eRequest Portal

Royal Free London

Neuroendocrine Tumour Unit eRequest Form

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This form is a request to the NET MDT and not a referral to the NET team. Deadline 12:00pm Friday.

It is the responsibility of the referrer to action outcomes unless otherwise stated.

Neuroendocrine Tumour Unit

Many thanks for your referral to the Neuroendocrine tumour Unit

In order to discuss your case efficiently, we would be grateful if you could follow the instructions below.

The instructions are divided into three parts:

 

1. THE PROFORMA – This proforma can act as a referral letter to the NET Unit

  1. Please fill in the form completely. Please note that these forms will be vetted by the NET team. We will not accept any incomplete forms and the case will not be discussed.
  2. We would also be grateful if you could attach alongside the form,
    1. Last clinic letters 
    2. Imaging reports
    3. Histology reports
    4. Blood reports (which include 5HIAA, Chromogranin A&B, plasma and urine metanephrines)
  3. Please indicate whether the patient has been made aware of the referral and diagnosis otherwise no further investigations/appointments will be organised from the NET team.

 

2. IMAGING - Relevant imaging types include CTs, MRIs, GA68 Dotatate PET, FDG PET, Octreotide, Bone scan.

  1. Please specify the type of imaging in the form and where and when the scans were done.
  2. Please organise to send the relevant imaging across to the Royal Free Hospital Node via IEP. 
    1. If the imaging was performed in another hospital other than yourselves – please inform us so that we can attempt to retrieve the scans.
  3. If scans cannot be sent via IEP, please send a copy of the imaging as a CD or DVD to the address at the bottom of this page. 

 

3. HISTOLOGY –This is a compulsory request

  1. Please request your histology department to send across the relevant histology samples which provides a diagnosis of a neuroendocrine or carcinoid tumour.
  • If biopsy material: HE- and any immunostained sections + either tumour block or 8 stained sections on APS slides
  • If resection specimens: HE- and any immunostained sections + 1 tumour block

In both scenarios: copy of the original report

  1. The histology samples are to be sent to the address below.

ADDRESS: 

NET MDT Co-ordinator

MDT Office

Virology

Ground Floor

Royal Free Hospital

Pond Street

NW3 2QG

 

Thank you.

Requesting Hospital: *
Date of Referral: *
(DD/MM/YYYY)
Cancer Pathway Type: *
MDT Discussion Type: *
Date 2WW referral received/Case
Upgraded: *
(DD/MM/YYYY)
Breach date: *
(DD/MM/YYYY)
NHS Number: *
Title *
Patient surname: *
Patient first name: *
Patient age:
Patient email:
Post Code: *
Patient address: *
Patient telephone number: *
Tumour type for consideration: *
Tumour Grade:
Patient ethnicity:
Date of birth (DD/MM/YYYY): *
Date patient first seen at local centre: *
(DD/MM/YYYY)
Requestor Name: *
Requestor Email: *
Referring Consultant: *
Keyworker (CNS): *
Keyworker email: *
General Practice Name: *
Practice Address: *
General Practitioner Name: *
Performance Status: *
Is patient aware of referral? *
Type of Referral:
Co-morbidities:
Presenting Symptoms: *
Significant past medical history including previous treatments, allergies and medication: *
Question to MDT: *
Investigations including ERCP, EUS, OGD, Colonoscopy, Histology reports and clinic letters
Imaging
Is imaging to be reviewed: *
Has imaging been sent via IEP / CD? *
Histology / cytology specimen Date Hospital Specimen sent over to RFH? Histology Reports Action

{{l.rFile}}
  
Investigation Reports(ERCP, EUS, OGD, Colonoscopy and clinic letters)
Bloods *      Yes   No
Value Date (DD/MM/YYYY)
EGFR
Creatinine
Bilirubin
AST
ALT
ALP
AFP
5HIAA
Chromogranin A
Plasma Metanephrines
Urine Metanephrines
Gut hormones
Date of next local outpatient appointment:
(DD/MM/YYYY)
Comment:
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