Constitution - East Midlands Cancer Network

HEAD AND NECK 

NETWORK SITE SPECIFIC GROUP 

And 

THYROID SUBGROUP 

CONSTITUTION 

Including Network Configuration and Operational Framework 

Agreed by: 

Mr Iain McVicar 

Consultant Maxillofacial Surgeon, Nottingham University Hospitals 

EMCN Head and Neck NSSG Chairperson 

& 

Mr D Ratliff, Consultant Surgeon, Northampton General Hospital 

Thyroid Subgroup Chairperson 

9 th July 2010 

Agreed by: 

Mr T Rideout 

Chief Executive, NHS Leicester City 

Chairperson, EMCN Board 

10 th August 2010 

Agreed by: 

Mr Prem Singh, CE NHS Derby City 

As the designated representative of the PCTs in the Network for 

Measures 10-1A-202i, 10-1A-203i, 10-1A-204i, 10-1A-205i, 10-1A-206i 

10 th August 2010 (Minutes of EMCN Board 10 th August 2010) 

Agreed by: 

The Trust Lead Clinicians of the MDTs 

10 th August 2010 (Minutes of NSSG of 10 th August 2010) 

For 10-1C-110i, 10-1C111i 

Agreed by: 

EMCN Head and Neck NSSG & Thyroid Subgroup 

9 th July 2010 

Status: 

Final 

Publication Date: July 2010 

Expiry Date: July 2012 

EMCN Peer Review Self Assessment/ head & Neck NSSG and Thyroid Subgroup Constitution 24.08.10 em 1/111

Contents 

Page 

1.0 Introduction and Background 5 

2.0 The East Midlands Cancer Network 5 

3.0 Scope of the East Midlands Cancer Network Head and Neck and 

Thyroid Service 

3.1 Primary Care Referral 

3.2 Network Configuration of Teams and Diagnostic Services 

Head and Neck 

Thyroid 

3.3 Distribution of Neck Lump Clinics 

3.4 Distribution of Specialist Thyroid Clinics 

3.5 Referral Guidelines for Primary Care Practitioners 

3.6 Named Hospitals, Wards and Associated MDTs 

3.7 Network MDT Configuration 

Facilities of Host Trusts 

3.8 Designated Hospitals Receiving Referrals - Thyroid Lumps 

6 

7 

8 

8 

9 

10 

11 

11 

11 

12 

18 

20 

4.0 Local Support Teams 24 

5.0 Guidelines for Referral of Patients with UAT 20 

6.0 Membership 

- Head and Neck 

- Thyroid 

25 

25 

29 

7.0 Terms of Reference 31 

8.0 User Engagement 31 

9.0 Commissioning Influence 32 

10.0 MDS and Data Collection 32 

11.0 Service Developments 33 

12.0 Clinical and Referral Guidelines 34 

13.0 Research and Trials 35 

14.0 Format of NSSG Meetings 35 

15.0 Agreements 35 

Appendix A: Terms of Reference of EMCN Head and Neck NSSG and 

Thyroid Subgroup 

Appendix B: Job Specification: EMCN Head and Neck NSSG Chair and 

Thyroid Subgroup Chair 

36 

39 

Appendix C: Policy for Collection of Minimum Dataset 41 

Appendix D: EM Head and Neck and Thyroid Cancer Clinical Guidelines 42 


Page Reference Number for Peer Review Measures 

Head & Neck NSSG 

Page Reference 

Measure Thyroid Subgroup 

Page Reference 

25 10-1A-201i 

29 

(Membership) 

31 10-1A-201i 

31 

(ToR) 

5 10-1A-202i 5 

7/8 10-1A-203i 7/9 

10 10-1A-204i 10 

--- 10-1A-205i 11 

7/11/34/46 10-1A-206i 7/11/34/46 

11/49 10-1A-207i 11/49 

11/34/50/71 10-1A-208i ---- 

34/50 10-1A-209i ---- 

34/51 10-1a-210i 34/51 

---- 10-1A-211i 9/52 

12 10-1A-212i ---- 

12 10-1A-213i 12 

--- 10-1A-214i 20 

20 10-1A-215i ---- 

21 10-1A-216i ---- 

24 10-1A-217i 20 

25 10-1C-101i 29 

34/42 10-1C-103i 104 

---- 10-1C-104i 25/29 

35/58 10-1C-105i ---- 

---- 10-1C-106i 35/104 

34/57 10-1C-107i ---- 

---- 10-1C-108i 34/105 

---- 10-1C-109i 34/104 

33 10-1C-110i 33 

41 10-1C-111i 41 

33 10-1C-114i 105 


NHS East Midlands 

* NATCANSAT has not yet produced an East Midlands Cancer Network (EMCN) Map. The 

EMCN is not fully co-terminous with NHS East Midlands as it does not cover north 

Lincolnshire or Bassetlaw. However the map does serve to illustrate the size and complexity 

of EMCN 

OXFORD 

Oxford Radcliffe Hospital 


1.0 Introduction and Background 

(Demonstrating Compliance with Measure 10-1A-201i and 10-1A-202i) 

The purpose of this document is to provide the East Midlands Cancer Network Board and 

East Midlands Stakeholder Organisations (Service users and their families or carers, Acute 

Trusts, Primary Care Trusts, Voluntary Sector Organisations, Users and Clinicians) with an 

overview of how the East Midlands Head and Neck and Thyroid Cancer Network is 

structured in order to provide Improving Outcomes Guidance (IOG) compliant services. 

The associated documents – Work Plan and Annual Report - demonstrate how the Head 

and Neck Cancer NSSG and its Thyroid Cancer Subgroup support the delivery of clinically 

safe, evidence based, clinically effective, IOG compliant cancer services for patients with 

head and neck and thyroid cancer, which are responsive to user identified issues and 

recommendations. 

The chairs of the three local Head and Neck groups and representation for the thyroid 

subgroup met on 20 th November 2009 to agree how to develop an East Midlands Cancer 

Network Head and Neck NSSG. It was agreed that there should be a single group for the 

network which deals with Upper Aerodigestive Tract (UAT) cancer with a Thyroid Subgroup. 

Following on from this meeting the inaugural meeting of the East Midlands Head and Neck 

Cancer NSSG was held on 12 th March 2010. 

The Network Management Board agree the format for the oversight of head and neck cancer 

for the whole group which is set out below for ease of reference:- 

Format 2 – as presented in the Manual for Cancer Services (Measure 10-1A-202i) 

A single group for the network which deals with UAT cancer having the structure, functions 

and terms of reference specified in Measure 10-1A-201i plus a separate single subgroup of 

the NSSG which deals with thyroid cancer. 

Please see section 6 for further details on the membership of the EMCN Head and Neck 

NSSG and Thyroid Subgroup. 

SEPARATE UAT NSSG AND THYROID SUBGROUP: Each group is reviewed 

separately and independently 

The following measures from the Manual for Cancer Services apply and will be reflected in 

the three documents: 

Measures 10-1c-101, 10-1C-102, 10-1C-109 to Applied once to each group 

10-1C-114 

Measures 10-1C-103, 10-1C-115, 10-1C116 

Applied once to each group 

Measures 10-1C-104, 10-1C-105, 10-1C-107 

Applied once – to UAT group 

Measures 10-1C-106, 10-1C-108 

Applied once to thyroid group 

2.0 The East Midlands Cancer Network 

The East Midlands Cancer Network (EMCN) embraces a core population of approximately 

4.2 million people. 

It was formed by the merger of the three previous East Midlands Cancer Networks – Derby- 

Burton, Mid-Trent and Leicestershire, Northamptonshire & Rutland and went operational on 

1 st October 2008. It is not fully co-terminous with NHS East Midlands. There are close cross 

boundary working relationships with the adjacent cancer networks – North Trent, Pan 


Birmingham, Mersey and Cheshire, Thames Valley and Anglia Cancer Networks, reflecting 

traditional patient pathways which are part of coherent integrated care pathways. 

The East Midlands Cancer Network is divided into discrete localities as follows: 

PCTs 

Total 

locality 

pop 

Trusts 

Hospitals 

Kettering 

Locality 

Northants 

Teaching 

PCT 

Northampton 

Locality 

Northants 

Teaching PCT 

LLR 

Locality 

Leicester 

City PCT 

Leicester 

County & 

Rutland 

PCT 

Burton 

Locality 

South 

Staffs 

PCT 

Derby 

Locality 

Derbyshire 

County PCT 

NHS Derby 

City PCT 

Nottinghamshire 

Locality 

Nottingham City 

PCT 


County PCT 

Lincs 

Locality 

Lincolnshire 

County PCT 

284,087 309,294 1,017,900 333,417 500,330 1,070,000 701,402 

Kettering 

General 

Hospital 

NHS FT 

Kettering 

General 

Northampton 

General 

Hospital 

Northampton 

General 

University 

Hospitals of 

Leicester 

UHL 

Burton 

Hosp FT 

Queens 

Hospital 

Derby 

Hospitals 

NHS 

Foundation 

Trust 

Burton 

Hospitals 

NHS 

Foundation 

Trust 

Royal Derby 

Hospital 

Nottingham 

University Hospitals 

NHS Trust 

Sherwood Forest 

Hospitals 

Foundation NHS 

Trust 

City Hospital 

Queens Medical 

Centre 

Newark Hospital 

Kings Mill Hospital 

United 

Lincolnshire 

Hospitals 

NHS Trust 

Lincoln 

County 

Hospital 

Grantham 

Hospital 

Pilgrim 

Hospital 

3.0 Scope of the East Midlands Cancer Network Head and Neck Cancer Service 

The three original East Midlands Cancer Networks – Derby-Burton, LNR and Mid Trent, 

submitted IOG Action Plans to cover the implementation of the NICE Improving Outcomes 

Guidance for Head and Neck Cancer including Thyroid Cancer. All three sets of relevant 

networks teams, NSSGs and Boards were Peer Reviewed successfully against the 

associated measures in the first diet of review. 

It was agreed with Mr Stephens Parsons that following the reconfiguration of the three 

networks into the East Midlands Cancer Network the IOG Action Plans would not need to be 

reworked. This means that there are five specialist teams reflecting the original planning. 

This seems entirely logical given the geography of the network and the previous 

agreements. 

The East Midlands PCT Chief Executives reaffirmed their ongoing support for the IOG Plans 

as they stood. This support is documented in the minutes of the EMCN Board (21.07.09 

appended as additional evidence). 

The East Midlands Head and Neck and Thyroid Cancer Network provide all key services 

related to head and neck and thyroid cancer. In particular there is good local access to 

specialised surgery and PET CT. 

The East Midlands Head and Neck and Thyroid Cancer Services are described below and 

are compliant with the IA Measures for Head and Neck Cancer. 


3.1 Primary Care Referral Policy 

(Demonstrating Compliance with Measure 10-1A-203i, 10-1A-205i and 10-1A-206i) 

The Chair of the East Midlands Cancer Network Board and the PCT Chief Executives of the 

reconfigured PCTs reviewed the original referral policy for head and neck and thyroid 

patients referred as “urgent, suspicious of cancer” at the EMCN Board on 10 th August 2010 

They, on behalf of the East Midlands Health Community endorsed the policy unchanged as 

outlined below: The policy is that such patients should be referred on the agreed form to the 

2WW Office (or similar) at: 

Kettering General Hospital for Northamptonshire PCT (Heartlands) 

Clinical Lead for Head and Neck – Mr A Tewary. Mr Tewary is a core member of the Head & 

Neck SMDT. 

Clinical Lead for Thyroid – Mr S Al-Hamali. Mr Al Hamali co-chair of the Northamptonshire 

Thyroid SMDT. 

Northampton General Hospital for Northamptonshire PCT (Daventry & South Northants 

and Northampton) 

Clinical Lead for Head and Neck – Mr W Smith. This is a local and specialist MDT 

Clinical Leads for Thyroid – Mr D Ratliff co-chair of the Northamptonshire Thyroid MDT 

University Hospitals of Leicester for Leicester City PCT and Leicestershire County & 

Rutland PCT 

Clinical Lead for Head and Neck - Mr J Hayter. This is a Local/Specialist MDT 

Clinical Lead for Thyroid - Dr I Peat. This is a Local/Specialist MDT 

United Lincoln Hospitals for Lincolnshire PCT 

Clinical Lead for Head and Neck - Mr Alasdair McKechnie. This is a local and specialist 

MDT working jointly with NUH through a VTC linked single MDT 

Clinical Lead for Thyroid – Mr A McRae. This is a local/ specialist MDT working jointly by 

VTC with NUH. 

Sherwood Forest NHS FT for Nottinghamshire County PCT 

All patients are discussed at the Nottingham MDT. 

Clinical Lead for Thyroid Mr Nigam – attends NUH MDT 

Nottingham University Hospitals for Nottingham City PCT 

Clinical Lead for Head and Neck – Ms Lorna Sneddon – This is a local and specialist MDT 

Clinical Lead for Thyroid – Mr Chas Ubhi. This is a local and specialist MDT 

Derby Royal Hospital for NHS Derby City and Derbyshire County PCT 

Clinical Lead for Head and Neck – Mr Keith Jones. This is a local and specialist MDT 

Clinical Lead for Thyroid – Mr Jerry Sharp. This is a local and specialist MDT 

Burton Hospitals for South Staffs PCT 

Clinical Lead for Head and Neck and Thyroid - Mr A Thompson. This is a local MDT 

There is a single point of contact agreed as follows: 

Trust Named Contact Telephone/email 

Kettering General Hospital 2ww Office 01536 493303 

Northampton General 2ww Office 01604 544235 

Hospital 

UHL Cancer Office 0116 250 2543 


Derby Hospitals 

Via Choose & Book or Direct Fax 01332 789157 

Colorectal Clinic 

Burton Patient Access Centre Direct Fax 01283 593090 

Kings Mill Choose and Book 01623 622515 

NUH Helen Andrews 0115 9691169 

United Lincoln Julie Miller 01522 512512 Extn 2660 

The Primary Care Referral Proforma for each Trust have been scrutinised and confirmed as 

fulfilling the requirements of the network policy. 

3.2 Network Configuration of Teams & Diagnostic Services 

(Demonstrating Compliance with Measure 10-1A-203i, 10-1A-205i) 

Each of the original networks was compliant with the number of specialist MDTs within the 

network. Given the complex geography and distance of the East Midlands that was one of 

the reasons why no reconfiguration was proposed after the merger. This was agreed with 

Mr S Parsons, Director, NCAT. 

As part of the Action Plan to implement the Improving Outcomes Guidance for Head and 

Neck Cancer the designated hospitals for Diagnosis and Assessment of patients fulfilling the 

criteria of urgent suspicious of head and neck and thyroid cancer and the associated 

clinicians are outlined in the following tables. All have the relevant contractual time. 

Head and Neck 

PCT 

Lincolnshire 

701,402 


678,301 


288,754 

Trust 

United 

Lincolnshire 

Hospitals 

NHS Trust 

Sherwood 

Forest 

Hospitals 

NHS 

Foundation 

Trust 

Nottingham 

University 

Hospitals 

NHS Trust 

Hospitals 

providing 

diagnostic 

services for 

Head and 

Neck cancer 

Lincoln 

County 

Hospital 

King’s Mill 

Hospital 

Queens 

Medical 

Centre 

City Hospital 

MDTs 

And Lead 

Clinician 

Lincoln 

County 

Mr A 

McKecnhie 

Pilgrim 

Hospital, 

Boston 

Mr A McRae 

All patients 

referred to 

Nottingham 

MDT 

Queens 

Medical 

Centre 

Ms L 

Sneddon 

Refers to 

Specialist 

MDTs 

Lincoln 

County 

Hospital – 

VTC with 

Nottingham 

Mr A 

McKechnie 

Queens 

Medical 

Centre 

Ms L 

Sneddon 

Queens 

Medical 

Centre 

Ms L 

Sneddon 

RT and 

chemo 

Provide both 

radio and 

chemotherapy 

In Lincoln 

RT 

Chemotherapy 

In Nottingham 

With some 

outreach 

chemo at 

SFHFT 

Provides both 

radio and 

chemotherapy 

Derby City 

237,905 

Derby 

Hospitals 

NHS 

Royal Derby 

Hospital 

Royal Derby 

Hospital 

Royal Derby 

Hospital 

Provides both 

radio and 

chemotherapy 


PCT 

Derbyshire County 

284,000 (40%) 

Trust 

Foundation 

Trust 

Hospitals 

providing 

diagnostic 

services for 

Head and 

Neck cancer 

MDTs 

And Lead 

Clinician 

Mr K Jones 

Refers to 

Specialist 

MDTs 

Mr K Jones 

RT and 

chemo 

South Staffs 

333,417 

Leicester City 

292,660 

Leicester County 

and Rutland 

Burton 

Hospitals 

NHS 

Foundation 

Trust 

University 

Hospitals of 

Leicester 

Queens 

Hospital, 

Burton 

Leicester 

Royal 

Infirmary 

Queens 

Hospital, 

Burton 

Mr A 

Thompson 

Leicester 

Royal 

Infirmary 

Mr J Hayter 

Royal Derby 

Hospital 

Mr K Jones 

LRI 

Royal Derby 

Hospital for RT 

Royal Derby 

and Burton for 

chemo 

UHL 

Radiotherapy 

Chemotherapy 

679,447 

Northamptonshire 

678,300 

Kettering 

General 

Hospital FT 

Northampton 

General 

Hospital 

KGH 

NGH 

Local MDT 

Mr W Smith 

Local MDT 

Mr W Smith 

Northampton 

General 

Hospital 

NGH 

Radiotherapy 

Chemotherapy 

Brachytherapy 

Some outreach 

chemo at KGH 

Thyroid 

PCT 

Lincolnshire 

701,402 

Trust 

United 

Lincolnshire 

Hospitals 

NHS Trust 

Hospitals 

providing 

diagnostic 

services 

for Thyroid 

cancer 

Lincoln 

County 

Grantham 

Hospital 

MDTs 

And Lead 

Clinician 

Local MDT 

Mr A 

McRae 

Refers to 

Specialist 

MDTs 

Lincoln County 

Hospital – VTC 

with Nottingham 

RT and 

chemo 

Provide both 

radio and 

chemotherapy 

In Lincoln 


County 

678,301 


288,754 

Sherwood 

Forest 

Hospitals 

NHS 

Foundation 

Trust 

Nottingham 

University 

Hospitals 

NHS Trust 

Pilgrim 

Hospital 

City 

Hospital, 

Nottingham 

City Hospital 

Queens 

Medical 

Centre 

Local MDT 

Mr J 

Chelladurai 

Mr Nigam 

from Kings 

Mill 

Hospital 

attends 

NUH MDT 

City 

Hospital, 

Nottingham 

Mr C Ubhi 

City Hospital, 

Nottingham – 

VTC with Lincoln 

RT 

Chemotherapy 

In Nottingham 

With some 

outreach 

chemo at 

SFHFT 

Provides both 

radio and 

chemotherapy 


PCT 

Derby City 

Derbyshire 

County 

500,330 

South Staffs 

333,417 


292,660 

Leicester County 

& Rutland 

679,447 


678,300 

Trust 

Derby 

Hospitals 

NHS 

Foundation 

Trust 

Burton 

Hospitals 

NHS 

Foundation 

Trust 

University 

Hospitals of 

Leicester 

Kettering 

General 

Hospital FT 

Northampton 

General 

Hospital 

Hospitals 

providing 

diagnostic 

services 

for Thyroid 

cancer 

Royal Derby 

Hospital 

Queens 

Hospital, 

Burton 

UHL 

KGH 

NGH 

MDTs 

And Lead 

Clinician 

Royal 

Derby 

Hospital 

Mr J Sharp 

Queens 

Hospital, 

Burton 

Mr A 

Thompson 

Leicester 

Royal 

Infirmary 

Dr I Peat 

Dr S Al- 

Hamali 

Mr D Ratliff 

Refers to 

Specialist 

MDTs 

Royal Derby 

Hospital 

Royal Derby 

Hospital 

LRI 

Joint 


MDT 

Co-chaired by Mr 

Al Hamali & Mr 

Ratliff 

RT and 

chemo 

Provides both 

radio and 

chemotherapy 

Royal Derby 

Hospital for RT 

Royal Derby 

and Burton for 

chemo 

UHL 

Radiotherapy 

Chemotherapy 

NGH 

Radiotherapy 

Chemotherapy 

Some 

outreach 

chemo at KGH 

3.3 Distribution of Neck Lump Clinics 

(Demonstrating Compliance with Measures 10-1A-204i & 10-1A-211i) 

The designated neck lump clinics outlined below are recognised as providing sufficient 

access for the respective PCT populations. These clinics are specified in the Primary Care 

Referral Guidelines which include designated clinicians and contact points see Clinical 

Guidelines. They have been agreed with the EMCN Haematology NSSG (Minutes in 

portfolio) 

Neck Lump Clinic Designated Hospital Thyroid Included 

Kettering General Hospital Neck Kettering General Hospital 

Yes 

Lump Clinic 

Northampton General Hospital Northampton General Hospital 

Yes 

Neck Lump Clinic 

University Hospitals of Leicester University Hospitals of Leicester Yes 


United Lincolnshire Hospitals Lincoln County Hospital 

Yes 


Nottingham University Hospitals Queens Medical Centre 

Yes 


Royal Derby Hospital Neck Lump Royal Derby Hospital 

Yes 

Clinic 

Burton Hospitals Neck Lump 

Clinic 

Queens Hospital, Burton 

Yes 


3.4 The Distribution of Specialist Thyroid Clinics 

(Demonstrating Compliance with Measure 10-1A-205i) 

The designated specialist thyroid clinics outlined below are recognised as providing sufficient 

access for the respective PCT populations. These clinics are specified in the Primary Care 

Referral Guidelines which include designated clinicians and contact points see Clinical 

Guidelines. 

PCT Designated Hospital Specialist Thyroid 

Clinic 


City Hospital Nottingham Yes 


Northamptonshire Northampton General Hospital Yes 


Leicester County & Rutland 

Derby City 


South Staffs 

LRI 

Royal Derby Hospital 

Yes 

Yes 

3.5 Referral Guidelines for Primary Care Practitioners 

(Demonstrating Compliance with Measure 10-1A-206i, 10-1A-207i and 10-1A-208i) 

(Measure 10-1A-206i) The referral guidelines for primary care practitioners regarding patients 

with head and neck symptoms are included in the Guidelines for the Investigation and 

Treatment of Head and Neck and Thyroid Cancer – Appendix D. 

(Measure 10-1A-207i) The referral guidelines for primary care have been distributed to 

primary care medical practices, primary dental practices, designated consultant clinicians, 

non-designated head and neck consultant clinicians (ENT surgeons, endocrine surgeons, 

OMFS surgeons, oral medicine specialists, endocrinologists, restorative dentistry 

consultants). These were distributed by PCT Cascade,post and the Trust internal distribution 

systems. 

