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Suspected/Malignant-Hepato-Pancreatico-Biliary Multidisciplinary Request Form
Change MDT
This form is a request to the HPB MDT and not a referral to the HPB team. Deadline 12:00pm Friday.
It is the responsibility of the referrer to action outcomes unless otherwise stated.
Patient Type:
*
Select
NHS
PRIVATE
Date of MDM:
*
(DD/MM/YYYY)
Cancer Pathway Type:
*
MDT Discussion Type:
*
Select
2ww
Consultant upgrade
Opinion and Advice Only
Transfer to specialist centre for diagnostics only
Other
Date 2WW referral received/Case
Upgraded:
*
(DD/MM/YYYY)
Breach date:
*
(DD/MM/YYYY)
Has imaging been sent via IEP?
*
Select
Yes
No
Imaging reviewed locally
Select
CT
MRI
MRCP
PET
ERCP
USS
(DD/MM/YYYY)
Characters (with spaces):
8000
Character(s) Remaining
Upload imaging report
Imaging report still required even if reviewed locally.
NHS Number:
*
Title
*
Select
Dr
Mr
Miss
Mrs
Ms
Prof
Patient surname:
*
Patient first name:
*
Patient age:
Patient email:
Post Code:
*
Patient address:
*
Patient telephone number:
*
Tumour type for consideration:
*
Select
Cholangiocarcinoma
Gallbladder
HCC
Liver Mets
Pancreas
Pancreatic Cystic Lesions
Other
In line with NICE Guidance, local Trusts should request a PET scan for all patients with a potential pancreatic cancer as soon as possible in parallel with MDT referral.
Pancreas Type:
*
Select
Pancreas cancer with metastases
Pancreas cancer without metastases
Pancreas cancer without metastases, potentially suitable for ‘hot whipples’
Liver Mets Type:
*
Select
Synchronous Resection
Liver mets with primary in situ
Liver mets - primary removed
*Patients are suitable for consideration of a ‘hot whipples’ if they have the following: painless obstructive jaundice which is unstented with radiological features consistent with pancreas cancer, without vascular involvement or metastases in a fit patient.
Patients are suitable for consideration for Synchronous Resection if they present with synchronous colorectal primaries and liver only metastatic disease.
Cholangiocarcinoma Type:
*
Select
Cholangiocarcinoma without metastases
Cholangiocarcinoma with metastases
Gallbladder Type:
*
Select
Gallbladder cancer without metastases
Gallbladder cancer with metastases
Date of birth (DD/MM/YYYY):
*
Date patient first seen at local centre:
*
(DD/MM/YYYY)
Requesting Hospital:
*
Select
Addenbrookes
Amersham
Ashford and St Peter’s Hospital
Barnet
Basildon
Bedford Hospital
Bristol Royal Infirmary
Broomfield
Cavell hospital ( Private hospital)
Charing Cross Hospital
CHELSEA AND WESTMINSTER HOSPITAL
Colchester
Ealing Hospital
Frimley Park
Homerton University Hospital
Ipswich
John Radcliffe Hospital
Kettering General Hospital
King’s College Hospital
Lister
Luton & Dunstable
Mount Vernon
Musgrove Park Hospital
NHS surgery
Norfolk Hospital
North Middlesex Hospital (NMUH)
Northwick Park Hospital
Norwich Hospital
Nottingham City Hospital
Peterborough Hospital
Portsmouth Hospitals University
Princess Alexandra Hospital (PAH)
Private hospital
Queens
Royal Berkshire
Royal Derby Hospital
Royal Free
Royal London
Royal National Orthopaedic Hospital
Royal Sussex County Hospital
Royal Victoria Hospital
Southend Hospital
St Bart’s hospital
St Helier
St Mary’s Hospital
Stoke Mandeville
The Royal Marsden
Torbay and South Devon NHS Foundation Trust
UCLH
University Hospital Dorset
University Hospital of Wales (UHW)
University Hospitals Coventry and Warwickshire
Watford
Wexham Park Hospital
Whipps Cross hospital
Whittington
Worcestershire Royal Hospital
Wycombe
Yeovil District Hospital
Requestor Name:
*
Requestor Email:
*
Referring Clinician:
*
Keyworker:
*
Keyworker email:
*
General Practice Name:
*
Practice Address:
*
General Practitioner Name:
*
Select
Other
Outcomes of colorectal tests/diagnostics
Upload file
Endoscopy
Colonoscopy
CT chest
Abdo pelvis
MRI liver +/- PET
Histology
Patient ethnicity:
Performance Status:
*
Select
0-Fully active
1-No heavy physical work, but can do anything else
2-Up more than half the day-cannot work
3-In bed/chair > half the day - need some help
4-In bed/chair > half the day - need a lot of help
Co-morbidities:
Select
Yes
No
Stroke
Cardiac Disease
Renal Failure
Respiratory impairment
Other
Presenting Symptoms:
*
Significant past medical history including previous treatments, allergies and medication:
*
Question to MDT:
*
Investigations including scan reports and Histology
Investigation Reports
Upload investigation report.
Bloods
*
Yes
No
Value
Date (DD/MM/YYYY)
EGFR
Creatinine
Bilirubin
AST
ALT
ALP
CA19-9
CEA
AFP
INR
Haematinics (if Hb < 130)
Ferritin
B12
Folate
NT pro BNP (if >400, needs ECHO)
Is patient aware of referral?
*
Select
Yes
No
Date of next local outpatient appointment:
(DD/MM/YYYY)
Upload referral letter:
For HCC only
Aetiology:
*
Hep B Yes
No
Hep C Yes
No
Alcohol Yes
No
Patient currently abstinent from alcohol? Yes
No
Cirrhosis:
*
Platelets
Cirrhosis
Yes
No
Varices
Yes
No
Splenomegaly
Yes
No
Performance status:
*
0
1
2
3
4
Childs Pugh Score:
*
5
6
7
8
9
≥10
Ascites
Yes
No
Bilirubin
Albumin
INR
Encephalopathy
Yes
No
MELD
UKELD
AFP
Liver Biopsy
Background liver
Lesion
Radiology
CT date
(DD/MM/YYYY)
MRI date
(DD/MM/YYYY)
USS date
(DD/MM/YYYY)
Comment:
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Reason for rejection
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Postal Address
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