Please make an appropriate secondary care referral if the findings within the report indicate this. Refer to further FAQs for advice on suggested management of incidental findings. The NHS Highland intranet TAM page may be helpful.

Refer as USC to the appropriate specialty. If the primary source is unclear, refer on the basis of the most significant abnormality to the appropriate specialty. If the predominant findings are likely lung primary or secondary please refer to respiratory as a USC.  Inform the patient of the reason for referral as a possible cancer diagnosis.

CT chest/abdo/pelvis is not a panacea to completely ruling out malignancy. By definition the GP is very concerned about their patient so even if the CT has reasonably confidently excluded malignancy, onward referral to secondary care may still be necessary (general medicine, GI, general surgery as per usual practice). This approach should also be considered if the patient has such poor renal function (GFR less than 30) that a CT may not be the best and safest test to arrange.

The Raigmore Radiology department are not routinely available to advice on incidental findings. Please refer to advise within this document and on TAM, or contact the appropriate speciality, taking into account the principles of realistic medicine.

Renal or hepatic cysts do not generally merit any follow-up unless advised. Atelectasis, pulmonary nodules under 5mm, lymph nodes under  1cm, diverticular disease, bony haemangiomas and Tarlov’s (perineural) cysts are usually incidental findings and do not require referral or follow up unless specifically stated. 

See advice on TAM/this FAQ for other respiratory findings including larger lung nodules, incidental thyroid nodules and incidental adrenal nodules.

The largest lymph nodes in the report should be considered most significant and direct further referral.

Significant regional lymphadenopathy in the neck / axilla / groin should direct referral to the same team as if the lymph nodes were symptomatic/palpable on a USC basis.

If the most significant lymphadenopathy is retroperitoneal/abdominal please refer to general surgery as a USC. If it is mediastinal or thoracic please refer to respiratory as a USC.

Solitary pulmonary nodules below 5mm and intrapulmonary lymph nodes are not significant. Above this size, if multiple indeterminate nodules in the absence of a significant finding elsewhere or for other lung abnormalities please see guidelines on incidental pulmonary findings on TAM. If further questions contact respiratory on nhsh.raigmorerespiratory@nhs.scot.

1. Incidental thyroid nodules are detected in up to 18% of patients undergoing cross-sectional imaging for other conditions. Thyroid nodules are more common in females and increase in incidence with age. In most patients further investigation for these incidental nodules is unnecessary.
2. The Scottish Thyroid Cancer Group advises that in patients over 35 years a nodule should be reported if more than 15mm. In patients over 30 years a nodule should be reported if more than 10mm.
3. If the nodule is described as suspicious on CT or there is evidence of neck lympadenopathy please obtain TFT's and refer to ENT.
4. Clinical evaluation for the likelihood of thyroid cancer should be undertaken by the referrer. History of hoarseness, dysphagia and dyspnoea, a history of head and neck or whole body irradiation or a strong family history of thyroid cancer should be taken. 
   1. Should any of the symptoms or factors in point 2 and 3 be present then please obtain TFT's and refer to ENT if euthryoid or hypothyroid
   2. Should any of the symptoms or factors in point 2 and 3 be present then please obtain TFT's and refer to endocrine if hyperthyroid for further evaluation. 

Incidentally discovered adrenal nodules or “incidentalomas” are a common finding on cross sectional imaging, especially in older individuals. The vast majority are benign and should not be associated with weight loss in the absence of an underlying malignancy. However, lesions greater than 4cm in size are associated with a high risk of malignancy and the risk of metastases is higher in those with a known malignancy.

For lesions described has having concerning appearances but which are solitary, please make a referral to urology on a USC basis.

For adrenal lesions described in the radiology report as ‘indeterminate’ or any variant thereof, please follow the below guidance.

In brief, there are two clinical questions:

1. Is the lesion benign?
2. Is the lesion hormonally active (ie secreting an excess of cortisol, aldosterone, androgens or catecholamines)?

The radiologist may be able to determine from the initial CT characteristics if the lesion looks benign (eg if homogenous and with a low density) and will hopefully have commented on this if it was clear. In these circumstances no further imaging is needed but functional testing is usually still recommended (see below). 

If no suspected primary malignancy is seen on the original CT, and the adrenal lesion cannot be characterised, then further imaging is recommended if clinically appropriate (either a dedicated CT adrenals or MRI adrenals).  Please make a referral to radiology for ‘adrenal CT’ in the first instance. This may be amended to MRI by the protocolling radiologist, so please give any contraindications to MRI that may exist. This can be made on a ‘routine’ basis given the strong presumption of benignity in the incidental adrenal lesion under 4cm.

Imaging does not tell if a lesion is hormonally active.  The following tests are recommended if clinically appropriate and can be undertaken in primary care with the exception of the aldosterone to renin ratio (if it is required), although the endocrine clinic would be happy to take referrals in cases where there is a high clinical suspicion of a hormonally active lesion eg rapid weight gain and Cushingoid features.

1. 24 hour urine collection for metanephrines/catecholamines (request an acid containing container from clinical biochemistry) to screen for phaeochromocytoma.
2. Overnight 1mg dexamethsone suppression test to exclude Cushing`s syndrome (prescribe 1mg of dexamethasone to be taken at bedtime and measure cortisol at 9am the following morning). Cortisol should suppress to less than 50nmol/l.

• Aldosterone:renin ratio (ARR). To screen for primary aldosteronism (Conn`s syndrome). This is only needed if the patient is hypertensive, and may not be required if hypertension is well controlled on a single agent or if the patient would not be an operative candidate. Liaise with endocrinology if ARR required.

If these endocrine investigations are normal and the clinical suspicion of an endocrine syndrome is low then no further biochemical testing is required.

If the report is vague and offers no further guidance, contact nhsh.reportingqueries@nhs.scot  by email, who will pass the query to the reporting radiologist / teleradiology provider. Please ensure the query is clear within  the email.

Contact General Surgery/Hepatobiliary team as a USC referral. Clinical evaluation of patient and scans is likely to be required. Whilst further tests/imaging may be needed this should not be the automatic next step after an abnormal CT and will be taken on by secondary care.

A solitary skeletal lesion which is reported as indeterminate should be reported to orthopaedics for further assessment. Whilst this may need further input this is unlikely to explain the symptoms prompting the CT scan.

A myeloma screen should already have been performed to exclude this before CT scan is booked. If this is now felt to be the most likely diagnosis please refer to haematology

If CT shows likely widespread bony metastases without obvious primary, then refer men to urology with DRE findings and an urgent PSA as possibly prostate disease and women to breast. If these teams exclude an obvious primary cancer it is likely that a discussion with oncology should be the next step.