(Measure 10-1A-208i) The referral proformas have been agreed by the NSSG and localised 

(by identifying a single referral point for each designated hospital to which proformas can be 

sent for direction to individual specialists) for each designated hospital across the EMCN. 

The referral proforma is used for patients with UAT symptoms which are outside the 'urgent 

suspicion of cancer' definition, and who have no neck lumps and allow for the referrer to 

categorise a patient by presenting features, so that the hospital can direct the referral to the 

relevant specialty (e.g. ENT, OMFS). The proforma have been cross referenced to the 

EMCN Guidelines to ensure that they are compliant with the agreed policies. 

3.6 The Named Hospitals and Wards with the Named MDTs Associated with each 

Hospital 


The named hospitals and wards where the curative surgical treatment for head and neck 

cancer will take place are set out in the table below. The hospitals each fulfil the following 

criteria: 

• They are the designated hospital for the diagnostic and assessment service (cross 

reference to Measure 10-1A-206i) 

• They are the hospital where one or more named MDTs carry out all their curative 

surgical procedures for head and neck cancer. 


• They have a designated head and neck ward (as specified in Measure 10-1D-108i) 

Designated Hospital Designated Ward Associated MDT 

Queens Medical Centre Ward C24 Nottinghamshire MDT (VTC 

with ULH) 

Lincoln County Hospital Waddington Ward Lincolnshire MDT (VTC with 

NUH) 

Northampton General 

Hospital 

Collingtree Ward 

Northamptonshire MDT 

(KGH, NGH, MKGH) 

University Hospitals of Kinmouth Ward (LRI) Leicestershire MDT 

Leicester 

Royal Derby Hospital Ward 16 Royal Derby Hospitals FT 

SMDT 

(Derby & Burton) 

3.7 Network MDT Configuration 

(Demonstrating compliance with Measure 10-1A-213i) 

The East Midlands Cancer Network Board has agreed, in consultation with the NSSG and 

the lead clinicians of each trust in the Network, the list of named MDTs and their locations in 

the network as set out in the table below. This list with the case mix types and their 

locations is the network MDT configuration for head and neck cancer. The team members 

and designated clinicians who provide the diagnostic and assessment service to the local 

catchment of the MDT are listed under each MDT in the following table. 

Head and NECK 

MDT 

VTC between Nottingham and Lincoln 

(Two teams – one in Lincoln (LCH) and one 

in Nottingham (QMC)) 

Surgeons - Nottingham 

Ms L Sneddon, Consultant Head and Neck Surgeon 

Mr P Hollows, Consultant Maxillofacial Surgeon 

Mr I H McVicar, Consultant Maxillofacial Surgeon 

Mr N Beasley, Consultant ENT Surgeon 

Mr J A McGlashan, Consultant Head and Neck Surgeon 

Surgeons – Lincolnshire 

Mr A McKechnie, Consultant Head and Neck Surgeon 

Mr M Clark, Consultant Maxillofacial Surgeon 

Mr A McRae, Consultant ENT Surgeon 

Mr J Chelladurai, Consultant ENT Surgeon 

Oncologists - Nottingham 

Dr J A Christian, Consultant Clinical Oncologist 

Dr M Griffin, Consultant Clinical Oncologist 

Oncologists – Lincoln 

Dr J Baumohl, Consultant Clinical Oncologist 

Dr T Sheehan, Consultant Clinical Oncologist 

COMPOSITION 

UAT MDT 

With Salivary gland tumours 

With UAT cancer invading the skull base 

Skull Base MDT at QMC – once a month 

with neurosurgeons, other ENT surgeons, 

opthalmologists, maxillofacial surgeons, 

neuro-radiologists etc. 


Head and NECK 

MDT 

COMPOSITION 

Radiologists - Nottingham 

Dr R K Lenthall, Consultant Radiologist, NUH 

Radiologists – Lincoln 

Dr I Rothwell 

Histopathologist - Nottingham 

Mr R O Allibone, Consultant Histopathologist 

Histopathologist – Lincoln 

Dr M Reed 

Clinical Nurse Specialist - Nottingham 

Ms J Graves 

Clinical Nurse Specialist – Lincoln 

Ms A Mason 

Speech and Language Therapist - Nottingham 

Ms S Slade 

Ms F Robinson 

Speech and Language Therapy – Lincoln 

Ms S Taylor 

Dietitian - Nottingham 

Ms M Donaldson 

Dietitian – Lincoln 

Ms S Whitworth 

Neurosurgical member 

Skull based tumours are discussed at both Head and Neck and Neurosciences MDT 

meetings. Both MDTs meet once a month in the Skull Base MDT. Neurosurgical members 

are Mr Iain Robertson and Mr Graham Dow who are extended members of the Head and 

Neck MDT. 

Northamptonshire Head and Neck MDT 

(Based at NGH) 

VTC with Kettering General Hospital 

Surgeons 

Mr W Smith, Consultant Head and Neck Surgeon 

Mr S Al-Hamali, Consultant ENT Surgeon 

Mr V Bahal, Consultant Head and Neck Surgeon 

Mr C Harrop, Consultant Maxillofacial Surgeon 

Mr A Tewary, Consultant ENT Surgeon 

Mr P Ameerally, Consultant Maxillofacial Surgeon 

Oncologists 

Dr G Andrade, Consultant Clinical Oncologist 

Head and Neck and malignant salivary gland 

Base of skull is referred on to the Oxford 

MDT 


Head and NECK 

MDT 

Dr C Elwell, Consultant Clinical Oncologist 

Dr R Matthew, Consultant Clinical Oncologist 

COMPOSITION 

Radiologists 

Dr A Bisset, Consultant Radiologist 

Dr C Clark, Consultant Radiologist 

Dr V Sukumar, Consultant Radiologist 

Histopathologists 

Dr N Gorgees, Consultant Histopathologist 

Dr J Nottingham, Consultant Histopathologist 

Dr D Walter, Consultant Histopathologist 

Dr S Milkins, Consultant Histopathologist 

Clinical Nurse Specialists 

Ms P Gibbings 

Ms A Hicks 

Speech and Language Therapists 

Ms E Coker 

Ms K Jackson-Waite 

Dietitian 

Mrs K Owen 

Leicestershire Head and Neck MDT 

(Based at UHL) 

Head and Neck 


Base of skull is referred on to the Nottingham 

MDT 

Surgeons 

Mr T Alun-Jones, Consultant ENT Surgeon 

Mr P Conboy, Consultant ENT Surgeon 

Mr J Hayter, Consultant Head and Neck Surgeon 

Mr A Moir, Consultant ENT Surgeon 

Mr C Avery, Consultant ENT Surgeon 

Oncologists 

Dr I Peat, Consultant Clinical Oncologist 

Dr S Vasanthan, Consultant Clinical Oncologist 

Dr T Sridhar, Consultant Oncologist 

Dr D Peel, Consultant Oncologist 

Radiologists 

Dr B Morgan, Consultant Radiologist 

Dr R Vaidhyanath, Consultant Radiologist 


Dr P Shaw, Consultant Pathologist 

Dr C Kendall, Consultant Histopathologist 


Ms R White 


Head and NECK 

MDT 

COMPOSITION 


Ms S Harris 

Dietitian 

Miss C Hanlon 

Royal Derby Hospitals Head and Neck MDT 

VTC with Queens Hospital, Burton 

Surgeons 

Mr K Jones, Consultant Maxillofacial Surgeon 

Mr S Mortimore, Consultant ENT Surgeon 

UAT MDT 


Base of skull was originally referred to 

Liverpool in the process of repatriation to 

NUH. 

Oncologists 

Dr M Kumar, Consultant Clinical Oncologist 

Radiologists 

Dr N Cozens, Consultant Radiologist 

Dr S Elliott, Consultant Radiologist 

Mr Kulkarni, Consultant Radiologist 


Dr I Robinson, Consultant Histopathologist 


Ms K Jukes 

Ms J Petrie 

Ms V Shepherd 


Ms A Cartwright 

Dietitian 

Ms S Moorley 

Ms L Munro 

Thyroid cancer (endocrine) only 

MDT 

VTC between Nottingham and Lincoln 

(Two teams – one in Lincoln (LCH) and one 

in Nottingham (CHN)) 

COMPOSITION 

Thyroid only 

Surgeons - Nottingham 

Mr C Ubhi, Consultant ENT Surgeon 

Surgeons - Lincoln 

Mr A McRae, Consultant ENT Surgeon 

Mr J Chelladurai, Consultant ENT Surgeon 


Head and NECK 

MDT 

COMPOSITION 

Oncologists - Nottingham 

Dr S Morgan, Consultant Clinical Oncologist 

Oncologist – Lincoln 

Dr T Sheehan, Consultant Clinical Oncologist 

Histopathologists - Nottingham 

Dr Z Chaudhary 

Histopathologists – Lincoln 

Dr M Reed 

Clinical Nurse Specialists - Nottingham 

Ms L Sellors 

Clinical Nurse Specialists - Lincoln 

Ms A Mason 

Northamptonshire Thyroid MDT 

VTC with Kettering 

Surgeons 

Mr D Ratcliff, Consultant Surgeon 

Mr S Al-Hamali, Consultant Surgeon 

Thyroid only 

Oncologists 

Dr R Matthew, Consultant Clinical Oncologist 

Radiologists 


Dr D Walter, Consultant Radiologist 


Dr N Gorgees, Consultant Histopathologist 

Dr J Nottingham, Consultant Histopathologist 


Ms P Gibbings 


Ms E Coker 

Dietitian 

Ms K Owen 

Leicestershire Thyroid MDT 

(UHL) 

Surgeons 

Mr T Alun-Jones, Consultant ENT Surgeon 

Mr P Conboy, Consultant ENT Surgeon 

Mr A Moir, Consultant ENT Surgeon 

Thyroid only 


Head and NECK 

MDT 

COMPOSITION 

Oncologists 

Dr I Peat, Consultant Oncologist 

Dr R Matthew, Consultant Oncologist 

Radiologists 


Dr D Walter, Consultant Radiologist 


Dr C Kendall, Consultant Histopathologist 


Ms P Gibbings 

Kettering Diabetic & Endocrine CNS 


Ms E Coker 

Dietitian 

Ms K Owen 

Royal Derby Hospitals Thyroid MDT 

VTC with Queens Hospital, Burton 

Surgeons 

Mr J Sharp, Consultant ENT Surgeon 

Mr A Thompson, Consultant ENT Surgeon 

Thyroid only 

Oncologists 

Mr M Kumar, Consultant Oncologist 

Dr R Vijayan, Consultant Oncologist 

Radiologists 

Dr N Cozens, Consultant Radiologist 

Dr S Elliott, Consultant Radiologist 

Dr Kulkarni, Consultant Radiologist 


Dr D Green, Consultant Histopathologist 

Dr I Robinson, Consultant Histopathologist 


Mrs K Jukes, Clinical Nurse Specialist 

Ms J Petrie, Clinical Nurse Specialist 

Ms V Shepherd, Clinical Nurse Specialist 


Mrs K Young, Speech and Language Therapist 

Dietitian 


Head and NECK 

MDT 

Mrs S Moorley, Dietitian 

COMPOSITION 

The facilities of the host trusts are as follows:- 

Host Trust 

Nottingham University Hospitals 

United Lincolnshire Hospitals 

Kettering General Hospital 

(as part of the linked Thyroid MDT) 

Facilities on site 

Thyroid Surgery 

Complex Specialist Head and Neck Surgery 

Craniofacial Surgery 

Chemotherapy 

Radiotherapy 

Imaging 

Radiology/Interventional Radiology 

Pathology 

Endoscopy 

Dietetics 

SALT 

ITU/HDU 

Designated Head and Neck Beds 

Prosthetics 

Nuclear Medicine 

Restorative Dentistry 

Videofluoroscopy 

PET-CT 

Local Support Group 


Head and Neck Surgery 

Chemotherapy 

Radiotherapy 

Imaging 

Radiology 

Pathology 

Endoscopy 

Dietetics 

SALT 

ITU/HDU 


Prosthetics 



Local Support Group 

Thyroid surgery 

Imaging 

Pathology 

Palliative and Supportive Care 

Patient Information 

Outreach Chemotherapy 

SALT 

Dietetics 

Endoscopy 


VOCAL Support Group (Local Support 

Group) 


Host Trust 

Northampton General Hospital 

(as part of the linked Thyroid MDT) 

University Hospitals of Leicester 

Royal Derby Hospital FT 

Burton Hospitals NHS Trust 



Complex Specialist Head and Neck Surgery 

Chemotherapy 

Radiotherapy 

Imaging 

Pathology 

Endoscopy 

Dietetics 

SALT 

FACE FAX Support Group 

ITU/HDU 


Prosthetics 


Hygienist 




Complex specialist Head and Neck Surgery 

Chemotherapy 

Radiotherapy 

Radiology (including interventional) 



Pathology 

Endoscopy 

Dietetics 

SALT 

ITU/HDU 



Prosthetics 

PET-CT for LNR 

Specialist Head and Neck Surgery 


Imaging 

Pathology 



Chemotherapy 

Radiotherapy 

ITU/HDU 

Prosthetics 


SALT 

Dietetics 

Endoscopy 


Support Groups 

Access to tracheostomy clinic 

Nurse led endoscopy 

Nurse led thyroid follow up 



Host Trust 


Imaging 

Chemotherapy 

Dietetics 

SALT 





Pathology 

3.8 The Designated Hospitals Receiving Referrals of Patients with Thyroid Lumps 

(Demonstrating Compliance with Measure 10-1A-214i, cross reference to 10-1A-211i) 

In agreement with the Network Management Board, PCT leads and NSSG the following are 

the named PCTs which will refer patients with lumps clinically of thyroid origin to the named, 

designated hospitals. The configuration and associated populations are as originally 

submitted and accepted by NCAT and peer reviewed as compliant in the second diet of 

review. 

Referring PCT 

Nottingham City PCT 

Nottinghamshire County 

Teaching PCT 

Population 

Receiving Hospital 

for Lumps of Thyroid 

Origin 

1,070,000 City Hospital 

QMC 

Lincolnshire PCT 701,402 Lincoln County 

Hospital 

Northamptonshire 284,087 Kettering General 

Teaching PCT 

Hospital 

(Heartlands) 


Teaching PCT (Daventry, 

South Northants and 

Northampton area) 

309,087 Northampton General 

Hospital 

Milton Keynes PCT 220,000 Milton Keynes General 

Hospital 

Leicestershire County and 1,017,900 University Hospitals of 

Rutland PCT 

Leicester 

Leicester City PCT 

Derby City 285,000 

Derbyshire County 284,000 

40% of population referred 

South Staffordshire 


Leicestershire County 


220,150 

66,000 

Royal Derby Hospitals 

NHS FT 

Burton Hospitals NHS 

Trust 

4.0 The Role of Local Support Teams in the Network 

(Demonstrating compliance with Measures 10-1A-215i, 10-1A-216i) 

MDT discussing 

patient 

Nottingham/Lincoln 

VTC MDT 


Thyroid MDT 

Leicestershire 

Thyroid MDT 

Royal Derby 

Hospitals NHS FT 

Measure 10-1A-215i – Distribution of Local Support Team: The distribution of the Local Support 

Teams remains as agreed with the original chairs of the Locality Groups at the time 

of the first diet of review. 

Named Local Support 

Team 

Designated Hospitals 

Area(s) Covered by Local 

Support Team 


Derbyshire Local Support 

Team 

Leicestershire Local Support 

Team 

Lincolnshire Local Support 

Team 

Northamptonshire Local 

Support Team 

Nottinghamshire Local 

Support Team 

Derby Hospitals NHS 

Foundation Trust 



University Hospitals of 

Leicester NHS Trust 

United Lincolnshire Hospitals 

NHS Trust 

Kettering General 

Hospital NHS Trust 


Hospital NHS Trust 

Nottingham University 

Hospitals NHS Trust 

Sherwood Forest 

Hospitals NHS 


 

 

 

 

 

 

 

 

 

 

 

 

 

Derby 

Derbyshire 

Burton 

Leicester 


Rutland 

Lincoln 

Lincolnshire 

Kettering 

Northampton 


Nottingham County 


Measure 10-1A-216i 

Role of Local Support Team 

Introduction 

It is clearly recognised that both patients treated curatively for Head and Neck Cancer as 

well as those treated symptomatically require considerable ongoing support both during and 

after any immediate treatment phase. 

To this end the service has established Local Support Teams to ensure that access to 

appropriate ongoing support is available as and when needed by each individual and their 

family or carers. 

Patients can have considerable co-morbidity. The surgical and non-surgical oncology 

treatments both of OMFS Cancer and ENT Cancers within the UAT can be physically 

demanding and alter radically the individual’s appearance and speech with all the 

concomitant potential for psychological morbidity as well as physical disability. 

To maximise the support provision as close as possible to the individual there is a small core 

team that co-ordinate the relevant input from the appropriate local community services and 

hospital services. 

Purpose of the Local Support Team for Head and Neck Cancer Patients 

• To manage the aftercare and rehabilitation of head and neck cancer patients within 

the relevant locality 

• To work closely with the relevant specialist MDT 

• To work closely with other teams who may have contact with Head and Neck patients 

on their cancer journey 

• To have agreed shared-care policies with the referring MDT to ensure that there is 

clarity of responsibility for the provision of relevant care at each stage on the pathway 

• To co-ordinate the provision from relevant local services for each individual 


Service that require to be available through the Local Support Team 

The Local Support Team will ensure access to the following services for the individual as 

required:- 

• Dietetics: advice on nutrition including modified consistency diet, special diets and 

supplements, monitoring of weight, feeding tube and associated stoma care 

management 

• SALT: communication and dysphagia management 

• Community Nursing: dressings, training of staff, valve care, monitoring of weight 

• Palliative and Supportive Care Macmillan CNS, Hospital and Community Palliative 

Care Teams 

• Welfare Rights: Disability rights if unable to return to work 

• Support Groups: FACE FAX, Laryngectomy Association 

• Information: Local information, Cancer Information, National Patient Information 

(Prescriptions) 

• Community dentistry 

• Prosthetics 

• Physiotherapy; shoulder issues following radical surgery 

• Occupational Therapy 

To ensure that the individuals and their family or carers receive timely and appropriate 

support. 

Whilst it is not envisaged that all disciplines will meet regularly on a formally basis it is 

envisaged that there will be clear channels for communication. 

Protocols agreed with the MDTs 

• Valve care 

• Nutritional Assessment 

• Dental access 

• Patient packs 

Please see below a summary of the protocol for referring patients back to members of the 

MDT from the local support team: 


Patients are advised to contact these key persons should problems arise in between regular 

reviews once discharged from hospital or completion of treatment 

PROBLEM 

SUPPORT TEAM 

MEMBERS 

MDT MEMBERS 

Swallow 

 

 

 

District Nurse 

GP 

Speech & 

Language 

Therapist 

Hospital Clinician 

Dietitian 

Stoma / Valve 

 

 

 


GP 

Speech & 

Language 

Therapist 


Nurse Practitioner 

Wound 

 

 

 


GP 

Speech & 

Language 

Therapist 


Symptom Management 

 

 

 


GP 

Speech & 

Language 

Therapist 


Alteration to the 

capacity for 

independence 

Relevant Short / Long / 

Term Team / GP 



Co-ordinated Lead 

It is envisaged that in each team the lynchpin for co-ordination will be the CNS. However, if 

this is not possible then this role could, in certain circumstances be fulfilled by the SALT or 

dietitian. 

5.0 The Guidelines for Referral of Patients with UAT 

(Demonstrating compliance with Measure 10-1A-217i and 10-1A-218i) 

The following are the guidelines for the referral of patients with UAT cancer from designated 

hospitals in the Network to the MDTs for UAT cancer. 

UAT, salivary glands, skull based tumours 

Patients fulfilling the following criteria should be referred: 

• Newly diagnosed UAT cancer including malignant salivary tumour and skull based 

tumours 

• They must meet the imaging criteria for suspected UAT, malignancy salivery tumour 

or skull based tumour. Imaging (CR or MRI) if this is a diagnostic test. 

• Clinical symptoms suggestive of recurrence in patients with a previous history of UAT 

cancer, malignant tumour of the salivary glands or skull based tumour 

• Palliative issues 

All relevant clinical information is required: 

• Previous relevant surgery 

• Case notes with history 

• All diagnostic test results 

Where a reoccurrence of a cancer is suspected they will be discussed without confirmed 

histology. 

Table 1 - Referral to MDT for UAT and malignant salivary gland tumours 

Designated Hospital MDT for discussion MDT Co-ordinator 

Queens Medical Centre Single MDT VTC with Lincoln Nicola Hodgkinson 

0115 9249924 Ext 65982 

Lincoln County Hospital Single MDT VTC with 

Nottingham 

Wendy Smith 

01522 512512 ext 2659 

Kettering General Hospital 


Northamptonshire Head and 

Neck MDT 

Donna Jacobs 

01604 544163 

Hospital 

Milton Keynes General 

Hospital 

(based at NGH) 

University Hospitals of Leicestershire Head and Lyn Connell 

Leicester 


Queens Hospital Burton 

Neck MDT 


Table 2 – Referral to MDT for Base of Skull lesions 

0116 2587624 

Tehmoor Najib 

01332 783331 

Designated Hospital MDT for discussion MDT co-ordinator 

Queens Medical Centre Single MDT VTC with Lincoln Nicola Hodgkinson 

0115 9249924 Ext 65982 

Lincoln County Hospital Single MDT VTC with Wendy Smith 



Hospital 

(including Kettering General 

Hospital patients) 


Leicester 


(including Queens Hospital, 

Burton patients 

Nottingham 01522 512512 ext 2659 

Oxford MDT 

Donna Jacobs 

Via the Northamptonshire 01604 544163 

Head and Neck MDT 

Nottingham MDT 

Via the Leicestershire Head 

and Neck MDT 

Nottingham MDT 

Via the Derby Head and 

Neck MDT 

Nicola Hodgkinson 

0115 9249924 Ext 65982 

Gemma Tooby 

0115 9249924 Ext 62922 

Thyroid 

Patients fulfilling the following criteria should be referred: 

• Newly diagnosed Thyroid cancer 

• They must meet the imaging criteria for suspected thyroid cancer 

Imaging (CT or MRI) if this is a diagnostic test. 

• Clinical symptoms suggestive of recurrence in patients with a previous history of 

thyroid cancer 

• Palliative issues 

All relevant clinical information is required:- 

• Previous relevant surgery 

• Case notes with history 

• All diagnostic tests results 

Where a reoccurrence of a cancer is suspected they will be discussed without confirmed 

histology. 

Table 3 – Referral to MDT for Thyroid Tumours 

Designated Hospital MDT for discussion MDT co-ordinator 

Nottingham City Hospital Single MDT VTC with Lincoln Jackie Cowley 

Lincoln County Hospital Single MDT VTC with 0115 9691169 Ext 58367 

Nottingham 

Kettering General Hospital Northamptonshire Thyroid 

MDT 

Bronwen Thomason 

01604 544585 


Hospital 

Northamptonshire Thyroid 

MDT 


Leicester 


(based at LRI) 

Lynn Connell 

0116 2587624 

Royal Derby Hospitals 

Queens Hospital, Burton 

Royal Derby Hospital Tehmoor Najib 

01332 783331 

The Northamptonshire MDT also takes ALL the Thyroid Cancer Patients from Milton Keynes 

General Hospital. These patients are cared for by Mr P Gurr who has a joint NGH/MKGH 

appointment. 

6.0 East Midlands Cancer Network Head and Neck Cancer NSSG and Thyroid 

Subgroup Membership: 

(Demonstrating compliance with Measure 10-1A-201i and Measure 10-1C-101i, 10-1C-104i) 


The NSSG Leads, at the Planning Meeting on 20 th November 2010, reviewed the 

membership requirements. It was agreed that the core membership would be as described 

within the Manual of Cancer Services, namely: 

 

 

 

 

 

 

 

MDT Lead from each Network MDT 

At least one nurse member of an MDT in the network 

A Service Improvement representative and NSSG lead 

Three User representatives, if possible or an agreed mechanism for securing user input 

NHS member responsible for users issues and patient/carer information (CNS) 

Member of the NSSG responsible for trials recruitment 

Named administrative/secretarial support (as documented) 

In the spirit of inclusion all members of the three previous NSSGs are members of the East 

Midlands Head and Neck Cancer NSSG or Thyroid subgroup.. The core membership of the 

East Midlands Head and Neck NSSG is compliant with the requirements of the guidance. It 

is multidisciplinary and has representation from each acute trust providing Local/Specialist 

services, links to Primary Care and to Users and Carers. Core members are marked**. 

However in recognition of the demands on clinical time it has been proposed that specialist 

groups marked* function as virtual subgroups and that at least one member will be present 

at the NSSG. 

Measure 10-1A-101i: The designated administrative support for the East Midlands Head 

and Neck Cancer NSSG and the associated Thyroid Subgroup is as follows: 

 

 

 

Mrs Beverley Dyson, Team Administrator EMCN 

Ms Janet Duffin, Service Development Manager, East Midlands Cancer Network 

Dr Elspeth Macdonald, Director, East Midlands Cancer Network 

These colleagues will work with the chair to organise the support for the meetings 

including venues, papers, minutes and other requirements identified by the NSSG 

Chair. 

East Midlands Cancer Network Head and Neck and Cancer NSSG 

Local Head and 

Neck MDT 

Name 

Base 

12. 03. 10 

09.07.10 

Kettering Local 

MDT 

Milton Keynes Local 

MDT link 

Burton Local MDT 

Mr A Tewary** Consultant ENT Surgeon, KGH √ 

Mr P Gurr** Consultant ENT Surgeon, NGH/MKGH √ 

Mr A 

Thompson** 

Consultant ENT Surgeon, QHB 

Specialist Head 

and Neck MDT 

Nottingham SMDT Ms L Sneddon** Consultant Head and Neck Surgeon QMC 

Derbyshire SMDT Mr K Jones** Consultant Maxillofacial Surgeon, RDH 

Leicestershire Mr J Hayter** Consultant Maxillofacial Surgeon, LRI 

SMDT 

Northampton SMDT Mr W Smith** Consultant Head and Neck Surgeon, NGH √ 

Lincolnshire SMDT Mr A 

Consultant Head and Neck Surgeon, LCH 

McKechnie** 

Thyroid MDTs Name Base 

Derbyshire SMDT 


local & SMDT 

Consultant ENT Surgeon, RDH 

Consultant Surgeon, NGH 

√ 

√ 

NUH local & SMDT 

Mr J Sharp** 

Mr D Ratliff** 

& 

Mr Al Hamali** 

Mr C Ubhi** 

Consultant Surgeon KGH 

Consultant ENT Surgeon, CHN 

√ 

√ 

√ 

√ 




Neck MDT 

Name 

Base 

12. 03. 10 

09.07.10 

With Lincoln MDT Mr A McRae** Consultant ENT Surgeon, LCH 

Name 

Base 

NSSG Chairs Mr I McVicar** 

Mr W Smith** 

Mr J Sharp** 

Consultant Maxillofacial Surgeon, QMC 

EMCN NSSG Chair 

Consultant Head and Neck Surgeon, NGH 


Surgical 

Representation 

Medical 

Representation 

Imaging 

Representation* 

Pathology 


Oncology 


Dr V Bahal 

Mr N Beasley 

Mr M Clark 

Mr P Conboy 

Mr C Harrop 

Mr A Hawrani 

Mr P Hollows 

Mr K Lingam 

Professor N 

London 

Mr J McGlashan 

Mr A Moir 

Mr S Mortimore 

Mr A Perks 

Dr T Howlett 

Dr M Levy 

Dr A Bisset 

Dr C Clark 

Dr N Cozens 

Dr S Elliott 

Dr K Kulkarni 

Dr R Lenthall 

Dr B Morgan 

Dr I Rothwell 

Dr V Sukumar 

Dr Vaidhyanath 

Dr D Walter 

Dr R Allibone 

Dr N Gorgees 

Dr J Falconer- 

Smith 

Dr C Kendall 

Dr T Khan 

Dr J Nottingham 

Dr M Reed 

Dr I Robinson 

Dr G Andrade 

Dr S Muhkerjee 

Dr J Christian 

Dr C Elwell 

Dr M Griffin 

Dr R Matthew 

Dr S Morgan 

Dr I Peat 

Dr T Sheehan 

Dr S Vasanthan 

Consultant Thyroid Surgeon, KGH 

Consultant ENT Surgeon, QMC 

Consultant Head and Neck Surgeon, ULH 

Consultant ENT Surgeon, LRI 

Consultant Maxillofacial Surgeon, KGH&NGH 

Consultant ENT Surgeon, QHB 

Consultant Maxillofacial Surgeon, QMC 

Consultant Surgeon, RDH 

Consultant Surgeon, LRI 

Consultant Head and Neck Surgeon, QMC 

Consultant ENT Surgeon, LRI 


Consultant Plastic Surgeon, CHN 

Consultant Physician and Endocrinologist, LRI 

Consultant Endocrinologist, LRI 

Consultant Radiologist, NGH 

Consultant Radiologist, KGH 

Consultant Radiologist, RDH 

Consultant Radiologist, RDH 

Consultant Radiologist, Queens Hospital Burton 

Consultant Radiologist, CHN 

Consultant Radiologist, LRI 

Consultant Radiologist, LCH 


Consultant Radiologist, LRI 


Consultant Histopathologist, QMC 

Consultant Histopathologist, KGH 

Consultant Chemical Pathologist, UHL 

Consultant Histopathologist, DRI 

Consultant Histopathologist, NGH 

Consultant Histopathologist, NGH 

Consultant Head and Neck Pathologist, LCH 

Consultant Pathologist, RDH 

Consultant Clinical Oncologist, NGH 

Consultant Oncologist, NGH 

Research Lead for NSSG 

Consultant Clinical Oncologist, CHN 





Consultant Oncologist, LRI 

Consultant Clinical Oncologist, LCH 

Consultant Clinical Oncologist, LRI 

Service Mrs Cameron** EMCN SIL √ 

√ 

√ 

√ 

√ 

√ 

√ 

√ 

√ 

√ 

√ 

√ 




Neck MDT 

Name 

Base 

12. 03. 10 

09.07.10 

Improvement Ms Walker EMCN Local Improvement Lead √ 

NCRN 

Ms J Berridge NCRN Mid Trent 

Representation* Ms S Hare NCRN Derby Burton 

Palliative Care 


Clinical Nurse 

Specialist 


Allied Health 

Professionals 

Speech and 

Language 

Therapists 

Dietetics 

Ms S Nicholson 

Dr G Finn 

Dr V Keeley 

Dr S Shah 

Ms F Dawson 

Ms L Elliott 

Ms P Gibbings 

Ms J Graves 

Ms A Hicks 

Ms K Jukes 

Ms J Petrie 

Ms V Shepherd 

Ms S Slade 

Ms S Stringer 

Mrs R White 

Ms A Mason 

Ms A Cartwright 

Ms E Coker 

Ms S Harris 

Ms K Jackson- 

Waite 

Ms F Millichap 

Ms F Robinson 

Ms K Young 

Ms Donaldson 

Miss C Hanlon 

Ms S Moorley 

Ms L Munro 

Mrs K Owen 

Ms V Harrison 

NCRN LNR √ √ 

Consultant in Palliative Medicine, John 

Eastwood Hospice 

Consultant in Palliative Care, RDH 

Consultant in Palliative Care, Cransley Hospice, 

Northants 

Clinical Nurse Specialist, LRI 


Clinical Nurse Specialist, NGH (User Issues) 

Clinical Nurse Specialist, KMH 

Clinical Nurse Specialist, NGH 

Clinical Nurse Specialist, RDH 

Clinical Nurse Specialist, Queens Hospital 

Burton 

Clinical Nurse Specialist, RDH 

Clinical Nurse Specialist, QMC 

Clinical Nurse Specialist, KMH 


Clinical Nurse Specialist, LCH 

Speech and Language Therapist, Queens 

Hospital, Burton 

Speech and Language Therapist, NGH 



Speech and Language Therapist, Milton Keynes 

Speech and Language Therapy Manager, QMC 

Speech and Language Therapist, RDH 

Clinical Specialist Dietitian, QMC 

Head and Neck Dietitian, LRI 

Dietitian, RDH 

Dietetics, Queens Hospital Burton 

Senior Dietitian, NGH 

Dental Public 

Consultant in Dental Public Health, 

Health 

Northamptonshire Heartlands PCT 

Community Sister C Nichol District Nurse Liaison, Queens Hospital Burton 

AHP Lead EMCN Ms R Hopkin EMCN Allied Health Professional Lead √ 

Medical Physics Mr S Evans Head of Physics, NGH 

Mr P Goldie Senior Physicist, NGH 

Dr J Marais Nuclear Medicine Physicist, NGH 

Mr D Monk Medical Physicist, LRI 

Biochemistry Dr Gidden Consultant Chemical Biochemist, NGH 

Patient 

Representative 

Mr T 

Thompson** 

Communicating 

Members 

Ms S Bashir 

Ms D Julal 

Ms V Mallows 

Mr T Alun- 

Jones 

Oncology Data Manager, QHB 

MDT Co-ordinator, RDH 

PCT Cancer Lead 

Consultant ENT Surgeon, Glenfield and LRI 

√ 

√ 

√ 

√ 

√ 

√ 

√ 

√ 

√ 

√ 

√ 

√ 




Neck MDT 

Name 

Base 

12. 03. 10 

09.07.10 

Administration 

Pharmacy 

Mr P Ameerally 

Mr C Avery 

Dr C Clark 

Dr A Kilvert 

Dr G 

McCreaner 

Dr S Milkins 

Dr B O’Malley 

Dr K Rizvi 

Ms V Phillips 

Ms L Sellors 

Mrs B Dyson** 

Dr Macdonald** 

Ms J Duffin** 

C Clarke 

C Ward 

Consultant Maxillofacial Surgeon, NGH 

Consultant Maxillofacial Surgeon, LRI 


Consultant Endocrinologist, NGH 

Consultant Biochemist, KGH 


Consultant Endocrinologist, KGH 


Patient Information Manager EMCN 

ENT Sister, NUH 

PA - EMCN 

EMCN Director 

EMCN Service Development Manager 

Network Pharmacist, EMCN LNR 

Network Pharmacist, EMCN Derby Burton 

Primary Care Chair EMCN Primary Care Group 

Circulation for Information 

Trust Managers for Ms J Pipes 

Information Mrs C 

Greenfield 

Ms J Jan 

Mr G Pilkington 

Ms L Hitchins 

Ms F Gordon 

Ms J Harper 

Ms S Donelly 

Network Lead 

Clinicians for 

Information 

Clinical 

Implementation 

Managers for 


Ms H O’Connell 

Mr M Lamb 

Dr W Goddard 

Dr P Shaw 

Ms A Johnson 

Ms M Emery 

Cancer Centre Manager, ULH 

Trust Cancer Manager, NUH 

Trust Lead Cancer Manager, SFFT 

Cancer Manager, Derby Royal Hospital 

Cancer Lead, Burton Hospitals 

Cancer Services Manager, UHL 

Lead Cancer Manager, Kettering General 

Cancer Centre Manager, Northampton General 

Cancer Service Manager, LRI 

EMCN Mid Trent Lead Clinician 

EMCN Derby Burton Lead Clinician 

EMCN LNR Lead Clinician 

EMCN 

EMCN 

√ 

√ 

√ 

√ 

√ 

East Midlands Cancer Network Thyroid Subgroup of the Head and Neck 

NSSG 

Local Thyroid Lead Name Designation and Base 09.07.10 

MDT 

Lincolnshire MDT Mr A McRae** Consultant Head and Neck Surgeon, LCH 

Boston MDT Mr J 

Consultant ENT Surgeon, PHB 

Chelladurai** 

Burton MDT Mr A Thompson** Consultant ENT Surgeon, QHB 

Kettering MDT Dr S Al-Hamali** Consultant Surgeon, KGH √ 

Link to Milton Mr P Gurr** Consultant ENT Surgeon, NGH 

Keynes MDT 

Specialist 

Thyroid MDT 

Northampton MDT Dr D Ratliff** Consultant Surgeon, NGH 

√ 

Chair EMCN Thyroid Subgroup of the Head 

and Neck NSSG 

Derbyshire Thyroid Mr J Sharp** Consultant ENT Surgeon, RDH √ 



NSSG 


MDT 

MDT 

Nottingham MDT Mr C Ubhi** Consultant ENT Surgeon, NUH √ 

Leicestershire Dr I Peat** Consultant Clinical Oncologist, LRI √ 

MDT - 

Other Surgical 

Members 

Medical Members 

Imaging 


Pathology 


Oncology 


Service 

Improvement 

NCRN 


Mr T Alun-Jones 

Mr V Bahal 

Mr J Chelladurai 

Mr P Conboy 

Mr A Moir 

Mr A Tewary 


Dr T Howlett 

Dr M Levy 

Prof J O’Donnell 

Dr A Bisset 

Dr D Walter 

Dr N Cozens 

Dr N Gorgees 

Dr C Kendall 

Dr J Nottingham 

Dr I Robinson 

Dr R Matthew 

Dr S Morgan 

Dr T Sheehan 

Dr R Vijayan 

Mrs T Cameron** 

Mrs L Walker 

Ms J Berridge 

Ms S Hare 

Ms S Nicholson 

Consultant ENT Surgeon, UHL 

Consultant Surgeon, KGH 

Consultant ENT Surgeon, PHB 

Consultant ENT Surgeon, UHL Research 

Lead 

Consultant ENT Surgeon, UHL 

Consultant ENT Surgeon, KGH 

Consultant Head and Neck Surgeon, NUH 

Consultant Physician, UHL 

Consultant Endocrinologist, UHL 

Consultant Chemical Biochemist, NGH 



Consultant Radiologist, Derby 


Consultant Histopathologist, UHL 

Consultant Pathologist, NGH 

Consultant Histopathologist, Royal Derby 

Consultant Oncologist, NGH 


Consultant Clinical Oncologist, LCH 

Consultant Oncologist, Royal Derby 

EMCN Service Improvement Lead 

EMCN Service Improvement – Local Lead 

NCRN Mid Trent 

NCRN Derby Burton 

NCRN LNR 

Palliative Care Dr S Shah Consultant in Palliative Care, Cransley Hospice 

Clinical Nurse 

Specialist 


Allied Health 

Professionals 

Communicating 

Members 

Administration 

Pharmacy 

Ms P Gibbings 

Ms A Mason 

Ms L Sellors 

Ms K Jukes 

Ms V Shepherd 

Ms E Coker 

Mr S Evans 

Mr P Goldie 

Ms C Greaves 

Mr J Marais 

Mr D Monk 

Ms K Young 

Dr A Kilvert 

Dr G McCreanor 

Prof M Nicholson 

Dr B O’Malley 

Dr K Patel 

Dr P Amin 

Mrs B Dyson** 

Dr Macdonald** 

Ms J Duffin** 

C Clarke 

C Ward 

Clinical Nurse Specialist, NGH 

Clinical Nurse Specialist, LCH 

Clinical Nurse Specialist, NUH 

CNS Derby Burton 

CNS Derby Burton 


Medical Physics, NGH 

Radiotherapy Physics, NGH 

Nuclear Medicine, ULH 

Nuclear Medical Physicist, NGH 

Medical Physicist, UHL 

SALT, Derby Burton 

Consultant Endocrinologist, NGH 

Consultant Biochemist, KGH 

Consultant Surgeon, UHL 



Consultant Endocrinologist, Derby 

PA - EMCN 

EMCN Director 

EMCN service Development Manager 

Network Pharmacist, EMCN LNR 

Network Pharmacist, EMCN Derby Burton 

√ 

√ 

√ 

√ 

√ 

√ 



NSSG 


MDT 

Primary Care Chair EMCN Primary Care Group 

Circulation for Information 

Trust Managers for 

Information 

Network Lead 

Clinicians for 

Information 

Clinical 


Managers for 


Ms J Pipes 

Mrs C Greenfield 

Ms J Jan 

Mr G Pilkington 

Ms L Hitchins 

Ms F Gordon 

Ms J Harper 

Ms S Donelly 

Ms H O’Connell 

Mr M Lamb 

Dr W Goddard 

Dr P Shaw 

Ms A Johnson 

Ms M Emery 

Cancer Centre Manager, ULH 

Trust Cancer Manager, NUH 

Trust Lead Cancer Manager, SFFT 

Cancer Manager, Derby Royal Hospital 

Cancer Lead, Burton Hospitals 

Cancer Services Manager, UHL 

Lead Cancer Manager, Kettering General 

Cancer Centre Manager, Northampton General 

Cancer Service Manager, LRI 

EMCN Lead Clinician 



EMCN Clinical Implementation Manager 

EMCN Clinical Implementation Manager 

7.0 Terms of Reference: 

(Demonstrating compliance with Measure 10-1A-201i and Measure 10-1C-104i) 

The East Midlands Head and Neck Cancer NSSG and Thyroid Subgroup Terms of 

Reference were drafted at the meeting of the Chairs on 20 th November 2010. They were 

then circulated to all three local groups and relevant stakeholders for comment and 

amendment. The final document was ratified formally by the East Midlands NSSG on 12 th 

March 2010. 

The Terms of Reference are included in full in Appendix A. 

It has been agreed with the East Midlands Cancer Network Strategic Board that network 

groups will be considered quorate when all three local networks and specialist groups are 

represented at any one meeting. 

8.0 User Engagement: 

To date the method of securing users input to individual NSSGs has varied across the three 

original networks. 

The East Midlands Strategic Partnership Group will be the primary source of advice and 

representation on site specific and cross cutting groups. 

In the establishment phase of the new East Midlands wide NSSG it is envisaged that a 

designated member of the NSSG, usually one of the site specific Clinical Nurse Specialists, 

will have responsibility for users issues. They will ensure that these issues are raised with 

the East Midlands Strategic Partnership Group and the local network partnership groups and 

their advice and comment fed back appropriately. They will also link to the EMCN Nurse 

Director. 

The East Midlands Cancer Network Head and Neck NSSG has elected one user 

representative as a core member of the group. The Thyroid Subgroup has still to secure user 

representation as part of the core membership. 


Prior to all new user representatives attending site specific meetings they will be offered a 

meeting with their local User Involvement Facilitator to give them the opportunity to discuss 

the role and responsibilities and clarify that they have attended appropriate training to enable 

them to participate actively. The User Facilitator will provide ongoing support to the 

individuals. It is expected as a standard of good practice that users actively engaged in the 

network will have undertaken Cancer Voices training and feel confident to participate at the 

events they attend. 

The Network Nurse Director or the Local Clinical Implementation Manager will discuss any 

points of clarification with new members if required. The user representatives attending the 

site specific group will have access to the local Clinical Implementation Manager to raise any 

issues arising from the meeting. 

The lead member of the Network Team who attends the site specific group will support the 

user representatives, ensure that they are introduced to the chair and ensure that the chair 

conducts formal introductions at each meeting. 

Other sources of user contribution will include agreed surveys (developed and ratified by the 

Partnership Groups at local and East Midlands level), plus other approaches as 

recommended by the service users such as focus groups and workshops. 

9.0 NSSG Commissioning Influence: 

The Network as a whole and its constituent groups feed in to the commissioning process at 

several levels: 

o The NSSG development plans are presented formally to the East Midlands 

Specialised Commissioning Group Board (SCG) upon which sit the Director of the 

East Midlands Specialised Commissioning Group and PCTs at Chief Executive level 

for each locality. 

o Commissioning of drugs has an agreed process with the Network and SCG. The 

submissions have to be supported East Midlands wide, co-ordinated by the Network 

Pharmacists and show clear reference to: 

 

 

 

 

 

NICE – http://www.nice.org.uk 

London Cancer New Drugs Group – http://www.nelm.nhs.uk/search 

Scottish Medicines Consortium (SMC) - http://www.scottishmedicines.org.uk 

All Wales Medicines Strategy Group 

http://www.wales.nhs.uk/sites3/home.cfmOrgID=37 

National Prescribing Centre - htpp@//www.npc.co.uk 

o Specific local development issues will be discussed at the locality boards upon which 

sit the PCT Cancer Commissioning leads for that locality. 

o Network team contributes to the Local Operational Plan (LOP) process of each PCT 

and the East Midlands Cancer Network (EMCN) Board reviews all the cancer lines in 

the LOPs 

o Network represented on the Regional Clinical Cabinet and Next Stage Review (NSR) 

Collaborative Programme Steering Group as well as the county NSR groups to 

ensure that links to all policy levers are utilised 


10.0 EM Head and Neck/Thyroid Cancer Minimum Dataset & Data Collection: 

(Demonstrating compliance with Measures 10-1C-110i and Measure 10-1C-111i) 

The East Midlands Head and Neck Cancer NSSG Chair has agreed with the East Midlands 

NSSG members representing all MDTs that the Network will collect: 

 

 

 

 

 

Monitoring for cancer wait times (Exeter Returns) in accordance with DSCN 20/2008 and 

any subsequent revisions 

https://nww.openexeter.nhs.uk/nhsia/index.jsp 

Registry Dataset in line with the National Contract for Acute Services 

http://nww.ic.nhs.uk/services/datasets/document-downloads/cancer v4.5b 

http://www.nhsia.nhs.uk/cancer/pages/dataset/docs/dataset.pdf 

Chemotherapy and radiotherapy data for Clinical Information Project 

Dataset for DAHNO 

www.ic.nhs.uk/webfiles/Services/NCASP/Cancer/New%20web%20document%20(Head 

%20and%20Neck)DAHNO 

Dataset for the Audit of the British Association of Endocrine & Thyroid Surgeons 

www.baets.org.uk 

The Clinical Information Analysis project data is an agreed upload from the Trusts. The input 

is funded by the East Midlands Cancer Network. 

Each team will be responsible for collecting the sections of the dataset that relates to their 

direct management of the patient. 

When a patient is referred between teams for specialist investigation/treatment then it will be 

the responsibility of the specialist MDT Team to transfer the relevant dataset they collect 

during the care of the patient back to the referring MDT Team. 

For Cancer Waiting Times (CWT) data if the patient is a 2ww referral then the Trust that 

receives that referral and first sees the patient is responsible for collecting and uploading the 

CWT dataset. Trusts are also responsible for uploading the treatment section of the CWT 

dataset for all patients they provide first treatment for. This should be in accordance with 

DSCN 20/2008. MDTs need to ensure that the relevant data items are available on the 

appropriate Trust IT systems. The dataset policy is included in Appendix C. 

11.0 East Midlands Head and Neck Cancer Service Development Plan 2010-2013: 

(Demonstrating compliance with Measures 10-1C-114i) 

A baseline review of services was undertaken at the inaugural meeting of the EMCN Head 

and Neck NSSG on 12 th March 2010. Following on from this a Service Development Plan 

for Head and Neck and Thyroid Cancer across the East Midlands was confirmed to cover 

the period 2010-2013. The key issues for development are summarised below: 

Service Issue Sites where available Development Plan Action 

Brachytherapy It was agreed that this had a limited 

role in head and neck cancer. The 

NSSG agreed to support the 

designation of a single site as the 

regional service 

EMCN Director to work with 

Brachytherapy Working Group 

and SCG. 

Develop access plan to be 

agreed for clinical guidelines 


Service Issue Sites where available Development Plan Action 

CNS Review EMCN Review of work load and Link to the EMCN Nurse 

options for innovation 

Director to ensure input 

Horizon 

Scanning for 

Trials and New 

Drugs 

End of Life 

Care 

(EOLC) 

Community 

Services 

Restorative 

Dentistry 

Patient 

Information – 

Head and neck 

and Thyroid 

To be identified 

Available in Nottingham and Leicester 

Awaiting roll out to Trusts from NCAT. 

Will be available at all Trusts 

Identify pilot options for outside 

funding 10-11 

Take through the EMDAG 

Process with the Network 

Pharmacists 

Ongoing. 

Next review Sept 10 

Contribute to the NSR work 

streams through the EMCN 

Nurse Director 

Scoping exercise to be 

undertaken by CNS subgroup to 

ascertain what is available 

across the EMCN 

Ensure access for all parts of 

the EMCN. None available in 

Derby Burton 

PIMs to work with Trusts to 

ensure Patient Information 

embedded 

The progress against the Service Development Plan will be reviewed annually. 

12.0 Clinical and Referral Guidelines 

(Demonstrating Compliance with Measures 10-1A-206i, 208i, 209i, 210i, 211i , 10-1C-103i, 105i, 

106i, 107i, 108i, 109i) 

The East Midlands Head and Neck Cancer NSSG has agreed that the referral guidelines for 

Head and Neck and Thyroid Cancer are those contained in the NICE Guidance 

www.nice.org.uk/CG027 

In compliance with Measure 08-1A-202i the PCT agreed point of contact for Referral for 

Suspected Cancer has been agreed as the 2ww office or equivalent in each Trust. This 

policy was reconfirmed by the PCT representatives at the EMCN Board on 10 th April 2010 

and noted formally in the agreement for the constitution by Mr P Singh, Chief Executive NHS 

Derby City as the designated PCT representative. 

Trust Named Contact Telephone/email 

Kettering General Hospital 2ww Office 01536 493303 

Northampton General 2ww Office 01604 544235 

Hospital 

UHL Cancer Office 0116 250 2543 

Derby Hospitals 

Via Choose & Book or Head Direct Fax 01332 786715 

and Neck Clinic 

Burton Patient Access Centre Direct Fax 01283 593090 

Kings Mill Choose and Book 01623 622515 

NUH Helen Andrews 0115 9691169 

United Lincoln Julie Miller 01522 512512 Extn 2660 


Patients presenting as an emergency will be stabilised then transferred to the relevant 

specialist team for further treatment. This policy has been circulated through the Trust 

Teams and Directorates. 

The East Midlands Head and Neck Cancer NSSG Clinical Guidelines were developed 

collaboratively and reviewed collectively. They were formally ratified by the Chair of the 

NSSG at the East Midlands NSSG meeting on 9 th July 2010. They were endorsed by the 

Chair of the Network on 10 th August 2010. The guidelines were distributed electronically to 

all members of the NSSG, Trust Lead Clinicians, Trust Lead Cancer Managers, Trust Lead 

Nurses and PCT Cancer Leads. They are included in Appendix D. 

In compliance with Measures 10-1C-105i and 10-1C-106i the NSSG/Thyroid Group agreed 

imaging guidelines for UAT cancer and thyroid cancer reflect The Royal College of 

Radiologists “Recommendations for Cross-Sectional Imaging in Cancer Management”. 

Please see Appendix D NSSG Clinical Guidelines for further details. 

In compliance with Measures 10-1C-107i and 10-1C-108i the NSSG the NSSG/Thyroid Group 

agreed pathology guidelines for UAT cancer and thyroid cancer reflect The Royal College of 

Pathologists Minimum Data Sets. www.rcpath..org.uk/resources 

13.0 East Midlands Head and Neck Cancer NSSG Research and Trials 

The East Midlands currently has three separate NCRN Groups who work in close cooperation. 

There is no intention at present, on the part of the National Cancer Research 

Network, of this structure changing. 

The trials portfolio will be kept under review to ensure that: 

 

 

 

 

there is equity of access to trials across the East Midlands 

there is equity of funding across the East Midlands 

barriers to recruitment are minimised 

good practice is shared 

The East Midlands SCG is working with the Network and the NCRN to resolve the issue of 

additional costs. 

14.0 Format of Head and Neck Cancer NSSG Meetings 

 

 

 

 

 

There will be a minimum of two East Midlands Head and Neck NSSG meetings per 

annum 

Key pieces of work may be facilitated through short term working groups (ideally 

electronically) 

Cancer commissioners to be invited to strengthen communications 

MDT representation needs to be robust to ensure that full engagement takes place 

Standing agenda items will be agreed 

15.0 Agreements 

These are on the front sheet of the EMCN Head and Neck Cancer NSSG Constitution. 


APPENDIX A: Terms of Reference of East Midlands Head Neck NSSG 

OVERALL AIMS 

EAST MIDLANDS CANCER NETWORK 

Derby/Burton, Mid Trent, Leicester Northampton and Rutland 

HEAD AND NECK CANCER SITE SPECIFIC GROUP 

And 

THYROID SUBGROUP 

TERMS OF REFERENCE 

To provide specialist advice and guidance to the East Midlands Cancer Network Strategic 

Board (NSB), Primary Care Trusts (PCTs) and the Specialist Commissioning Group (SCG) 

and PCT Commissioners on the standards of service for patients with head and neck and 

thyroid cancer reflecting current best practice and opportunities for development. 

The Network Site Specific Group (NSSG) will aim to ensure that patients with head and neck 

and thyroid cancer receive high quality equitable cancer care throughout the East Midlands 

Cancer Network regardless of geography or socio-economic factors and will, wherever 

possible, endeavour to improve the standard of care provided. 

The overarching East Midlands Head and Neck Cancer NSSG is supported by the three 

mandated local groups. These local groups ensure that there is strong clinical engagement 

across the complex geography of the East Midlands. They also provide support and 

guidance both in making and implementing East Midlands’ wide policies and guidelines as 

well as ensuring robust coherent service development and local implementation of policies. 

SPECIFIC RESPONSIBILITIES 

1. Agree and/or review annually clinical and managerial protocols and guidelines for the 

head and neck and thyroid cancer services to meet national and local guidelines and 

standards of best practice 

2. To ensure that all parts of the care pathway including primary care, supportive and 

social care are fully integrated 

3. To work with the East Midlands Strategic Partnership Group to ensure that care 

reflects patient needs and users views on quality of care inform redesign where 

needed 

4. To work with the East Midlands Strategic Partnership Group to ensure that robust, 

high quality and relevant information is available network wide 

5. To act as the source of clinical expertise on the particular tumour site for the network 

and provide guidance to the NSB, PCTs and SCG on priorities for development 

within services 

6. Agree and/or review (where appropriate):- 

- minimum datasets and key clinical indicators (consistent with the registry needs 

and national audit) 

- IOG implementation 


- Head and Neck and Thyroid cancer activity – 2ww and non-2ww 

- Serious Untoward Incidents (SUIs) 

- Investment plans 

7. Use the results of any network audits to advise the NSB, PCTs and SCG on quality 

of services in the Network and associated service developments 

8. Support long term audit and monitoring of outcomes and performance 

9. Review current services annually and identify gaps in service provision or quality and 

build proposals for improvement into development plans 

10. Make recommendations to NSB on the future configuration arrangements for service 

delivery 

11. In conjunction with the Network team contribute to Peer Review including: 

- self assessment against the national standards 

- preparation for visits as selected 

- ensuring remedial actions are undertaken 

- production of business plans supported by the Network Team 

- production of and advice on the implementation of head and neck and thyroid 

cancer service development plans 

- contribute to the production of a network strategic development plan 

12. Work with the Cancer Research Network teams across the East Midlands to agree 

and review an approved list of trials for head and neck and thyroid cancer and ensure 

there are consistent mechanisms in place to assess all cancer patients for trials entry 

13. Work with the local NSSGs and Multidisciplinary Teams (MDTs) to review trials 

recruitment against the agreed portfolio and support actions to increase local and 

regional recruitment 

14. To contribute to the Network Education and Training Strategies 

15. Work closely with other generic groups (imaging, pathology, commissioning, 

palliative care etc) to ensure their specialist requirements/standards are incorporated 

within the tumour site guidelines document. 

16. Support the introduction of effective new treatments 

17. Review opportunities for innovation in practice, skill mix and in the delivery of care 

The group is free to seek clinical opinion from outside the network as appropriate. 

Subgroups and short life working groups will operate as required by the work of the group. 

MEMBERSHIP 

There will be a single rotating Chair nominated by the members of the group. The tenure of 

office of the chair will be two years as agreed by the NSSG Leads. The rotation of the Chair 

will be Mid Trent, Derby-Burton, LNR. The specification of the post is included Appendix B. 


The Chair is the nominated lead for Service Improvement supported by the local leads for 

each local group and EMCN Service Improvement Lead. 

Trials review and recruitment strategy will be the responsibility of the nominated 

oncology/research lead. 

The Group will include members from Derby/Burton, Mid Trent and LNR local cancer 

networks and will reflect the requirements of the Manual of Cancer Standards. There will be 

core representation from each local network from: 

Surgery 

Radiology 

Pathology 

Clinical Oncology & Medical Oncology 

Palliative Care 

Nursing and Allied Health Professionals 

There will be two/three user representatives – one from each local group but, in the event of 

there not being this representation, this is through an agreed mechanism with feedback 

through the local Patient and Public Partnership Group (3Ps) and strategic meetings with the 

East Midlands Strategic Partnership Group. 

Quorate is representation from each of the three local network groups and specialist groups. 

Group membership will be reviewed annually. 

Appropriate contact will be established with other relevant tumour site specific groups – in 

particular sarcoma and skin cancer. 

FREQUENCY OF MEETINGS 

The East Midlands Group will meet as a minimum twice a year (one of these meetings being 

the Plenary Session) with local network business meetings as necessary by local 

agreement. With the agreement of the NSSG the local leads and Chair may hold executive 

meetings as required to aid planning and performance. 

VENUE 

The venue for the meetings will be at a central location in the East Midlands Network. 

COMMUNICATIONS 

The NSSG will address barriers between organisations, professionals and levels of care. 

Members of the East Midlands NSSG will feed back to their local network groups. 

Ratified minutes of the East Midlands NSSG will be circulated to the members of the group 

and to the local network management teams 

There will be agreed input into the commissioning cycle both at East Midlands Strategic 

Board level and through the local Boards 


APPENDIX B 

East Midlands Cancer Network 

Job Specification: Head and Neck Cancer Network Site Specific Group Lead 

& Thyroid Subgroup Chairperson 

Job title: 

Responsible to: 

Lead, Head and Neck Cancer Network Site Specific Group 

Thyroid Subgroup Chairperson 

Director of East Midlands Cancer Network 

Roles and Responsibilities 

The Head and Neck Cancer Network Site Specific Group (NSSG) Lead has overall 

responsibility for the development of co-ordinated, cohesive and integrated networked 

cancer services for that specific tumour site. This will be achieved primarily by ensuring that 

the NSSG operates efficiently and effectively to facilitate these developments across the 

network. 

Specifically, the Lead should: 

• Ensure the NSSG has representation from all the key stakeholders operating in the 

care of head and neck cancer across East Midlands Cancer Network 

• Work with East Midlands Cancer Network to ensure all Trusts in the network are 

involved and primary care is appropriately represented. 

• Aim to ensure groups are multi-professional in nature 

• Take responsibility for agreeing and maintaining terms of reference for the NSSG, 

including the development of a future vision for the service and associated short-term 

objectives and targets. 

• Ensure that systems and processes are in place to: 

o Review (& update) local & national standards 

o Collect minimum cancer data sets 

o Support accreditation/quality assurance 

o Agree common audits and bench-marking 

o Agree common clinical trials 

o Facilitate user involvement in the development of services 

• Ensure that any tumour specific issues of clinical governance are supported by 

adequate protocols across the network. 

• Organise NSSG meetings. The East Midlands Cancer Network office will provide 

secretarial assistance to book rooms and circulate agenda for these meetings. 

• Prepare the agenda for, and chair, NSSG meetings, ensuring that adequate time is 

allowed for each item under discussion and stakeholders’ views are sought. 

• Ensure that minutes and action notes are circulated to the wider network as 

appropriate. 

• Ensure that the East Midlands Cancer Network Director is properly briefed about the 

progress being made by the NSSG. 


• Ensure an Annual Report is presented to the East Midlands Cancer Network 

Strategic Board 

• Co-ordinate views on new staffing and equipment proposals which impact on the 

care offered and feed these views into the Network Board 

• Lead discussions with other NSSGs or cross cutting groups on issues of common 

interest. 

Personal Qualities and Experience 

Ideally, the Lead will: 

• Be a recognised expert in the care of head and neck cancer patients 

• Have widespread experience in the general care of cancer patients 

• Show commitment to developing the NSSG as a network team 

• Be capable of leading a team of clinicians within a complex organisational network 

• Have the ability to think strategically 

• Be able to influence others to develop a commonly held vision for the development of 

the service. 

• Demonstrate enthusiasm for working collaboratively with other organisations, 

including other Trusts and primary care. 

• Be energetic and enthusiastic, and capable of enthusing others 

• Have excellent communication skills 

• Be a team player, able to lead and work within a multidisciplinary environment, with 

an appreciation of the skills which different professions can bring to the service 

• Have capacity in their current workload to carry out the function of Lead 

Term of Office 

The term of office will be as agreed with the NSSG 


APPENDIX C - Policy for Collection of Minimum Dataset 

(Demonstrating Compliance with Measure 10-1C-111i) 

The Manual of Cancer Services 2004 states that each NSSG should agree a network-wide 

policy specifying which type of team should collect which portion of the agreed MDS. 

The East Midlands Cancer Network has agreed that each team is responsible for collecting 

the sections of the dataset that relate to their direct management of the patient. Data 

collected by the unit is shared with the centre for patients requiring specialist surgery or nonsurgical 

oncology and vice versa. 

For the purposes of the NSSG it is the responsibility of each Team to report all patients who 

begin their cancer pathway in that Trust even though these patients may not receive all their 

subsequent treatment at that Trust. 

The situation in respect of Cancer Wait Times (CWT) data collection is that if the patient is 

an Urgent GP Referral (2 week wait or Urgent Suspected Cancer) then the local Trust that 

receives that referral and first sees the patient is responsible for collecting and uploading the 

appropriate CWT dataset. 

Many data items are collected routinely through PAS and other information systems. 

However in most cases at present these are not linked effectively. Data linkage is an area 

that the network will seek to facilitate. 

Signed: 

Mr Iain McVicar 

Mr Tim Rideout 

Chair of Head and Neck 

Chair of EMCN Board 

Cancer NSSG 

Date: 9 th July 2010 Date: 10 th August 2010 

Mr D Ratliff 

Chair of Thyroid Subgroup 

Date: 9 th July 2010 


APPENDIX D: Head & Neck and Thyroid Clinical Guidelines 


Guidelines for the Investigation and Treatment of Head and Neck 

and Thyroid Cancer 

Status: Final 

Ratified by: Mr Iain McVicar, NSSG Chair on 09.07.10 

Endorsed by: Tim Rideout, Chair of the Network 10.08.10 

Review Date: July 2011 


Table of Contents 

Page 

1. Summary of Operational Arrangements 45 

2. Primary Care Referral Arrangements 

2.1 Head and Neck Referral Arrangements 

2.2 Thyroid Referral Arrangements 

2.3 Distribution Process for Primary Care Referral Guidelines 

3 Referral Guidelines Between Teams 

3.1 Network wide UAT Referral Proforma for Routine Referrals 

3.2 Internal Referral Guidelines for Non-Designated Hospital Clinicians 

3.3 Distribution Process for Internal Referral Guidelines 

3.4 Designated Hospitals Receiving Referrals of Patients with Thyroid . 

Lumps 

3.5 Referral Guidelines Between Teams 

3.6 Head and Neck Specific Clinical Guidelines 

45 

46 

48 

49 

50 

50 

50 

51 

52 

53 

56 

- Neck 

- Oral Cavity and Lip Cancer 

- Oropharyns 

- Nasopharynx 

- Laryngeal 

- Hypopharynx 

- Noses and sinuses 

- Ear and Temporal Bone 

- Salivary Gland 

- General Principles for Radiotherapy and Chemotherapy 

3.7 Thyroid Cancer Specific Clinical Guidelines 104 

Appendix D1 Primary Care Referral Guidelines Schema 106 

Appendix D2 Network-wide UAT Referral Proforma for Routine Referrals 111 



Measure Page Number 

10-1A-206i 46 

10-1A-207i 49 

10-1A-208i 50 

10-1A-209i 50 

10-1A-210i 51 

10-1A-211i 52 

10-1A-214i 52 


Head and Neck Clinical Guidelines 


10-1C-103i 42 

10-1C-105i 58 

10-1C-107i 58 

10-1C-109i 104 


Thyroid Clinical Guidelines 


10-1C-103i 42 

10-1C-106i 104 

10-1C-108i 104 

10-1C-109i 104 


1. Summary of Operational Arrangements 

Head and neck Cancer is the eighth most common cancer in men and sixteenth in 

women with several types and sites of cancer, many of which are rare with treatment 

being complex and difficult for patients. Hence, many disciplines are involved. 

Skilled assessment, care and rehabilitation are crucial to quality of life outcomes and 

require good sustained organisation. Robust clinical guidelines are put in place to 

ensure this happens. 

The arrangements for diagnosis and treatment of head and neck cancer are 

governed by the NICE Improving Outcomes Guidelines published in November 

2009. The key principles from this document as followed by the East Midlands 

Cancer network are:- 

- Services for patients with head and neck cancers should be commissioned at 

the East Midlands Cancer Network level. Assessment and treatment services 

should become increasingly concentrated in Cancer Centres serving 

populations of over a million patients. 

- Multi-disciplinary teams (MDTs) with a wide range of specialists will be central 

to the service, each managing at least 100 new cases of upper qerodigestive 

tract cancer per annum. They will be responsible for assessment, treatment, 

planning and management of every patient. Specialised teams will deal with 

patients with thyroid cancer, and with those with rare or particularly 

challenging conditions such as salivary glands and skull base tumours. 

- Arrangements for referral at each stage of the patient’s cancer journey should 

be streamlined. Diagnostic clinics should be established for patients with 

neck lumps. 

- Clinical nurse specialists, speech and language therapists, dieticians and 

restorative dentists play crucial roles but a variety of other therapists are also 

required, from the pre-treatment assessment period until rehabilitation is 

complete. 

- Co-ordinated local support teams should be established to provide long term 

support and rehabilitation for patients in the community. These teams will 

work closely with every level of the service, from primary care teams to the 

specialist MDT. 

- MDTs should take responsibility for ensuring that accurate and complete data 

on disease stage, management and outcomes are recorded. Information 

collection and audit are crucial to improving services and must be adequately 

supported. 


- 

- Research into the effectiveness of management – including assessment, 

treatment, delivery of services and rehabilitation – urgently requires 

development and expansion. Multi-centre clinical trials should be encouraged 

and supported. 

2. Primary Care Referral Arrangements 


2.1 Head and Neck Referral Arrangements 

The East Midlands Cancer Network Head and Neck Cancer NSSG and Thyroid 

Subgroup agreed the implementation of referral guidelines for patients where there 

was a suspicion of head and neck/thyroid cancer in line with the recommendations of 

the Manual of Cancer Services. 

A patient who presents with symptoms suggestive of an upper aerodigestive 

tract/head and neck cancer should be referred to an appropriate specialist. 

Any patient with persistent symptoms or signs related to the head and neck in whom 

a definitive diagnosis of a benign lesion cannot be made should be referred or 

followed up until the symptoms and signs disappear. If the symptoms and signs 

have not disappeared after 6 weeks an urgent referral should be made. 

Primary healthcare professions should advise all patients, including those with 

dentures, to have regular dental checkups. 

The key questions for the primary care practitioner, which then govern the type and 

destination of the referral of a patient with potential head and neck cancer are:- 

For patients with neck lumps 

• Is the lump clinically thyroid or not 

• Are there ’urgent’ features to the lump itself 

• Are there other ‘urgent‘ features, not directly of the lump itself. If so, are they 

pointing to UAT or to haematological malignancy 

• Does the patient have stridor 

For patients with no neck lump 

• Are there ‘urgent’ features or not 

• Does the patient have stridor 

The answers to these questions determine the 2 or 3 steps through the referral 

schemas given in Appendix D1. 

Specific recommendations 

In a patient with unexplained red and white patches (including suspected lichen 

planus) of the oral mucosa an urgent referral should be made. A non-urgent referral 


should be made in the absence of these features. If oral lichen planus is confirmed 

the patient should be monitored for oral cancer as part of routine dental examination 

(See: NICE Clinical Guideline No. 19 – www.nice.org.uk/CGO19). 

In patients with unexplained ulceration of the oral mucosa or mass persisting for 

more than 3 weeks an urgent referral should be made. 

In adult patients with unexplained tooth mobility persisting for more than 3 weeks an 

urgent referral to a dentist should be made. 

In any patient with hoarseness persisting for more than 3 weeks, particularly 

smokers aged 50 years and older and heavy drinkers, an urgent referral for a chest 

X-ray should be made. Patients with positive findings should be referred urgently to 

a team specialising in the management of lung cancer. Patients with a negative 

finding should be urgently referred to a team specialising in head and neck cancer. 

In patients with an unexplained lump in the neck that has recently appeared or a 

lump that has not been diagnosed before that has changed over a period of 3 to 6 

weeks, an urgent referral should be made. 

In patients with an unexplained persistent swelling in the parotid or submandibular 

gland, an urgent referral should be made. 

In patients with unexplained persistent sore or painful throat, an urgent referral 

should be made. 

In patients with unilateral unexplained pain in the head and neck area for more than 

4 weeks, associated with otalgia (ear ache) but with normal otoscopy, an urgent 

referral should be made. 

Investigations 

With the exception of persistent hoarseness, investigations for head and neck cancer 

in primary care are not recommended as they can delay referral. 

Local Services and Contact points 

Referral Arrangements 

Hospital Designated Clinician Contact Details 

Lincoln County Hospital 

Pilgrim Hospital, Boston 

Grantham Hospital 

Mr A McKechnie 

2ww office 

Fax 01522 573351 

Queens Medical Centre 

City Hospital 

Miss L Sneddon 

2ww office 

Tel:- 0115 8405801 

Fax:-0115 8405802 

Kettering General Hospital Mr A Tewary 2ww Office 

01536 493303 

Northampton General Hospital Mr W Smith 2ww Office 

01604 544235 


Leicester 

Mr J Hayter 

Cancer Unit Office 

0116 2502543 


Referral Arrangements 


Queens Hospital, Burton Mr A Thompson Patient Access Centre 

Direct Fax – 01283 593090 

Royal Derby Hospital Mr K Jones Via Choose and Book or 

Direct Fax – 01332 786715 

2.2 Thyroid referral arrangements 

In patients presenting with symptoms of tracheal compression, including stridor due 

to thyroid swelling, immediate referral should be made 

In patients presenting with a thyroid swelling associated with any of the following an 

urgent referral should be made:- 

• A solitary nodule increasing in size 

• A history of neck irradiation 

• A family history of an endocrine tumour 

• Unexplained hoarseness or voice changes 

• Cervical lymphadenopathy 

• Very young (pre-pubetal) patients 

• Patients aged 65 years and older 

In patients with a thyroid swelling without stridor or any of the features indicated in 

the list above, the primary healthcare professional should request thyroid function 

tests. Patients with hyper- or hypothyroidism and an associated goitre are very 

unlikely to have thyroid cancer and could be referred non-urgently, to an 

endocrinologist. Those with goitre and normal thyroid function tests who do not have 

any of the features indicated in the above list should be referred non-urgently. 

Initiation of other investigations by the primary healthcare profession, such as 

ultrasonography or isotope scanning, is likely to result in unnecessary delay and is 

not recommended. 

The GP should be informed within 24 hours (by telephone or fax) of the diagnosis 

being communicated to the patient for the first time and should be made aware of the 

information which has been given to the patient and of the planned treatment. 

Subsequent alterations in prognosis, management or drug treatment should be 

communicated promptly to the GP. 

The patient should be informed of the diagnosis by a member of the specialist team. 


Local Services and Contact Points 

Referral Arrangements - Thyroid Cancer 


Nottingham City Hospital 

Nottingham Queens Medial 

Centre 

Mr C Ubhi 


2ww office 

Tel:- 0115 8405801 

Fax:-0115 8405802 

Lincoln County Hospital 

Grantham and Kesteven 

Hospital 

Mr A McCrae 

2ww office 

Fax 01522 573351 

Pilgrim Hospital, Boston Mr J Chelladurai 

Kettering General Hospital Mr S Al-Hamali 2ww Office 

01536 493303 

Northampton General Mr D Ratliff 

2ww Office 

Hospital 

01604 544235 

UHL Dr I Peat Cancer Unit Office 

0116 2502543 

Royal Derby Hospitals Mr J Sharp Via Choose and Book or 

Direct Fax – 01332 786715 

Queens Hospital, Burton Mr A Thompson Patient Access Centre 

Direct Fax – 01283 593090 

Referral schemas Appendix D1 – Page 66 are included to help through the steps for 

referral of either head and neck or thyroid tumours. 

2.3 Distribution Process for Primary Care Referral Guidelines 

(Demonstrating compliance with Measure Number 10-1A-207i) 

The distribution of the Primary Care Referral Guidelines for suspected Head and 

Neck Cancer including Thyroid Cancer was achieved as follows:- 

Primary Care Medical Practices: 

• Email 

• Cascade through the PCT cascade system 

• Post 

Primary Care Dental Practices: 

• Post 

• Distribution through the PCTs 

Designated and non-designated Hospital Consultants (ENT surgeons, endocrine 

surgeons, OMFS surgeons, oral medicine specialists, endocrinologists, restorative 

dentists: 

• Through the Cancer managers in each Acute Trust 

• Through the relevant directorate managers 

• By MDT 

• By personal copy through the post/email 

It is anticipated that all clinical guidelines for each tumour site in the East Midlands 

Cancer Network will be available on the Network website. 



3.1 Network-wide UAT Referral Proforma for Routine Referrals 


A referral proforma, the format of which was agreed by the EMCN Head and Neck 

and Thyroid NSSG at it’s meeting on 9 th July, will be used for Network-wide referral 

for routine referrals of patients. 

This is used for: 

• Patients with UAT symptoms which are outside the ‘urgent suspicion of 

cancer’ definition and who have not neck lumps. 

• It allows the referrer to categorise a patient by presenting features, so that the 

hospital can direct the referral to the relevant specialist (e.g. ENT, OMFS). 

• The network-wide format is made locally specific by identifying a single 

referral point for each designated hospital to which proformas can be sent for 

direction to individual specialists. 

A copy of the referral proforma is included as Appendix D2 - Page 71. 

3.2 Internal Referral Guidelines for Non-Designated Hospital Clinicians 


The following are the internal guidelines for hospital clinicians for head and neck 

cancer presenting to non-designated clinicians. These guidelines are based on the 

schema proposed by the Manual for Cancer Services. 

Head and Neck patient 

with signs and 

symptoms suggestive of 

cancer presents to nondesignated 

clinician 

Cancer 

highly likely 

Cancer diagnosis 

uncertain and 

biopsy deemed 

necessary for 

initial diagnosis of 

malignancy 

▪ URGENT 

REFERRAL 

▪ CORE MEMBER OF 

MDT 

▪ WITHOUT BIOPSY 

▪ URGENT 

REFERRAL 

▪ CORE MEMBER OF 

MDT WITH RESULTS 

The locally specific, named, designated clinicians are included in the table below: 

Table 1: Onward referral to core MDT members without biopsy plus those patients 

with neck lumps: 


Hospital of nondesignated 

clinician 

Queens Medical 

Centre Nottingham 

City Hospital, 

Nottingham 

Kings Mill Hospital 

Refer to Core 

MDT Member 

Mr P Hollows 


Mr I McVicar 

Mr N Beasley 


Contact 

Nicola 

Hodgkinson 

0115 9249924 

Ext 65982 

MDT for 

discussion 

Nottingham Head 

and Neck MDT 

Lincoln County 

Hospital 

Pilgrim Hospital, 

Boston 

Grantham and 

Kesteven General 

Hospital 

Queens Hospital, 

Burton 


Kettering General 

Hospital 


Hospital 

United Hospitals of 

Leicester 

Mr A McKechnie 

Mr M Clarke 

Mr A McRae 


Mr A McCrae 

Mr A Thompson 

Mr K Jones 

Mr J Sharp 

Mr Tewary 

Mr Harrop 

Mr Smith 

Mr Tewary 

Mr Smith 

Mr Harrop 

Mr Gurr 

Mr Avery 

Mr Conboy 

Mr Moir 

Mr Alun Jones 

Mr Hayter 

Wendy Smith 

01522 512512 

Ext 2659 

Tehmoor Najib 

01332 783331 

Annette Perry 

Extn 5058 

MDT Co- 

ordinator:- 

01604 544163 

MDT Co- 

ordinator:- 

01604 544163 

MDT Co- 

ordinator:- 

0116 2587624 

Lincolnshire Head 

and Neck MDT 


and Neck MDT 


and Neck MDT 

Royal Derby 

Hospitals Head 

and Neck MDT 

Northants Head 

and Neck MDT 

Northants Head 

and Neck MDT 


Head and Neck 

MDT 

3.3 Distribution Process for Internal Referral Guidelines 


The Internal Referral Guidelines are distributed to the following using the stated 

processes:- 

Designated consultant Clinicians:- 

• Email 

• Post 

Non-designated OMFS/ENT Clinicians:- 

• Email 

• Post 

Endocrine Surgeons:- 

• Email Post 


Oral Medicine Specialists:- 

• Email 

• Post 

Endocrinologists:- 

• Email 

• Post 

3.4 The Designated Hospitals Receiving Referrals of Patients with Thyroid 

Lumps 

(Demonstrating Compliance with Measure 10-1A-211i, cross reference to 10-1A-214i) 

In agreement with the Network Management Board, PCT leads and NSSG the 

following are the named PCTs which will refer patients with lumps clinically of thyroid 

origin to the named, designated hospitals. The populations were agreed with NCAT 

as part of the IOG Action Plan submissions by the three former networks. They were 

reviewed and accepted as compliant on the basis of these populations. 

Referring PCT 

Nottingham City PCT 

Nottinghamshire County 

Teaching PCT 

Receiving Hospital for 

Population Lumps of Thyroid 

Origin 

1,070,000 City Hospital 

QMC 

Lincolnshire PCT 701,402 Lincoln County Hospital 

Northamptonshire 284,087 Kettering General 

Teaching PCT 

309,087 Hospital 

(Heartlands) 


Teaching PCT (Daventry, 

South Northants and 

Northampton area) 


Hospital 

Milton Keynes PCT 220,000 Milton Keynes General 

Hospital 

Leicestershire County and 1,017,900 University Hospitals of 

Rutland PCT 

Leicester 

Leicester City PCT 

Derby City 



South Staffordshire 


Leicestershire County 


500,330 Royal Derby Hospitals 

NHS FT 

333,417 

66,000 


Trust 

MDT discussing 

patient 

Nottingham/Lincoln 

VTC MDT 


Thyroid MDT 


Thyroid MDT 

Royal Derby 

Hospitals NHS FT 



Tertiary Referral Guidelines 

Tertiary referrals come from consultants outside the Head and Neck cancer teams 

and other hospitals. 

Tertiary referrals should be made to a named Consultant and usually after an initial 

telephone conversation. 

The required tests that should have been completed prior to a tertiary referral being 

made are set out below:- 

1. A biopsy taken and a positive histological diagnosis of cancer made. 

2. Imaging (CT or MRI) if this is a diagnostic test. 

a. Imaging other than as a diagnostic test is helpful providing no delays to 

the patient’s tertiary referral will result. For example, where there are 

waits for CT or MRI slots. Imaging is often repeated at the tertiary 

centre even if the patient has previous scans. 

3. Clinical information is also required. 

a. Previous relevant surgery. 

b. If previous case notes not available a photocopy of the relevant areas 

to be sent with the referral. 

c. All diagnostic test results. 

4. Where a reoccurrence of a cancer is suspected by the referring unit these 

patients will be accepted by the tertiary centre without confirmed histology. 

Childhood Head and Neck Cancer 

Growing masses in the Head and neck in children and your people (

participate in the management of such patients and may join the surgical tem when 

surgery is to be performed. The referring clinicians may not undertake such surgical 

procedures in isolation. This treatment should be performed by the local specialists 

who with involvement from the visiting referring surgeons if required. 

Vascularised Bone Graft 

This is undertaken at all designated operating sites. 

Out of Network Referrals 

Referral of patients out of the East Midlands Cancer Network for treatment of Head 

and Neck Cancers is rare but would occur as part of the ongoing care of the patient 

in the following circumstances:- 

1. Patients requiring hyperbaric oxygen. 

2. Patients requiring photodynamic therapy have been referred to UCH. 

Pre-treatment Assessment and Management 

Careful assessment of each patient’s clinical, nutritional and psychological stage 

must be carried out to inform MDT decisions on treatment options. Co-morbidity, 

performance status, psychological state, nutritional status and alcohol dependence 

should be assessed. The Clinical Nurse Specialist should ensure that all patients 

and carers receive appropriate support and information, that their non-medical needs 

are assessed and that there is effective liaison between hospital staff, primary care 

teams and other agencies as required. 

Patients who are dependent on smoking, drinking or other addictive substances that 

increase the risk of head and neck cancers should be offered interventions to help 

them stop. 

The full range of treatment options should be discussed with the patient with 

supporting written information if required. These discussions may be held over a 

number of meetings so that patients have adequate time to consider the MDT’s 

proposals. 

a) Dental Assessment 

Once a treatment plan has been agreed a dental assessment should be carried out 

on those patients where treatment will affect the mouth or jaws. Any necessary 

dental extractions should be carried out pre-treatment with sufficient time allowed for 

healing. The patients should be encouraged to have good oral hygiene and attend 

their general dental practitioner if appropriate. Referral to a specialist restorative 

dentistry consultant should be considered in appropriate patients. 

b) Speech and Language Therapist (SLT) and Nutritional Assessment 

If a patient is to have treatment that will affect eating or swallowing the team should 

discuss the method of feeding that will be used and inform the primary care team 


well in advance if tube feeding is required so that the patient can be supported at 

home. The iagramma and SLT should work together with the patient to explain 

swallowing and nutritional issues and make sure the patient is prepared, before 

treatment begins, for any short or long term interventions that may be required. 

c) Anaesthetic Assessment 

Patients who are to undergo surgery that will involve the airways should be assessed 

by the specialist anaesthetist who works with surgeons at the MDT. 

d) Treatment options 

Diagnostic Services 

Cancer can only be diagnosed in the head and neck by definitive histology. This can 

be in the form of fine needle aspirate, core biopsy or open biopsy. The specimen 

should be reported by a head and neck pathologist. 

Outpatient Arrangements 

Oral cavity lesions are most commonly diagnosed by biopsies performed on an 

outpatient basis under local anaesthesia. 

Treatment Options 

The patient should have clear explanations and written information of treatments 

involved and their risks and common side effects and should have the opportunity to 

discuss likelihood of cure and quality of life after treatment. 

The minimum investigations will include:- 

1. Biopsy 

2. Appropriate imaging 

3. Baseline medical investigations such as full blood count, liver function tests, 

urea and electrolytes, clotting screen etc. 

All patients require a full medical examination to assess fitness for treatment and 

assess co-morbidity (sometimes previously undiagnosed) 


Head and Neck Specific Guidelines 

Status: Final 

Ratified by: Mr Iain McVicar, NSSG Chair on 09.07.10 

Endorsed by: Tim Rideout, Chair of the Network 10.08.10 

Review Date: 09.07.12 


Table of Contents 

Page 

Head and Neck Specific Clinical Guidelines 

- Neck 19 

- Oral Cavity and Lip Cancer 25 

- Oropharynx 31 

- Nasopharynx 35 

- Laryngeal 38 

- Hypopharynx 44 

- Nose and sinuses 49 

- Ear and Temporal Bone 53 

- Salivary Gland 56 

- General Principles for Radiotherapy and Chemotherapy 62 

Thyroid Specific Clinical Guidelines 65 

In compliance with Measure 10-1C-105i the NSSG agreed imaging guidelines for UAT cancer 

reflect The Royal College of Radiologists “Recommendations for Cross-Sectional Imaging in 

Cancer Management”. 

In compliance with Measure 10-1C-107i the Head & Neck NSSG Pathology Guidelines are: 

http://www.rcpath.org/resources/pdf/headandneckdatasetjun05.pdf 


CLINICAL GUIDELINES FOR HEAD AND NECK 

In compliance with Measure 10-1C-105i the NSSG agreed imaging guidelines for UAT cancer 

reflect The Royal College of Radiologists “Recommendations for Cross-Sectional Imaging in 

Cancer Management”. 

1. NECK 

Key Points 

The status of cervical lymph nodes is the single most important prognostic factor. 

Single node metastasis at presentation reduces the cure rate by 50%. 

Prognosis is dependent on a number of metastases, level in the neck, presence 

of extra-capsular spread, perineural and /or vascular invasion. 

A significant number of malignant nodes will be less that 10 mm. in diameter. 

The incidence of micrometastases is highly dependent on the site and size of the 

primary tumour, e.g. glottic tumours (1%), nasopharyngeal tumours (80%). 

The majority of tumours metastasise in a predictable manner to certain nodal 

groups. 

Bilateral nodal disease should be considered for tongue base, nasopharyngeal 

and supraglottic laryngeal tumours. 

Standardised reporting of neck dissection specimens according to the Royal 

College of Pathologists Guidelines is essential. 

Assessment of the Neck 

Clinical examination 

This is generally inaccurate with sensitivity and specificity 60 – 70%. 

CT scanning has a higher sensitivity (69 –93%) than clinical examination. 

MRI is slightly better than CT in assessing the clinically negative neck. 

Ultrasound guided FNAC, although requiring expertise and experience, is a very 

useful technique for the assessment of neck node metastases. It has a sensitivity 

of 76% and a specificity 100% in necks that are clinically negative. 

Staging of the neck 

Nx 

N0 

N1 

N2a 

N2b 

N2c 

N3 

Nodes cannot be assessed 

No node metastases 

Ipsilateral single node < or equal to 3cms diameter 

Ipsilateral single neck node – 3-6cms 

Ipsilateral multiple nodes – 3-6cms 

Bilateral, contra-lateral nodes 3-6cms 

> 6cms node 

Staging of neck disease is the single most important factor in the prognosis of the 

patient. 


Final stage is the culmination of clinical examination, imaging, +/- cytological 

results and histopathological report. 

MANAGEMENT OF THE NECK IN HEAD AND NECK CANCER. 

Nomenclature for Neck Dissection 

Radical neck dissection 

Modified radical neck 

dissection 

Selective neck dissection 

Extended radical neck 

dissection 

Classification of neck dissection techniques 

Is the fundamental procedure by which any other 

neck dissection is compared. 

Levels I–V dissected; accessory nerve, internal 

jugular vein and sternomastoid muscle resected. 

Denotes preservation of one or more of the 

accessory nerve, internal jugular vein or 

sternomastoid muscle (types I, II, III respectively), 

levels I-V dissected. 

Denotes preservation of one or more groups of 

lymph nodes e.g. supraomohyoid (level I – III) 

Lateral neck dissection (level II,III,IV) 

Denotes radical neck dissection plus removal of one 

or more additional lymphatic and/or non-lymphatic 

structure(s). 

Treatment of cervical lymph nodes is either ELECTIVE (clinically negative neck) or 

THERAPEUTIC (clinically positive neck). 

CLINICALLY NEGATIVE NECK (N0) 

Treatment should be prescribed: 

i. Where there is a high incidence of occult nodal metastases (over 20%). 

Most sites and stages of squamous cell carcinoma in the neck and head fall 

into this category, except lip, early glottic cancer and lower alveolus. All other 

tumours qualify for elective treatment of the neck because the incidence of 

occult node metastases is over 20% (although this is accepted practice, it is 

not supported by strong evidence). 

ii. 

Where the neck needs to be entered for surgical access to the primary 

tumour and/or micro-vascular anastomoses 

iii. 

When the patient is an irregular attender. 

iv. 

Where the status of lymph nodes cannot be adequately assessed e.g. 

obesity. 


Elective radiotherapy to the neck is as effective as elective surgical treatment and 

the choice of treatment is heavily influenced by the mode of treatment for the primary 

tumour. 

Choice of Neck Dissection 

Oral cavity and oropharyngeal tumours are managed with selective neck 

dissections involving levels I–IV. 

Laryngeal and hypopharyngeal tumours require a selective neck dissection of 

levels II – IV. 

Classical radical neck dissection has no role to play in the management of the N0 

neck. 

Selective neck dissection is as effective as modified radical neck dissection type 

II. 

Sentinel node biopsy is still a research tool. 

RADIOTHERAPY FOR THE CLINICALLY NEGATIVE NECK 

Primary treatment 

This should be considered in situations as follows: 

If the primary tumour is treated with radiotherapy, the ‘at risk’ lymph node regions 

harbouring occult disease should be included in the treatment field. 

Elective radiotherapy is preferred when both sides of the neck are treated 

electively such as e.g. nasopharyngeal tumours. 

Postoperative radiotherapy 

This is indicated where the histopathological report reveals:- 

a) Multiple nodal level involvement. 

5. Presence of extra capsular spread 

THE CLINICALLY POSITIVE NECK (N1 – 3) 

Treatment of the clinically positive neck involves a combination of surgery and 

radiotherapy. 

Single modality treatment may be sufficient for N1 disease. 

Combined modality treatment (surgery plus post operative radiotherapy) is 

generally indicated for N2 and N3. The dose should be tailored to the bulk of the 

disease. 

Modified radical neck dissection is as oncologically effective as classic radical 

neck dissection even in advanced disease when combined with post-operative 

radiotherapy. 


MRND type 1 is recommended for the management of node positive necks where 

possible. 

Level V involvement is uncommon such that the need for comprehensive i.e. 

level V neck dissection even in node positive necks has been questioned. 

Conversion to radical neck dissection from modified radical neck dissection is 

required where there is involvement of non-lymphatic structures (accessory 

nerve, jugular vein etc.) 

Post operative radiotherapy to the neck is indicated when there are bad prognostic 

features: 

a) Multiple nodal level involvement 

b) extra-capsular spread 

c) perineural invasion 

d) perivascular invasion 

e) involvement of nonlymphatic structures 

f) involvement of skin of the neck 

g) bilateral positive nodes 

THE OCCULT PRIMARY TUMOUR – MANAGEMENT OF THE NECK 

5% of patients with head and neck cancer fall into this category as the primary site 

can nearly always been identified. Metastatic lymph nodes containing SCC with the 

exception of supraclavicular fossa nodes should be considered as metastases from 

the upper aero-digestive tract. Supraclavicular fossa nodes usually arise from 

regions outside the head and neck, e.g. oesophagus, stomach. 

Management and Diagnosis 

Full examination of the upper aero-digestive tract is essential. Endoscopy should 

be performed under general anaesthetic with biopsy if the tumour is obvious. 

If no tumour is obvious then biopsy should be taken of the nasopharynx, 

ipsilateral tonsillectomy and tongue base. Bi-lateral tonsillectomy has been 

advocated as there is a 10% incidence of contra lateral nodes from occult tonsil 

primary. 

RADIOLOGY: chest x-ray, CT scan or MRI scan of the head and neck should be 

performed preferably prior to biopsy. The CT of the chest is useful where there 

are respiratory symptoms or clinical suspicion of tumours of the lower 

aerodigestive tract e.g. bronchus. 

CYTOLOGY: FNAC is mandatory. A repeat FNAC should be considered if the 

initial aspiration is negative. Tru-cut biopsy may be considered if FNAC 

equivocal. 

GENERAL EXAMINATION: examination of the breasts, chest, abdomen should 

be performed. 

Management of the neck in the occult primary 


Evidence for management is retrospective and of variable quality. It is, however, 

apparent that surgical salvage after failed radiotherapy is not effective in terms of 

survival. Management is highly dependent on the outcome of the FNAC. 

If the FNAC is positive, a neck dissection should be performed. 

If the neck is N1 stage, postoperative radiotherapy should be given where poor 

prognostic factors exist (see above). 

For N2, N3 necks, combined modality treatment is indicated. Consideration 

should be given to chemo radiotherapy. 

If the FNAC is negative, an excisional biopsy is performed under frozen section 

control. If positive for SCC, proceed immediately to neck dissection (radical neck 

dissection or preferably modified radical neck dissection). Postoperative 

radiotherapy should be given where there are bad prognostic features on 

histological examination. 

Management after incisional biopsy/”lumpectomy” 

a) For N1/NX disease – neck dissection. 

b) N2, N3 disease, a neck dissection should be performed with post-operative 

radiotherapy. Chemo-radiotherapy should only be performed within a clinical 

trial. 

Management of the likely primary sites 

Elective mucosal irradiation (EMI) should be individualised for each patient, 

bearing in mind the potential severe morbidity and many patients may be treated 

unnecessarily. 

Elective mucosal irradiation does not improve survival. Ipsilateral mucosal 

radiation is advocated, as it is an alternative with less morbidity. 

Recurrence after Combined Treatment 

This carries a very poor prognosis and often associated with distant metatastes. Reexcision 

maybe considered to control neck recurrence and the associated 

distressing symptoms. Patient should be referred to palliative care physicians as 

soon as possible. 

Radiotherapy Techniques 

Radiotherapy should only be delivered under the remit of an accredited 

department. 

Modern methods will utilise mega voltage photons from a linear accelerator 

(typical energies 4 – 6 NVs). In early cancer of oral cavity, orapharynx, 

hypopharynx and larynx, the first station/echelon nodes are treated in continuity 

with the primary tumour. 


Number of fields and energy of photons/electrons used are dependent on the 

exact geometry of the tumour and patient. This information is, under certain 

circumstances, best obtained by the means of a CT scan. 

Intensity modulated radiotherapy (IMRT) maybe of value in reducing the side 

effects in the unexplored neck. This is still experimental and is the subject of 

clinical trials. 

Concomitant chemo-radiotherapy may improve progression free survival but only 

where patients are medically suitable. 

Altered fractionation techniques and adjuvant treatment do have improved 

outcomes and should be considered for patients who are medically fit and well 

and able to tolerate this intensive treatment. 

Indications for post-operative radiotherapy are derived from careful pathological 

examination. 

Indications for post-operative radiotherapy are: 

a. Multiple nodal involvement. 

b. Extracapsular spread. 

c. Perineural invasion. 

d. Perivascular invasion. 

e. Involvement of the overlying skin. 

It is important to complete post-operative radiotherapy within eleven weeks of 

surgery, particularly in patients who are at high risk of recurrence (see above). 

Palliative treatment 

Incurable nodal disease may be managed with palliative chemotherapy or 

radiotherapy. 

Chemotherapy including cisplatin, 5FU and methotrexate. 

Palliative radiotherapy should be delivered in a simple field arrangement, by 

lateral parallel pair or single anterior field doses. 


2. GUIDELINES FOR ORAL CAVITY AND LIP CANCER 

ORAL CAVITY 

Diagnosis 

This is based on: 

Physical examination of the oral cavity and oropharynx: 

Examination under anaesthetic – indicated when clinical assessment difficult. 

Panendoscopy for those at high risk of a second primary tumour. 

Clinical diagram to outline the extent of tumour. Careful documentation with a 

standard tumour map. 

Biopsy report should include the differentiation, tumour thickness, evidence of 

vascular and peri–neural invasion. 

Imaging 

All malignant tumours of the upper aerodigestive tract require radiological 

imaging. A variety of techniques including MRI, CT, plain radiography and 

isotope scanning maybe necessary. 

An orthopantomogram is required on all patients. 

MRI scan remains the preferred modality for imaging of the oral cavity primary 

tumour. 

Ideally, MRI should be performed BEFORE biopsy of the primary tumour. 

Consultation 

All patients with a diagnosis of head and neck cancer must be seen in a multidisciplinary 

team setting. 

Staging 

Primary Tumour 

All patients must be staged prior to treatment planning: 

TX 

T0 

T1s 

T1 

T2 

T3 

T4 

Primary tumour cannot be assessed 

No evidence of primary tumour 

Carcinoma in situ 

2-4 cms diameter 

> 4cms diameter 

Tumour of any size invading adjacent structures e.g. bone, skin, 

extrinsic muscles 


Staging of the primary tumour is based on: 

Clinical examination including visualisation and palpation 

Imaging 

Histological diagnosis 

MANAGEMENT OF ORAL CANCER 

Early Oral Cancer 

T1/T2 – this maybe treated by a single modality therapy either surgery or primary 

radiotherapy. 

Surgery is the preferred modality of treatment unless the patient is medically 

unfit. 

Larger T2 lesions (greater than 3 cms) usually require combination therapy. 

Surgery is preferred for tumours of anterior oral tongue, floor of mouth and buccal 

mucosa. 

Radiotherapy is preferred if the oral commissure is involved. 

Gingival/palatal lesions are treated surgically. 

SURGERY 

Consideration must be given to: 

Insertion of feeding gastrostomy – preferably prior to definitive surgery. 

Tracheostomy when required. 

Dental extractions if necessary (preferably performed under anaesthetic, and at 

the time of EUA and biopsy. 

Excision of neck dissection specimens and primary tumour in continuity. 

Frozen section evaluations iagrammatical. 

Orientation of primary and neck dissection specimen for the pathologist by the 

surgeon. 

RADIOTHERAPY 

Radiotherapy may be appropriate especially in the very elderly in whom anaesthesia 

is a particular risk. 

Equivalent survival rates can be achieved either with primary radiotherapy or 

surgery to T1 and low volume to T2 tumours of the oral cavity. Disadvantages of 

external beam radiotherapy: 

a. Cannot be used a second time. 

b. Salvage surgery following radiotherapy is often associated with low 

survival and high morbidity. 

Side effects include: 

a. Xerostomia, mucositis and osteo-radionecrosis of the mandible. 


Patients may require multiple dental extractions prior to and after treatment. 

Late Oral Cancer (T3, T4 tumours) 

These should be treated by a combination of surgery/post operative radiotherapy. 

Special Surgical Considerations 

1. Mandible 

A segmental mandibulectomy (full thickness resection of bone) is carried out 

where invasion of the bone is evident. 

Primary reconstruction of the jaw is preferable over delayed mandibular 

reconstruction. 

A full range of reconstructive techniques including composite flaps must be 

readily available. 

A suitable mandibular reconstruction plating system should be available. 

Vascularised fibula or vascularised iliac crest remains the gold standard for 

mandibular reconstruction. 

6. Soft tissue defects 

The fasciocutaneous radial forearm flap is the standard versatile, reliable 

and robust flap for oral and oropharyngeal soft tissue defects. More bulky 

reconstructions require rectus abdominus flap. 

Pedicle flaps e.g. pectoralis major should only be contemplated for salvage 

procedures. 

A two-team approach to surgery is mandatory to shorten operative time and 

to reduce post-operative complications. 

TREATMENT OF THE NECK IN ORAL CAVITY TUMOURS 

7. The clinically negative neck (N0) 

In oral cavity and oropharyngeal cancer the incidence of occult metastases 

is approximately 34%. Expectant management of N0 of the clinically 

negative neck is not recommended, i.e. a policy of ‘wait and see’ is to be 

avoided. 

If surgery to the primary tumour is contemplated, simultaneous neck 

dissection should be considered. 

If radiotherapy is planned for the primary tumour then elective radiotherapy 

may be used to manage the clinically negative neck. 


Anterior oral cavity lesions 

Because of lymphatic crossover in anterior oral cavity lesions or those 

located at or near the mid-line, consideration should be given to bilateral 

treatment of the neck – radiotherapy or bilateral neck dissection. 

Oral tongue lesions 

These have a high incidence of metastases to levels I – IV. Selective neck 

dissection in oral tongue tumours should include levels I – IV. 

8. The clinically positive neck (N1 – N3) 

With palpable neck node involvement or conclusive evidence following 

imaging of the neck, surgical treatment is preferred. 

Selective neck dissection for N1 neck can be contemplated for oral cavity 

tumours with isolated/single nodal metastases. 

Modified radical neck dissection/radical neck dissection or even extended 

radical neck dissection maybe be required for more extensive disease. 

Most patients will require post-operative radiotherapy. 

CRITERIA FOR POST-OPERATIVE RADIOTHERAPY 

Primary Site 

Positive margins. 

Large T2, all T3 and T4, irrespective of nodal status. 

Peri-neural or intra-vascular invasion on definitive histological assessment. 

Poorly differentiated squamous cell carcinoma. 

Radiotherapy should begin as soon as possible and after surgery. Radiotherapy 

should commence no later than six weeks after surgery. 

Neck 

More than one positive node. 

Presence of extra capsular spread. 

Perivascular invasion. 

Perineural invasion. 

Involvement of the overlying skin. 

LIP CANCER 

Cancer of the lower lip is common. Cancer of the upper lip and commissures is rare. 


DIAGNOSIS 

9. Clinical assessment 

Complete history including history of sun exposure and tobacco usage. 

Clinical examination remains the mainstay for diagnosis. 

Careful examination of the oral cavity and oropharynx under direct vision is 

recommended. 

Incisional biopsy need only be considered if the clinical appearance is 

equivocal. 

10. Imaging 

An orthopantomogram is indicated for assessment of the anterior mandible 

and dentition prior to radiotherapy. 

Dental Assessment – consideration for pre-radiation extractions, 

restoration or prophylactic treatment. 

TREATMENT 

Primary Lip Cancer 

Surgical excision is generally preferred as the initial treatment. 

Frozen sections are helpful. 

Small lesions can be excised under local anaesthetic +/- intravenous sedation. 

Superficial early lesions of the vermillion may be treated by laser or lip shave. 

Full thickness lip lesions require immediate repair/reconstruction. 

Reconstruction of the defect 

< 1/3 of the lip removed - V or W closure. 

>1/3 – 2/3 of the lower lip – local flap reconstruction e.g. Johannson Step 


>2/3 of the lower lip – usually requires micro-vascular free tissue transfer method 

– fasciocutaneous forearm flap. 

Invasion to adjacent tissues e.g. lip e.g. mandible is extremely rare. 

Radiotherapy and Chemoradiotherapy 

Radiation therapy is satisfactory particularly for patients who are medically unfit to 

undergo surgery. 

Treatment by external beam radiotherapy 

Brachytherapy will require gingival shielding to reduce mucositis. 


Large lip tumours require surgery as the primary treatment with appropriate 


Management of the Neck in Lip Cancer 

Occult lymph node metastases in lip cancer is low. The policy of lip cancer 

behaves differently from oral cavity and oro pharyngeal cavity cancer. 

CLINICALLY NEGATIVE NECK 

A policy of “watch and wait” is recommended. 

T2 tumours of the lip – 15 – 35% of occult lymph node metastasis. No firm 

evidence to prescribe routine selective neck dissection. A policy of watch and 

wait is recommended for this lesion. 

T3 –T4 lesions +/- poorly differentiated – bilateral selective neck dissection – (I – 

III) is contemplated where patients are medically fit. 

CLINICALLY POSITIVE NECK 

N1 

Ipsilateral selective neck dissection or modified radical neck dissection is 

recommended. Consider contra-lateral supra-omohyoid neck dissection. 

N2/N3 

Consider bilateral neck dissection. Tracheostomy maybe required. 

Indications for post-operative radiotherapy 

As for the management of the neck in oral cavity cancer. 

Recurrence 

This is uncommon but is best managed with aggressive surgical resection with 

frozen section control. 


3. CLINICAL GUIDELINES FOR OROPHARYNX 

GENERAL CONSIDERATIONS 

Tumours in this head and neck subsite can be further subdivided into four 

anatomical areas. They are: 

a. Tonsil 

b. Base of tongue 

c. Soft palate 

d. Pharyngeal wall 

Many tumours in this subsite are large with considerable overlap of the above 

subsites. 

Assessment 

Examination under anaesthetic and biopsy is mandatory for all cases to: 

a. Establish histological diagnosis. 

b. Stage the tumour. 

c. Exclude synchronous head and neck tumours. 

d. Assess extent of possible surgical resection. 

e. Indicate type of required reconstruction. 

f. Assess and manage the dentition. 

Investigations 

a. MRI is required for all cases. 

b. CT thorax should be considered in advanced disease (high incidence of 

distant metastases in oropharyngeal cancer). 

c. FNAC of enlarged lymph nodes. 

d. Orthopantomogram to assess dentition. 

Pre-Treatment Consultations 

a. Dietary 

Most patients require enteral feeding preferably by feeding gastrostomy, as 

both radiotherapy and surgery interfere with swallowing. 

b. Speech and language assessment 

Treatment of oropharyngeal tumours, especially surgery, has an enormous 

impact on communication and swallowing. 

c. Oral surgical assessment 

This is required two-fold: 

i. to assess and treat any existing dental disease. 


ii. 

to assess suitability for mandibulotomy procedures. 

TONSIL 

Many tonsillar carcinomas present with an enlarged lymph node as a primary 

symptom. 

T1/T2 Lesions 

These are uncommon but can be managed by: 

a. trans-oral surgery (rarely) 

b. radical radiotherapy 

T3/T4 Lesions 

These require combined treatment in the form of: 

a. temporary tracheostomy, neck dissection, mandibulotomy and resection of 

primary tumour + reconstruction. 

b. post-operative radiotherapy including the contra-lateral neck. 

Reconstruction 

Defects of the tonsillar bed can be preferably managed with microvascular radial 

artery forearm flaps or pectoralis major myocutaneous flap. If the primary tumour 

involves the retromolar trigone, rim resection of mandible or segmental resection is 

appropriate. Full thickness resection requires mandibular reconstruction with either 

microvascular fibula or iliac crest graft. 

BASE OF TONGUE 

General Principles 

Treatment options include: 

1. Brachytherapy in conjunction with bilateral neck dissection. 

2. External beam radiotherapy possibly in conjunction with chemotherapy has 

been advocated in some centres. Various chemotherapy regimes can be used 

which include platinum-based drugs, carboplatin or cisplatin with 5 

fluorouracil. 

3. Neck dissection + mandibulotomy + incontinuity resection of tongue base with 

immediate reconstruction with microvascular radial forearm flap. 


Many base of tongue tumours present as persistent cervical lymphadenopathy. 

Primary modality of treatment is influenced by the status of disease in the neck. 

N0 necks may be best managed with primary radiotherapy to the primary site and 

ipsilateral neck. 

N1-N3 ipsilateral necks are best managed with primary surgery with strong 

consideration for incontinuity resection of the tongue base with immediate 

reconstruction with microvascular radial artery forearm flap. 

PRIMARY TUMOUR 

T1 lesion can be treated by surgery e.g. transhyoid approach OR transoral laser 

techniques 

T2, T3 and T4 lesions require combined treatment. 

Recurrence of base of tongue tumour after primary chemo-radiotherapy often 

requires management by total glossectomy with laryngectomy and bilateral neck 

dissection. This has a high morbidity requiring careful counselling and extensive 

rehabilitation. 

SOFT PALATE 

Tumours in this area usually appear on the edge of the soft palate or uvula. 

T1 tumours may be managed by trans-oral resection or laser excision. 

T2,T3,T4 tumours require management as outlined for tonsillar tumours. 

POSTERIOR PHARYNGEAL WALL 

T1 tumours can be managed either by endoscopic resection or radical radiotherapy. 

T2, T3, T4 tumours require combined treatment as outlined for tonsillar tumours. 

MANAGEMENT OF THE NECK IN OROPHARYNGEAL CANCER 

Base of tongue, posterior pharyngeal wall and palatal lesions frequently encroach 

across the midline. This can result in bilateral lymph node metastases. This concept 

needs consideration when planning treatment. 

N0 neck 

This should be managed electively either by radical radiotherapy or selective neck 

dissection. 

If the primary tumour is managed by surgery, selective neck dissection (levels I-III) 

should be carried out in continuity with the primary tumour. 

N1-N3 neck 


This is managed either by selective or type I modified radical neck dissection. 

When the neck is managed surgically, the primary tumour should also be managed 

similarly. 

Post-operative radical radiotherapy is indicated if more than one node is involved or 

if extra-capsular spread is identified. 


4. CLINICAL GUIDELINES FOR NASOPHARYNX 

INTRODUCTION 

Tumours of the nasopharynx present with a variety of symptoms and include: 

e. Nasal obstruction 

f. Conductive unilateral hearing loss 

g. Cranial nerve palsy secondary to skull base invasion 

h. Unexplained cervical lymphadenopathy 

SIGNS 

Nasopharyngeal tumours may either be obvious or undetectable on initial 

examination. Examination under anaesthetic and biopsy is essential to confirm the 

diagnosis. 

Unlike many other anatomical sites in the upper aerodigestive tract, tumours of the 

nasopharynx need distinguishing between squamous cell carcinoma and lymphoma 

(other rare tumours also occur at this site). 

ASSESSMENT 

Cervical lymphadenopathy is the frequently presenting feature of nasopharyngeal 

carcinoma. Blind biopsies should be taken from the nasopharynx (as well as 

tongue base and ipsilateral tonsil) to detect occult primary tumour. 

CT scanning and MRI are complementary in the assessment of nasopharyngeal 

tumour. 

Chest x-ray 

Blood test including LFT 

Liver ultrasound if LFT abnormal 

Bone scan 

CT thorax 

FNAC of cervical lymphadenopathy 

Dental examination (see later) 

Patients with a nasopharyngeal carcinoma have a high incidence of distant 

metastases compared with other tumours of the aerodigestive tract. 

TREATMENT OPTIONS 

Localised Disease 

a. Radiotherapy 

b. Chemotherapy 


c. Surgery 

Radiotherapy +/- Chemotherapy 

High dose radiation therapy +/- chemotherapy is the primary treatment for 

nasopharyngeal carcinoma, even in patients with palpable neck disease. External 

beam irradiation is the method of delivery, occasionally boosted by interstitial 

implants. 

Platinum-based chemo-radiotherapy produces better results than radiotherapy 

alone, albeit at the cost of increased toxicity. 

Surgery 

There are few indications for surgery in the initial management of nasopharyngeal 

carcinoma. 

METASTATIC DISEASE 

Patients with distant metastases are incurable 

High dose radiotherapy to the primary site and neck may be indicated to provide 

symptom control 

RECURRENT NASOPHARYNGEAL CANCER 


Patients with failed primary treatment or recurrent disease may be treated either by: 

a. Further external beam radiotherapy 

b. Interstitial radiotherapy 

c. Surgical resection 

Radiotherapy 

The surgical implantation of gold grains into the nasopharynx via a palatal split 

approach under direct vision has reported up to 80% control for residual disease and 

54% for recurrent disease. Patients with disease outside the nasopharynx have 

lower control rates. 

Surgery 

This may be indicated with disease that has spread into the paranasopharyngeal 

space but not involving the internal carotid artery and skill base. A trans-maxillary 

approach is the preferred access procedure. 

Modified radical neck dissection is indicated for nodal recurrence. 


Morbidity 

Strong consideration should be given to the provision of a feeding gastrostomy prior 

to either radiotherapy or surgery. Dental assessment prior to treatment is mandatory 

as radiotherapy for nasopharyngeal carcinoma often produces severe xerostomia 

and acceleration of dental disease. Regular dental hygienist appointments are 

important and extraction of carious teeth should be carried out prior to radiotherapy. 

Regular monitoring of thyroid function to detect primary hypothyroidism is important 

following neck irradiation. 

Survival 

Small localised cancers of the nasopharynx are rare but curable with primary 

radiotherapy. Survival approaches 80% - 90% in this group. 

Moderately advanced disease with no evidence of lymph node metastases carries 

survival rates of 50% - 70%. 

Patients with advanced disease and cervical node metastases carry a very poor 

prognosis even when local control is achieved. 

Most recurrences occur within five years of diagnosis. 


5. CLINICAL GUIDELINES – LARYNGEAL TUMOURS 

An Overview 

Management of cancer of the larynx involves: 

a) Diagnosis and appropriate staging 

b) Treatment of: 

Glottic cancer – early/late 

Supraglottic tumours –early/late/advanced 

Subglottic tumours 

c) Management of the neck 

d) The use of chemotherapy in laryngeal cancer 

Diagnosis of Laryngeal Cancer 

Diagnosis of laryngeal cancer involves formal examination under anaesthetic 

after provisional diagnosis by direct or indirect laryngoscopy. All patients require 

a histological confirmation by biopsy 

Photo documentation is preferred. 

It is preferable that all patients with a provisional diagnosis of laryngeal cancer 

should undergo formal examination under anaesthetic by surgeons involved in 

subsequent management. 

An accurate anatomical description of the tumour extent is essential to ensure 

accurate staging of the disease both clinically and radiologically. 

Glottic, supraglottic and subglottic tumours differ significantly in their patterns of 

behaviour and modes of spread. Separate consideration should be given to each 

anatomical site. 

In general, radiotherapy and conservative surgery alone are options for early 

disease. 

Combined radiotherapy and surgery are used for advanced disease and those 

patients with cervical node metastases. 

It is no longer acceptable for surgeons to manage patients with laryngeal cancer 

on the basis of one surgical option (total laryngectomy). The surgeon’s repertoire 


must include conservative methods: laser, partial laryngectomy, selective neck 

dissection and surgical voice restoration. 

All patients subjected to laryngectomy must be offered modern methods of voice 

restoration including valve speech. 

GLOTTIC TUMOURS 

Early Glottic Cancer 

Early glottic cancer is potentially curable with either modality 

Single modality is usually the preferred choice. 

Standard UK practice for treating T1 and T2 laryngeal cancer is radiotherapy 

Surgical modality may be by either endoscopic or open resection (partial 

laryngectomy). Endoscopic laser techniques are increasingly popular in some 

centres. 

STAGE FOR GLOTTIC TUMOURS 

Tx 

T0 

T1s 

T1a 

T1b 

T2 

T3 

T4 

Primary tumour cannot be assessed 

No evidence of primary tumour 

Carcinoma in situ 

Limited/mobile (one cord) 

Limited/mobile (both cords) 

Extends to supra or subglottis (impaired mobility) 

Cord fixation 

Extends beyond larynx 

Stage T1s 

Carcinoma in situ can be reversed by the cessation of smoking. Excisional 

biopsy by laser provides excellent control. Excision with preservation of the vocal 

ligament is probably the best option. 

Stage T1a 

Endoscopic laser resection or radiotherapy provide equal control rates. 

The surgical access may define method of treatment. Partial laryngectomy may 

be required, but voice results are better with radiotherapy and/or endoscopic 


laser resection. Endolaryngeal laser surgery is more cost effective than 

radiotherapy. 

Stage T1b 

Treatment options are the same as T1a. 

Stage T2 

T2a (no cord restriction) radiotherapy may be preferable for superficial tumours. 

T2b (tumours impairing cord movement) can be treated either with partial 

laryngectomy or radiotherapy. 

Advanced Glottic Cancer 

Stage T3 

Treatment needs to be individualised. 

A review of prognostic factors is relevant. Better prognosis is seen in glottic 

lesions, female patients and N0 necks. 

Many advanced glottic cancers are under staged and are upgraded to T4 due to 

unsuspected cartilaginous involvement. 

Options for treatment include surgery, radiotherapy or combined therapy. 

Loco-regional control may be better in the surgically treated patient. 

Salvage surgery usually requires total laryngectomy but salvage partial 

laryngectomy has been reported with good outcomes. 

Stage T4 

Primary surgery with postoperative radiotherapy is the treatment of choice. Patients 

who are not fit for or refuse surgery can be offered chemoradiotherapy since this 

may provide better overall survival compared to radiotherapy alone. 

SUPRAGLOTTIC TUMOURS 

There is a high incidence of overt and occult metastases in supraglottic cancer. 

Early disease is treated with single modality, advanced disease with combined 

surgery and radiotherapy. 


Early supraglottic cancer 

Early supraglottic tumours (T1-2) can be treated either with conservative surgery 

(including endolaryngeal resection) or radiotherapy. Consideration should be 

given to bilateral elective management of the neck either by primary radiotherapy 

or bilateral selective neck dissection. 

Advanced Supraglottic Cancer (T3-4) 

Total laryngectomy with postoperative radiotherapy has been the mainstay of 

treatment. No survival advantage has been demonstrated compared to 

chemoradiotherapy and salvage laryngectomy if necessary. 

Primary laryngectomy with follow up with postoperative radiotherapy confers 

significant survival advantage compared to radical radiotherapy alone followed by 

salvage surgery. 

Patients undergoing conservative laryngeal surgery should be medically fit and 

with adequate pulmonary function prior to surgery. 

SUBGLOTTIC TUMOURS 

Most of these tumours are indistinguishable from glottic tumours. 

Most present late with stridor and require total laryngectomy with postoperative 

radiotherapy. 

MANAGEMENT OF THE NECK IN LARYNGEAL CANCER 

The management of the neck is highly dependent on the site of the primary tumour. 

The clinically negative neck (N0) 

Early glottic cancer (T1-T2) does not require elective neck treatment since the 

risk of occult neck metastases is low. 

Neck irradiation is as effective as elective neck dissection. 

Elective neck treatment is recommended for: 

a) Advanced glottic cancer 

b) Transglottic cancer 

c) All T stages of supraglottic cancer 

d) Subglottic cancer 


The treatment of the neck should follow wherever feasible the same modality as 

treatment of the primary. 

If the primary site is treated with radiotherapy then elective neck radiation should 

be performed. 

If the primary site is treated by surgery then appropriate elective neck dissection 

should be performed. 

a) Glottic cancer – ipsilateral neck dissection (Levels II,III,IV) 

b) Supraglottic cancer – bilateral selective neck dissection (Levels II, III, IV) 

c) Subglottic extension of glottic cancers/subglottic cancer – bilateral neck 

dissection (Levels II, III, IV and VI) 

d) If the paratracheal nodes are histologically positive then postoperative 

radiotherapy should be considered for the mediastinum. 

Indications for postoperative radiotherapy: 

a) Multiple node metastases 

b) Extra capsular spread 

c) Positive paratracheal nodes (Level VI) – mediastinal irradiation 

In salvage surgery after failed primary radiotherapy neck dissection should be 

considered even if the neck is negative. 

The clinically positive neck (N+) 

If radiotherapy/chemoradiotherapy is used to treat the primary tumour both sides 

of the neck should be included in the irradiation fields. 

If post radiotherapy assessment at six weeks demonstrates residual neck 

disease then modified radical neck dissection (MRND) or radical neck dissection 

(RND) should be prescribed. 

If the primary tumour is treated by surgery then MRND is performed. 

Ipsilateral neck dissection is indicated for glottic cancer 

Bilateral neck dissection is indicated for supraglottic cancer. 

Indications for postoperative radiotherapy are: 

a) Multiple positive nodes 

b) Extra capsular spread 

c) Positive paratracheal nodes 

d) Involvement of adjacent structures 

e) Skin involvement 


Special Circumstances 

Stridor 

This presents a difficult problem; most have advanced disease that dictates 

combined treatment: 

Endoscopic debulking is carried out where this is feasible. 

Tracheostomy although not desirable may be necessary. 

Emergency laryngectomy should only be used in exceptional circumstances. 

Recurrent/residual disease 

Further management is dependent on the primary treatment. 

Recurrence after radiotherapy is managed by salvage surgery. 

Total laryngectomy is the most commonly performed salvage surgery. 

Conservative laryngeal procedures may be considered in selected cases. 

Unresectable recurrences are treated with radiotherapy with or without 

chemotherapy. 

Stomal recurrence particularly if arising superiorly may be respectable and 

requires mediastinal resection and possible pharyngectomy with reconstruction. 

Chemotherapy in Laryngeal Cancer 

The role of chemotherapy in laryngeal cancer continues to evolve. 

Carefully controlled trials of chemotherapy should be supported on the following 

basis: 

High response rates to chemotherapy are achievable in laryngeal 

cancer 

Chemotherapy with radiotherapy may improve laryngeal preservation 

rates 

Awareness that the effect of concurrent chemoradiotherapy may be to 

increase toxicity 


Optimal combinations of chemotherapy and radiotherapy have yet to 

be determined 


6. CLINICAL GUIDELINES – HYPOPHARYNX 

ASSESSMENT 

Thorough assessment of a patient with hypopharyngeal carcinoma includes: 

i. Endoscopy 

j. Chest x-ray 

k. CT and MRI 

l. Pulmonary function testing 

11. Endoscopy 

Tumour site and extent of disease should be recorded iagrammatically and 

biopsy taken for histological examination. 

At the same assessment, oesophagoscopy and bronchoscopy are used to 

eliminate synchronous primary tumours and tracheal invasion respectively. 

Percutaneous endoscopic gastrostomy may be appropriate at this 

assessment. 

b. Chest X-Ray 

This is better than bronchoscopy in identifying a second primary tumour. 

Chest CT is preferable. 

12. CT/MRI 

Cross sectional imaging should be performed in all cases. CT has the 

advantage of assessing the presence of thyroid cartilage invasion. 

MRI scan offers a better soft tissue image. 

Chest CT should be performed for most tumours. 

Most patients with hypopharyngeal carcinoma should undergo both MRI and 

CT scanning. 

13. Pulmonary Function Tests 

These are useful where a tumour is amenable to surgical treatment. 

TREATMENT 

General Considerations 

1. Physical state 

2. Mental state 

3. Patient’s wishes (in light of extent of surgery and morbidity) 


Combined surgery and radiotherapy is the optimal treatment for all except the earlier 

stage tumours. 

Local control is improved with a combination of surgery and radiotherapy. 

Conservative surgical techniques are preferable for early stage disease. Resection 

should be wide to provide clear margins as positive margins have a poor prognostic 

factor. 

Submucosal spread of tumour is common and more extensive especially in piriform 

sinus carcinoma. The patient should be advised to stop smoking. 

Neoadjuvant chemotherapy should only be prescribed within a setting of a clinical 

trial. 

SURGERY 

T1 and T2 tumours 

Early tumours are infrequent. Single modality treatment of the primary tumour can 

be either: 

a. partial pharyngolaryngectomy 

b. radiotherapy 

c. endoscopic resection 

Insufficient evidence exists to identify one method as superior to all others. 

Radiotherapy appears to be less effective in tumours that are bulky or involve the 

piriform sinus apex. 

T3 and T4 tumours 

These require combined radical surgery with post-operative radiotherapy. 

The type of surgery depends on the site and extent of the tumour. Most tumours 

require total laryngectomy with partial pharyngectomy or total 

pharyngolaryngectomy. 

Resection and reconstruction 

No clear guidelines exist and each situation demands individual techniques. 

Endoscopic resection is suited for early posterior wall and piriform fossa tumours. 

Partial pharyngectomy with or without partial laryngectomy is useful for advanced 

tumours. 


Reconstruction 

Several options exist dependent on the extent of the defect: 

Partial pharyngectomy defects 

a. Primary closure – small posterior wall defects 

b. Radial forearm free flap 

c. Myocutaneous pectoralis major flap 

d. Jejunal patch flaps are useful 

Total pharyngolaryngectomy 

a. Free jejunal transfer is the technique that provides the most optimal outcome 

b. Tubed free radial forearm flap is an alternative 

c. gastric transposition may be required for extensive defects 

RADIOTHERAPY 

Primary radiotherapy with salvage surgery is commonly prescribed in many UK 

centres. 

Primary radiotherapy is appropriate for: 

a. Small hypopharyngeal tumours 

b. Patients medically unfit for extensive surgery 

c. Patients who refuse extensive surgery e.g. pharyngolaryngectomy 

Dose of primary radical radiotherapy varies from 55 Gy to 70 Gy over a period of 4-7 

weeks. 

Post-operative radiotherapy 

This is indicated for: 

a. T3-T4, N0-N3 tumours 

b. T1-T2, N0 tumours if histology shows: 

i. positive margins 

ii. vascular invasion 

iii. perineural invasion 

iv. extra-capsular spread 

v. if neck dissection is not being carried out. 

Radiotherapy should be commenced within six weeks of diagnosis. 

Lymph node metastases 

Two-thirds of patients have positive lymph node metastases at the time of 

presentation and diagnosis. 


Occult metastases are found in 40% of patients with hypopharyngeal tumours with 

an N0 stage neck. 

Occult spread occurs commonly to levels II – IV (rare for levels I or V to be involved 

in an N0 neck). 

Spread is bilateral in midline and bilateral tumours. 

Management of lymph node metastases 

N0 neck 

Little scientific evidence on the best mode of management. The management of the 

N0 neck is highly dependent on the management of primary tumour i.e. 

a. Primary radiotherapy to the neck if primary radiotherapy to the tumour site. 

b. Neck dissection if surgery is prescribed for the primary tumour 

c. Selective neck dissection of levels II, III and IV is recommended with inclusion 

of level IV in tumours that extend to the post cricoid region or apex of piriform 

fossa. 

d. Oro-pharyngeal extension demands, in addition, level I dissection. 

Clinically positive neck (N1 – N3) 

Modified radical neck dissection is indicated. 

Levels II, III, IV are adequate for N1 disease. 

Surgery should be used for recurrent disease if it is resectable followed by postoperative 

radiotherapy if it has not already been prescribed. 

Chemotherapy has a palliative role. 

REHABILITATION 

Involvement of the speech therapist as early as possible is the cornerstone of 

rehabilitation. 

All patients to be seen by a speech therapist prior to commencement of treatment. 

Surgical voice restoration should be considered either primarily or as a secondary 

procedure. 

Low-pressure valves are necessary when free tissue transfer has been used for 


Long-term use of feeding gastrostomy is frequently required. 


PALLIATIVE CARE 

One-third of patients are incurable on presentation. 

Pain control and the use of percutaneous endoscopic feeding gastrostomy helps to 

maintain the quality of life. 

Palliative radiotherapy can produce tumour shrinkage and provide relief of 

symptoms. 


7. CLINICAL GUIDELINES – NOSE & SINUSES 

INTRODUCTION 

Tumours in the sinonasal region are rare. 

Instance < 1/100,000 people per year. 

Squamous cell carcinoma commonest tumour. 

Other tumours include: 

adenocarcinoma 

olfactory neuroblastoma 

adenoid cystic carcinoma 

malignant melanoma 

sarcomas 

Anatomical site 

All areas of the nasal cavity and paranasal sinuses can be affected. Common sites 

include maxillary sinus, lateral wall of the nose and ethmoidal air cells. Frontal and 

sphenoidal sinus tumours are very rare. 

Assessment and Diagnosis 

Symptoms include: 

Unilateral nasal obstruction 

Unexplained epistaxis 

Cheek/facial swelling 

Visual disturbances 

Imaging 

CT - 

MRI - 

Biopsy - 

coronal and axial cuts with intravenous contrast enhancement 

three planar T1 pre and post gadolinium DPTA +/- T2 fat suppression. 

usually under a general anaesthetic. An endoscopic approach is 

preferred to avoid transgression of normal tissue planes. 

Related consultations 

Patients with sinonasal tumours may also require the input of: 

a. oral and orbital prosthetic rehabilitation. 

b. neurosurgical input. 

c. Medical oncology. 


Most patients require combined modality treatment. 

Radiotherapy may be given before or after surgery. Usual dose of 60-66Gy in 30-33 

fractions over 6 weeks. 


Neck nodes do not require prophylactic treatment. 

Concomitant chemotherapy – this is increasingly indicated with radiotherapy in both 

the pre and post-operative situation for patients with SCC and other tumours such as 

rhabdomyosarcoma and advanced lymphoma. 

Brachytherapy – this may be used for SCC for the columella and anterior nasal 

septum. 

Radiotherapy alone is required for lymphoma or for palliative treatment. 

Surgical Management 

a. Maxillectomy 

SCC is the commonest indication for this operation. 

Midfacial degloving, lateral rhinotomy or Weber-Fergusson incisions may 

be combined with orbital exenteration or extended to craniofacial 

resection. 

Immediate prosthetic rehabilitation is optimal. 

Modern approach of immediate reconstruction of the maxillectomy defect 

involves the use of microvascular free tissue transfer including the use of 

composite flaps e.g. iliac crest: DCIA/scapula/fibula flaps. 

Modified denture/prosthetic obturator provision is an alternative but 

considered only in the medically compromised patient. 

b. Partial or medial maxillectomy (lateral Rhinotomy) 

Indicated for: 

Localised tumours of the nasal mucosa, nasal septum and lateral wall. 

Rapid access with reasonable cosmesis e.g. elderly patients. 

c. Midfacial degloving 

This procedure is an access procedure to maxilla, ethmoids and nasal 

cavity. 

Often combined with bicoronal incision for skull base/craniofacial 

resection. 

d. Rhinectomy 

Required for extensive tumours of the anterior cartilaginous septum and 

nasal dorsum. 

Usually SCC. 

Local skin flap or prosthetic reconstruction. 

Multiple reconstructive procedures are required but delayed until 

pathological clearance established. 

Prosthetic rehabilitation (adhesive or implant retained) is a well-tried 

reconstructive alternative. 


e. Endoscopical endonasal approaches 

Suitable for relatively benign neoplastic e.g. inverted papilloma and small 

tumours. 

f. Neck dissection 

Indications for neck dissection for sinonasal malignant disease are: 

a. Clinical evidence of cervical node enlargement. 

b. Imaging evidence of cervical node enlargement. 

c. Access for microvascular anastomosis. 

HISTOPATHOLOGY 

Frozen sectional control is usually required for extensive resection. 

Second opinion pathology may be indicated for individual tumours. 

MANAGEMENT OF SPECIFIC TUMOURS 

1. Squamous cell carcinoma 

Combined surgery and radiotherapy usually required with the exception of 

small localised tumours. 

14. Adenocarcinoma associated with hard wood exposure but not exclusive. 

Commonly involve the antero-ethmoidal air cells. 

Surgical excision e.g. craniofacial +/- maxillectomy +/- post-op radiotherapy is 

the mainstay of treatment. 

15. Adenoidcystic carcinoma 

Widespread local dissemination by perineural lymphatic and embolic 

dissemination. 

Pulmonary metastases common. 

Wide excision and post-operative radiotherapy mainstay of treatment 

(radiotherapy delays local recurrence but does not affect overall survival). 

Late recurrence is common. 

10-20 year follow-up recommended. 

16. Olfactory neuroblastoma 

Arises from olfactory epithelium e.g. superior nasal cavity. 

Craniofacial resection usually required. 

Referral to supra-regional centre. 

17. Inverted papilloma 

Arises commonly in middle meatus involving the maxillary, ethmoid and 

frontal sinuses. Local invasion of bone but potential for malignant 

transformation (1-2%) 

Surgical excision mainstay of treatment. 


18. Angiofibroma 

Arises within the sphenoplalatine region with extension into nasopharynx, 

sphenoid and infratemporal fossa. 

Surgery is the mainstay of treatment with radiotherapy for recurrence. 

Endoscopic excision combined with embolisation also possible. 

FOLLOW-UP MANAGEMENT 

Baseline post-operative imaging at three months. 

EUA and debridement of cavity may be required on a regular basis. 


8. CLINICAL GUIDELINES FOR EAR AND TEMPORAL BONE 

INTRODUCTION 

Cancers arising in the temporal bone are extremely rare. 

Tumours may involve the ear in the following way: 

a. Primary cancer involving the ear from auricle, external auditory canal or 

middle ear and temporal bone. 70% of ear cancer originates in the skin of the 

pinna. 

b. Tumours from adjacent sites extending into the temporal bone. These include 

malignancies from the parotid gland, TMJ, skin of the pre-auricular and postauricular 

sulcus. 

19. Metastases from tumours arising in breast, kidney, lung, prostate and other 

sites. 

DIAGNOSIS 

Diagnosis is usually required before planning definitive treatment (small lesions of 

the pinna may be suitable for excisional biopsy). Associated enlarged lymph nodes 

should undergo FNAC assessment prior to definitive treatment. 

IMAGING 

High resolution CT is the investigation of choice for assessing bony anatomy of the 

temporal bone. MRI is useful to define a tumour that may arise from the brain or 

involve or arise from surrounding anatomical sites e.g. parotid gland. Carotid 

angiography may be indicated to establish unequivocally the involvement of the 

carotid artery. If involvement of the internal carotid artery is suspected, then its 

sacrifice (or reconstruction) may be considered by some surgeons as part of the 

resection. Under these circumstances, assessment of the effect of occlusion of the 

ICA is required. This usually involves a test balloon occlusion under local 

anaesthetic to assess the neurological sequelae. 

STAGING 

There is no staging system for malignancies of the ear accepted by either the AJCC 

or UICC. 


TREATMENT 

Cutaneous carcinoma of the pinna 

Surgical resection remains the mainstay of treatment, either by traditional methods 

or Mohs micrographic technique. Where lymphadenopathy exists, surgery in the 

form of extended neck dissection involving parotidectomy is required (to eliminate 

the parotid/preauricular lymph nodes). 

Patients who require resection of carcinoma of the pinna need the input of surgeons 

who are trained in a repertoire of reconstructive techniques. 

Radiotherapy can offer a high cure rate for small carcinomas of the pinna. 

Carcinomas involving the external auditory canal/temporal bone 

With a lack of accepted staging system, clinical experience dictates management. 

Complete surgical resection with clear microscopic margins is the preferred initial 

primary treatment where the tumour is resectable. A number of surgical approaches 

are available and include: 

a. Mastoidectomy – includes all types of modified radical and radical 

mastoidectomy. 

b. Lateral temporal bone resection (TBR) – removal of the osseous and 

cartilaginous external auditory canal, tympanic membrane, malleus and incus. 

c. Subtotal TBC – includes the additional removal of the otic capsule. 

20. Total TBR – involves the additional removal of the petrous apex. 

The above procedures may be combined with parotidectomy and neck dissection 

depending on the extent of the local disease and associated lymphadenopathy. 

Surgical resection and reconstruction that involves the internal carotid artery is 

controversial. No studies are available to show improved survival with the 

aggressive approach. The role of pre-operative or post-operative radiotherapy is 

unknown. Indications for post-operative radiotherapy, however, include: 

a. Close resection margins (less than 5mms), when proximity of tumour to 

important structures such as internal carotid artery precludes wide margins. 

b. Positive resection margins. 

21. Perineural invasion. 

These conditions apply to the majority of temporal bone resections – post-operative 

radiotherapy is indicated in most cases. 


PROGNOSIS 

Cutaneous carcinoma of the pinna has been described by several authors as having 

a higher rate of recurrence and worse prognosis than other skin cancers. Patients 

with carcinoma of the pinna should only be managed by surgeons who are regularly 

involved in head and neck cancer surgery. Squamous cell carcinoma of the ear has 

a reported recurrence rate of 14% with death in 2.5% of patients from local failure. 

The prognosis for carcinoma of the external auditory canal/temporal bone where 

disease is confined to the canal is approximately 50% with 5 year’s survival but falls 

to approximately 29% with middle ear involvement. 

SUMMARY 

Carcinoma of the temporal bone is rare. 

No studies are available to evaluate treatment options. Clinical experience dictates 

the management. 

Complete surgical resection with clear margins is the preferred initial treatment. 

The precise role of pre and post-operative radiotherapy is unclear although postoperative 

radiotherapy is indicated in most cases. 


9. CLINICAL GUIDELINES FOR SALIVARY GLAND TUMOURS 

INTRODUCTION 

Salivary gland tumours are a diverse range of histology and clinical behaviour. 

Benign tumours are relatively common. 

Malignant tumours are relatively rare. 

Carcinomas are classified as: 

a. High grade 

b. Low grade 

c. Mixed behaviour 

The 1991 WHO histological classification is as follows: 

a. Adenomas 

b. Carcinomas 

c. Non-epithelial tumours. 

d. Malignant lymphomas 

e. Secondary tumours 

f. Unclassified tumours. 

g. Miscellaneous/tumour-like disorders 

Clinical pathology correlation has proved unreliable and overall clinical behaviour 

rather than histology provides a better guide for treatment and prognosis. 

Malignant salivary gland tumours are more common in the submandibular, 

sublingual and minor salivary glands than the parotid gland. The parotid gland is the 

commonest site of salivary gland tumours, most of which are benign. 

Adenomas 

Pleomorphic adenoma 

Myoepithelial adenoma 

Basal cell adenoma 

Warthin’s tumour – Adenolymphoma 

Ductal papilloma 

Cystadenoma 

Carcinomas 

Acinic cell carcinoma 

Mucoepidermoid carcinoma 

Adenoid cystic carcinoma 

Polymorphous low-grade (terminal 

duct) 

Papillary cystadenocarcinoma 

Mucinous adenocarcinoma 

Adenocarcinoma 

Carcinoma in pleomorphic adenoma 

(malignant mixed tumour) 

Squamous cell carcinoma 

Undifferentiated carcinoma 


Assessment and Investigations 

Many malignant tumours, particularly low grade, are indistinguishable from benign 

lesions. 

Definitive histology is usually available after surgical resection. 

Diagnosis of high grade malignant tumour is based on: 

a. Clinical features – pain, rapid growth, fixation to adjacent tissues, facial nerve 

involvement or neck node metastases. 

b. MRI scanning – non-homogenicity, muscle infiltration and enlarged lymph 

nodes all suggest malignancy. 

c. FNAC – useful for major salivary gland tumours where malignancy is suspected 

(the role of FNAC in overtly benign disease is questionable). Expert 

cytopathology should distinguish malignant from benign disease in 90% of 

cases. 

d. Open biopsy – this should be avoided as tumour spillage has an adverse affect 

on survival. 

e. Frozen section – often more difficult than in SCC of the upper aerodigestive 

tract. False negative rates are high and frozen sections are not as reliable in 

salivary gland malignancy. 

Management 

Surgery remains the mainstay of treatment for malignant tumours of the salivary 

glands. This may or may not be followed by post-operative radiotherapy. 

SUBMANDIBULAR GLAND 

Primary tumour 

Total excision of the gland is appropriate – extra capsular excision or supra-hyoid 

or supra-omohyoid neck dissection is deemed appropriate. The argument for 

wide resection for adenocystic carcinoma including sacrifice of lingual, 

hypoglossal and marginal mandibular nerve is equivocal. High grade malignancy 

in younger patients should be treated aggressively with excision of the gland 

involving a 2cm margin of healthy tissue. 

Large tumours with bone involvement i.e. mandible, require composite resection 

of soft tissue and rim or segmental mandibular resection. 

Management of the neck 

High grade tumour with no node metastases (N0) should undergo elective supraomohyoid 

dissection. 

Patients with positive neck metastases should have modified radical neck or full 

radical neck dissection. 


RADIOTHERAPY 

Indications include: 

High grade or bulky disease. 

Residual neck disease 

Microscopical extra-capsular spread within adjacent lymph nodes. 


Inoperable tumours are best managed with palliative radiotherapy. 

PAROTID GLAND 

Primary tumour 

Conservative parotidectomy should be performed with preservation of the facial 

nerve provided there is no microscopic invasion. 

Deep lobe tumours will require total parotidectomy. 

Facial nerve preservation is recommended unless tumour infiltration is obvious 

per-operatively. 

Primary nerve grafting should be considered if clearance of the main facial nerve 

trunk has been achieved. 

Adenoid cystic carcinoma requires total parotidectomy sacrificing any part of the 

facial nerve involved with tumour. 

Neck 

Neck dissection should be performed where there is evidence of nodal disease 

either on clinical assessment or MRI scan. 

Prophylactic neck dissection should be considered for patients with high grade 

tumours e.g. adeno-carcinoma, SCC, high grade muco-epidermoid carcinoma. 

RADIOTHERAPY 

Postoperative 

As for submandibular gland. 

Palliative 

As for submandibular gland. 

MINOR SALIVARY GLANDS 

Confirmation of diagnosis usually requires open biopsy e.g palatal swelling. 

The prognosis is more closely related to the stage of disease rather than 

histology i.e. larger tumours do worse than smaller tumours. 


Treatment 

Surgery remains the mainstay of treatment. 

On bloc resection with wide adequate resection margins is the cornerstone of 

treatment. 

Ablative defects require reconstruction e.g. temporalis muscle flap for posterior 

maxillectomy defects. 

Management of the neck 

Clinically positive neck requires: 

Modified radical or radical neck dissection where there is evidence of lymph node 

involvement on clinical examination or MRI scan. 

Clinically negative neck: 

Prophylactic neck dissection is only indicated for high grade tumours e.g. adenocarcinoma, 

carcinoma in pleomorphic adenoma or undifferentiated carcinomas. 

Indications for Radiotherapy 

Microscopic residual disease. 

Adenoid cystic tumours. 

Aggressive undifferentiated tumours. 

THE NATURAL HISTORY OF COMMON TUMOURS 

Acinic cell carcinoma 

3% of parotid tumours. Peak incidence 5 th decade. 

Demonstrates variable histological pattern – multifocal and occasionally bilateral. 

Survival 90% at 5 years and 55% at 20 years. 

Lymph node metastases in 10%. 

Total parotidectomy, wide local excision with preservation of uninvolved nerves is 

the mainstay of treatment. 

Prophylactic neck dissection not indicated. 

Mucoepidermoid tumour 

Variable malignancy with low and high grade lesions. 

Low grade lesions show a benign nature. 

Commonest major malignant salivary gland tumour (4-9%). >90% in the parotid – 

almost always in the superficial lobe. 

Commonest malignant salivary gland tumour in children. 

Highest incidence 3 rd – 5 th decade. M=F. 

Histologically divided into low, intermediate and high grade lesions. These 

divisions correlate directly with the prognosis. 

5 years survival with low grade is 86% 

5 years survival for high grade 22%. 


40% incidence of lymph node metastases for intermediate and high grade 

tumours. 

Low grade tumour require local resection by parotidectomy with adjuvant 

radiotherapy for the high grade lesion. 


Common salivary gland malignancy – mucosal sites more frequent than major 

salivary glands. 

2-6% of parotid malignant tumours – 15% of submandibular tumours. 

Low pervasive growth – high incidence of perineural infiltration. 

Variable histological appearance. 

High rate of morbidity due to local recurrence and distant metastases particularly 

to lung. 

NB: 20% of patients with primary metastases survive more than 5 years. 

5 years survival of 60% with 20 years survival of 20%. 

Treatment by wide local resection with preservation of uninvolved major nerves. 

Post-operative radiotherapy indicated. 

Adenocarcinoma 

Uncommon tumour usually in the parotid gland. 

M=F – any age affected. 

Histological appearance variable. 

Low grade well-differentiated papillary vs mucinous high grade undifferentiated 

lesions. 

Distant metastases in 40% for high grade tumours. 

5 years survival: 75% for low grade tumours, 19% for high grade tumours. 

Treatment is by wide local resection with elective neck dissection and postoperative 

radiotherapy. 

Malignant mixed tumour (carcinoma within PSA) 

99% arise from pleomorphic adenoma after a period of 10-15 years. 

Frequency between 2-5%. 

The most aggressive of all malignant neoplasms with incidence of blood borne 

metastases. 

5, 10 and 15 years cure rates of 40%, 24% and 19% respectively. 

Treatment involves radical resection plus neck dissection with post-operative 

radiotherapy. 

Squamous cell carcinoma 

M:F = 2:1 

A very rare tumour – difficult to differentiate from high grade muco-epidermoid 

lesion or secondary deposit from a distant site. 

Elderly patients >60 years old very bad prognosis. 

Treatment with radical surgery and post-operative radiotherapy. 


10. GENERAL PRINCIPLES FOR RADIOTHERAPY AND 

CHEMOTHERAPY TREATMENT FOR MANAGEMENT OF 

CARCINOMAS OF THE HEAD AND NECK 

Pre-treatment assessment of the patient in a multi-disciplinary team setting is 

essential for radiotherapy treatment. At the consultation full staging information 

should be available, this should include details of any examination under anaesthetic 

carried out, with appropriate histology results and appropriate radiological 

investigations. Where cases have not been seen pre-operatively photographs and 

surgical mapping are essential. These should be read in conjunction with the 

pathology report to delineate areas of higher risk where extra radiation dose may be 

necessary. 

Where significant areas of the oral cavity and oro-pharynx will be irradiated patients 

will require dental assessment prior to radiotherapy and should know the importance 

of continued dental hygiene following their treatment. 

Nutritional support 

Consideration should be given to insertion of a PEG feeding tube prior to intensive 

chemo-radiation where significant parts of the oral cavity and oro-pharyngeal 

mucosa will be irradiated. Many of these patients require tube feeding and insertion 

of a PEG tube prior to treatment can reduce treatment interruptions. 

Immobilisation shell 

Patients undergoing radical treatment will require an immobilisation shell. To reduce 

anxiety adequate preparation with explanation of how the shell is made including 

diagrams and leaflets in the clinic is helpful. 

Dose and fractionation 

Stage 1 and 2 disease T1 to T2 larynx only 

Patients with stage T1 or T2 laryngeal cancer can be treated with a hypofractionated 

regime of 55Gy in 20 daily fractions over four weeks. The same 

treatment regime can be used for small volume tumours at other sites as clinically 

appropriate although has a less robust evident base than for treatment of carcinoma 

of the larynx. It may be preferred to use standard fractionation of 60 to 66Gy in daily 

2Gy fractions over 6 to 6½ weeks. 

Stage 3 and 4 disease any node positive Ts/T4 N0 

Fit patients with stage 3 or 4 head and neck cancer treated with a definitive 

radiotherapy should not be treated with conventional fractionation alone (10Gy per 

week). Treatment should be with either modified fractionation or synchronous 

chemo-radiotherapy. The moderately accelerated regime e.g. DAHANCA 66-66Gy 

in 5½ weeks or concomitant boost 72Gy in six weeks seem most attractive. The 

radiotherapy regimes used with Platinum based chemotherapy are usually delivered 


over 6 to 7 weeks, but there is also considerable experience in using chemoradiotherapy 

over 4 weeks. The following regimes are recommended: 

Moderately accelerated radiotherapy 66-68Gy in 2Gy fractions 6 times a week over 

5½ weeks or 66-70Gy in 6½ to 7 weeks with synchronous chemotherapy. A recent 

study has shown that Cetuximab concurrently with radiotherapy has equivalent 

efficacy to chemo-radiotherapy with less toxicity. NICE approval of this is awaited. 

Medical Co-morbidity 

Patients with extensive medical co-morbidity may be treated with definitive 

radiotherapy alone in conventional or short regimes. 

Prophylactic nodal doses 

50Gy in 2Gy fraction should be delivered to uninvolved nodal areas where risk of 

involvement is >20%. 

Post operative radiotherapy 

Post operative radiotherapy should be offered to patients with the following: 

1. Incomplete excision margin (*= denotes high risk of recurrence). 

2. If there is extra-capsular nodal spread (*+ denotes high risk of recurrence). 

3. When a nodal disease is found in more than one surgical level. 

4. If there are any nodes more than 3cm in size. 

5. More than two nodes pathologically involved. 

6. Advanced T disease. 

The suggested dose is 60Gy in daily 2Gy fractions over six weeks with a boost of up 

to 6Gy in 3 fractions. Two recent publications have shown a benefit to adding single 

agent Cisplatin to this radiotherapy regime and it should be considered for patients 

with one or more very high-risk factors as defined about. Patients over the age of 70 

were not treated in these trials and particular caution should be used in patients with 

significant co-morbidity when using Cisplatin as toxic deaths occurred. 

Treatment interruptions should be avoided (see departmental policies on avoiding 

interruptions in radical radiotherapy). 

Palliative radiotherapy 

Suggested regimes: 

27Gy in 6 fractions in 2-3 weeks 

20Gy in 5 fractions 

30Gy in 10 fractions 

Supportive care on radiotherapy and chemotherapy 

Patients should be advised to stop smoking and moderate alcohol intake. 


Patients should be assessed regularly during their radiotherapy and chemotherapy 

with particular regard to the extent of mucositis, pain control and nutritional status. 

Prophylactic anti-fungals and mouthwashes have been shown to reduce the severity 

of mucositis and should be prescribed to all patients along with soluble analgesia at 

the start of treatment. Opiate analgesics will be required for significant numbers of 

patients towards the end of their treatment. It is essential to ensure that ongoing 

care of radiotherapy reaction is organised and patient’s and carers should be given 

appropriate contact numbers for advice in the post-radiotherapy period. 


11. Guidelines for the Management of Thyroid Cancer 

The East Midlands Cancer Network Thyroid Group and associated Services adhere 

to the Royal College of Physicians, British Thyroid Association Guidelines for 

the Management of Thyroid Cancer, 2007. These are guidelines are reflected in 

the local operational policies. 

http://www.british-thyroid-association.org/Guidelines/ 

www.rcplondon.ac.uk 

11.1 NSSG Policy Regarding which Named Surgeons Perform Lymph Node 

Resections on Thyroid Cancer Patients 


The Thyroid Subgroup agreed at the meeting held on 9 th July 2010 in consultation 

with all the MDTs in the network that the following named surgeons in the network 

are authorised to perform lymph node resections on thyroid cancer patients. 

• Each of the named surgeons below is a core MDT members. (They may also 

be members of UAT MDTs). 

MDT 

Lincolnshire Thyroid MDT 

Nottingham Thyroid MDT 

Northamptonshire Thyroid MDT 


Derbyshire Thyroid MDT 

Designated Surgeons 

Mr A McRae 



Mr N Beasley 

Mr C Ubhi 

Mr S Al Hamali 

Mr V Bahal 

Mr P Gurr 

Mr D Ratliff 

Mr A Tewary 

Mr T Alun – Jones 

Mr P Conboy 

Professor N London 

Mr A Moir 

Professor 

M Nicholson 

Mr J Sharp 

Mr A Thompson 

Thyroid Subgroup Imaging Guidelines: (Measure 10-1C-106i) 

In compliance with Measure 10-1C-106i the NSSG Thyroid Subgroup agreed imaging 

guidelines thyroid cancer reflect The Royal College of Radiologists “Recommendations for 

Cross-Sectional Imaging in Cancer Management”. 


Thyroid Subgroup Pathology Guidelines (Demonstrating Compliance with Measure 10- 

1C-108i) 

The EMCN Thyroid Subgroup agreed to adopt as the network guidance for thyroid 

cancer the guidance produced by the Royal College of Pathologists, namely: 

• Royal College of Pathologists: Standards and Datasets for Reporting Cancers 

Dataset for thyroid cancer histopathology reports 2010 

• Royal College of Pathologists: Standards and Datasets for Reporting Cancers 

Dataset for parathyroid cancer histopathology reports 

February 2006 

The full Royal College of Pathologists documents are appended as hard copies. 

http://www.rcpath.org/resources/pdf/g098datasetforthyroidcancerhistopathologyreportsfinal.pdf 

Areas of Responsibility: 

The responsibility for the pathology and associated testing lies with the diagnostic 

and assessment services. 

There may be subsequent discussion at the MDT particularly in cases of medullary 

carcinoma where it is necessary to establish if this is a sporadic or familial case of 

thyroid cancer. 

Thyroid Subgroup Service Development Plan (Measure 10- 1C-114i) 

At the East Midlands Thyroid Cancer Subgroup on 9 th July 2010 a review of the 

current services was undertaken to ensure that there was equity of access and 

identify areas where development could be undertaken to enhance what was 

recognised as a high quality service. The issues identified were included in the 

Thyroid Subgroup Service Development Plan for Thyroid Cancer confirmed to cover 

the period 2010-2013. The key issues for development are summarised below: 

Service Issue Issue to address Development Plan Action 

CNS Review EMCN Review of work load and Link to the EMCN Nurse 

options for innovation 

Director to ensure input 

EOLC 

Patient 

Information – 

Head and Neck 

and Thyroid 

TYA Path 

VTC Upgrades 

Awaiting roll out to Trusts from NCAT. 

Will be available at all trusts 

BTA Leaflets 

Ensure robust link to the TYA Service 

as appropriate 

Facilitate VTC Links for network 

meetings both at NSSG and MDT level 

Contribute to the NSR work 

streams through the EMCN 

Nurse Director 

Patient Information Managers to 

work with Trusts to ensure 

Patient Information embedded. 

Work with the TYA Subgroup to 

develop the referral and choice 

criteria 

Dec 2010 to be complete 


Appendix D1 - Primary Care Referral Guidelines 

FIGURE 1 – SCHEMA – Numbers refer to numbered footnotes below 

NECK LUMP THYROID FEATURES 

SUSPICIOUS 

OF 

MALIGNANCY 

STRIDOR 

REFERRAL 

GUIDELINE 

Clinically thyroid 

Features 

suspicious of 


+/- stridor 

1A 

STRIDOR 

> Same-day 

referral 

>Designated 

clinician or 

A&E 

> 

Management 

then diagnosis 

No features 

suspicious of 


NECK 

LUMP 

Clinically nonthyroid 

NO STRIDOR 

> Fast-track 

appointment 

>Designated 

clinician for 

thyroid 

> Neck Lump or 

thyroid clinic 

2 

See Figure 2 

>Routine 

appointment 

> Designated 

clinician for 

thyroid 

> Neck lump or 

thyroid clinic 

2 


FIGURE 2: SCHEMA – Numbers refer to numbered footnotes 


SUSPICIOUS 

OF 

MALIGNANCY 

STRIDOR 

REFERRAL 

GUIDELINE 

See Figure 1 

Clinically thyroid 

> Lump persists 

after 3 weeks 

despite antibiotics 

> Inf. Mono. 

Excluded 

> No associated 

(non-lump) features 

of malignancy 

1B 

> Fast-track 

appointment 

> Designated 

clinical for UAT 

or Cons Haem- 

Onc 

> Neck Lump 

Clinic 

3 

NECK 

LUMP 

Clinically nonthyroid 

> Lump has 

associated (nonlump) 

features of 

UAT malignancy+/- 

stridor 

4 

> Lump has 

associated (nonlump 

features of 

haematological 

malignancy +/- 

stridor 

7 

> Lump disappears 

within 3 weeks +/- 

antibiotics or positive 

for Inf Mono 

> No associated 

(non-lump) features 

of malignancy 

NO STRIDOR 

STRIDOR 

NO STRIDOR 

> Fast-track 

appointment 

> Designated 

clinician for UAT 

> Direct or at 

neck lump clinic 

5 

> Same-day 

referral 

> Designated 

clinician or A&E 

> Management 


> Fast-track 

appointment 

> Cons Haem- 

Onc 

> Direct or at 

neck lump clinic 

5 

Not applicable 


FIGURE 3: SCHEMA – Numbers refer to numbered footnotes– see pages 3-4 

The local Operational Policies confirm the current clinical points of contact as outlined earlier 

in the constitution. 


SUSPICIOUS 

OF 

MALIGNANCY 

STRIDOR 

REFERRAL 

GUIDELINE 

NECK 

LUMP 

> Lump has 

associated (nonlump) 

features of 

UAT malignancy+/- 

stridor 

4 

NO STRIDOR 

STRIDOR 

> Fast-track 

appointment 

> Designated 

clinician for 

UAT 

> Direct 

> Same-day 

referral 

> Designated 

clinician or 

A&E 

> 

Management 


> Lump has 

associated (nonlump 

features of 

haematological 

malignancy +/- 

stridor 

7 

> Routine 

appointment 

> Central 

contact point of 

designated 

hospital referral 

proforma 


Notes to numbered points on Figures 1-3 

1A 

Features suspicious of cancer associated with a thyroid lump (reference: guidelines 

for the management of thyroid cancer in adults, 2002. British Thyroid Association 

and Royal College of Physicians): 

• Solitary nodules increasing in size 

• Patient has history of neck irradiation or family history of thyroid cancer 

• Patient over 65 

• Unexplained hoarseness or voice change associated with a goitre 

• Associated cervical lymphadenopathy 

1B 

Features suspicious of cancer associated with the non-thyroid neck lump itself 

(reference: Department of Health Referral Guidelines for the Diagnosis of Cancer, 

reviewed 2005): 

• Persists for 3 weeks despite antibiotics 

• Infections Mononucleosis excluded 

2 

Depending on network-agreed local arrangements, designated clinicians for UAT 

assessment may also be designated for thyroid assessment and the services may 

be provided in one common neck lump clinic; or endocrinologists/endocrine 

surgeons may be designated for assessment of thyroid cancer only and work in a 

specific thyroid clinic. 

3 

See measure 1D-112 regarding the requirements for common working between 

designated clinicians for UAT cancer assessment and consultant haematooncologists. 

4 

Features suspicious of UAT cancer which are not features of the lump itself 

(reference: Department of Health Referral Guidelines for the Diagnosis of Cancer, 

revised 2005): 

• Hoarseness for more than 6 weeks 

• Oral mucosal ulcer persisting for more than 3 weeks 

• Oral swelling persisting for more than 3 weeks 

• Red or red and white patches of the oral mucosa 

• Dysphagia for more than 3 weeks 

• Unilateral nasal obstruction, especially with purulent discharge 

• Unexplained tooth mobility, not associated with periodontal disease 

• Cranial neuropathies 

• Orbital masses 

5 

Referral to a neck lump clinic or direct to a designated clinician is at the discretion of 

the referrer depending on the nature of the presenting features. 


6 

• In the absence of a thyroid lump, there are unlikely to be any other head and 

neck features which would discriminate towards thyroid cancer compared to 

UAT cancer. Stridor is dealt with independently. 

• Features of haematological malignancy, without neck lumps, are not relevant 

to head and neck specific guidelines. 

• The very rare cases of UAT and thyroid cancer presenting only with features 

due to distant metastases are not covered by these guidelines. They are 

better dealt with as part of guidelines on the diagnosis and management of a 

separate entity “carcinoma of unknown origin”. 

7 

Features suspicious of haematological malignancy (reference: Department of Health 

Referral Guidelines for Suspected Cancer). 


Appendix D2 - Network-wide UAT Referral Proforma for Routine Referrals 

PATIENT INFORMATION: 

Patient Surname: 

Patient First Name(s): 

Title: 

GP/HOSPITAL INFORMATION: 

Referring GP: 

Referring Practice: 

GP Practice Code: 

Sex: 

Address: 

DOB: Practice Tel No: 

Practice Fax No: 

Hospital Number: 

NHS Number: 

Post Code: 

Date of Referral: 

Home Tel No: 

Work Tel No: 

Mobile: 

Has the patient been told they may have cancer 

YES/NO 

Is an interpreter required YES/NO If YES, what language 

Referral to: (please tick one box): 

ENT 

MAXILLOFACIAL 

REFERRAL INFORMATION (please tick boxes against relevant symptoms. Tick at least one box) 

Anatomical Site: 

Oral Cavity (Maxillofacial only) 

Neck 

Larynx 

Larynx (ENT only) 

Salivary Gland 

Clinical Features: 

Hoarseness< 2 weeks 

Unilateral painful salivary gland swelling 

Oral Ulcer< 2 weeks 

Painful lump in neck >3 weeks 

Tonsillar enlargement 

Unusual oral swelling >3 weeks 

Unexplained generalised sore throat 

Suspicious white patches of oral mucosa 

Painful swallowing < 4 weeks 

Risk Factors: 

Non-Smoker Smoker Alcohol 

consumption 

Comments: (e.g. current symptoms, past history, social history, allergies, current medication)

Constitution - East Midlands Cancer Network

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