For health professionals. This section uses clinical terms and is general education for doctors, nurses and students, not advice for an individual patient. Patients and families: please read our patient guides instead, Cancer Myth Busters · Understanding your cancer report · Living through cancer treatment, or speak with your own doctor.

When to refer to an oncologist

Name: When to Refer to an Oncologist: Red Flags & Trial Digest
Creator: Dr. Haritha Chiramana

A quick guide for family physicians, physicians, surgeons, gynaecologists and emergency doctors: what needs same-day action, what needs an urgent referral, and what to do before the patient reaches an oncologist. Each cancer site has its own card; specialists will find detailed notes for their field further down. Other cancer sites are added as their modules are reviewed.

Same day: send to emergency and call the oncology team

Fever ≥38 °C, or feeling suddenly unwell, during chemotherapy (possible febrile neutropenia): start antibiotics within the first hour, do not wait for counts.
New back pain with leg weakness, numbness, or bladder or bowel change in a patient with cancer: suspected spinal cord compression; steroids and same-day whole-spine MRI.
Swelling of the face, neck and arm with dilated chest veins: superior vena cava obstruction.
Confusion, vomiting, constipation, polyuria in a patient with cancer: check calcium for hypercalcaemia.
New seizure, severe headache or focal weakness: suspected brain metastases.
Breathlessness or cough on immunotherapy or trastuzumab deruxtecan: possible pneumonitis; stop the drug and assess urgently.
Heavy bleeding, severe diarrhoea or dehydration on cancer treatment.

Urgent referral by cancer site

Each card lists the findings that need an urgent referral, then what to do, and not do, before the patient reaches an oncologist.

Breast cancer

Urgent: within 2 weeks

Refer urgently if

Any new breast lump in a woman aged 30 or over, or a lump that is hard, fixed, irregular or growing at any age.
Skin changes: dimpling, puckering, peau d’orange, ulceration, or redness and swelling that does not settle after one course of antibiotics (inflammatory cancer).
Nipple changes: new inversion, one-sided rash or scaling not healing in 2–3 weeks (Paget disease), spontaneous single-duct or bloody discharge.
An axillary lump without an obvious infective cause, or adenocarcinoma in an axillary node.
A lump during pregnancy or breastfeeding lasting more than 2 weeks.
Any breast lump in a man that is eccentric, hard or involves the nipple.
Abnormal screening mammogram (BI-RADS 4 or 5).

Before referral: do

Imaging first: ultrasound under 30–40, mammography ± ultrasound from 40.
Core needle biopsy if available, with ER, PR and HER2.
Record the family history (breast, ovarian, pancreatic, prostate cancer; ages).
Note pregnancy status, comorbidities and medicines.

Before referral: do not

Do not excise a lump before imaging and core biopsy: it compromises staging and breast conservation.
Do not repeat antibiotics for a red, swollen breast that has not settled.
Do not continue creams for months on a one-sided nipple rash.
Do not reassure on a normal mammogram when there is a suspicious lump.
Do not order tumour markers or PET-CT to “rule out” cancer.

Lung cancer

Urgent: within 2 weeks

Refer urgently if

A chest X-ray or CT suggesting cancer: a mass, lobar collapse, hilar or mediastinal widening, or a new nodule over 8 mm.
Haemoptysis in anyone aged 40 or over, or in a smoker or ex-smoker at any age.
A cough, breathlessness, chest pain or weight loss lasting more than 3 weeks in a smoker, an ex-smoker, or someone with long biomass (wood, dung) smoke exposure, especially with clubbing or a supraclavicular node.
“TB” that is not microbiologically proven, or not improving after about 4 weeks of treatment.
A pleural effusion that is blood-stained, has a low ADA, keeps refilling, or has no proven cause.
Hoarseness for more than 3 weeks with a left vocal-cord palsy; shoulder or arm pain with Horner syndrome (Pancoast tumour).
Unexplained hyponatraemia or hypercalcaemia, or a brain, bone, liver or adrenal metastasis of unknown origin.

Suspected lung cancer: do

Sputum NAAT (CBNAAT/TrueNat) before any antituberculous treatment.
Contrast CT of the chest and upper abdomen, before any biopsy.
Send two pleural fluid samples for cytology with a cell block, plus ADA.
Record smoking (cigarettes, bidis, pack-years) and biomass exposure; start smoking-cessation advice.
Same-day referral for facial or arm swelling (SVC obstruction), stridor, massive haemoptysis or cord compression.

Suspected lung cancer: do not

Do not start a “trial” of antituberculous treatment for a mass, collapse or unexplained effusion.
Do not reassure on a normal chest X-ray when symptoms persist or there is haemoptysis.
Do not start steroids before tissue is taken, unless the airway is threatened.
Do not use tumour markers or PET-CT to “rule out” cancer; PET can be positive in TB.
Do not exclude lung cancer because the patient is young, female or has never smoked.

Colorectal cancer

Urgent: within 2 weeks

Refer urgently if

Rectal bleeding with a change in bowel habit, or rectal bleeding that continues after treatment for piles.
Unexplained iron-deficiency anaemia in a man or a post-menopausal woman (or any adult without an obvious cause such as heavy periods).
A rectal or abdominal mass, including a right iliac fossa mass labelled as intestinal TB without tissue proof.
A positive faecal immunochemical test (FIT), whether done for screening or for symptoms.
A change in bowel habit lasting more than 3–4 weeks over the age of 40–45, or at any age with weight loss or anaemia.
Liver lesions of unknown origin or a raised CEA found by chance.

Suspected colorectal cancer: do

Digital rectal examination and proctoscopy in everyone with rectal bleeding.
Haemoglobin and ferritin; FIT where available (a negative FIT does not override red flags).
Refer for colonoscopy (and upper endoscopy for anaemia), not barium studies.
Ask about family history of bowel, endometrial or other Lynch-type cancers.
Same-day referral for obstruction (distension, vomiting, no flatus), perforation or heavy bleeding.

Suspected colorectal cancer: do not

Do not attribute bleeding to piles without examining the rest of the bowel when symptoms persist.
Do not treat iron-deficiency anaemia with iron alone without looking for blood loss.
Do not start antituberculous treatment for an ileocaecal mass without biopsy.
Do not use CEA to rule cancer in or out.
Do not dismiss symptoms because the patient is young.

Brain tumours

Same day or within 2 weeks

Refer urgently if

Same day: headache with vomiting and drowsiness, papilloedema, a new focal deficit progressing over days, status epilepticus, or a child with morning vomiting and ataxia.
Within 2 weeks (MRI with contrast): a first unprovoked seizure in an adult; new or changed headache over 50 or with any red flag; progressive personality, memory or speech change; a new paralytic squint or head tilt in a child.
Any new neurological symptom in a person with known cancer: MRI with contrast, not plain CT.
A ring lesion growing on antituberculous treatment, or a lesion in someone over 40 with weight loss or a smoking history.

Suspected brain tumour: do

Full neurological examination and fundoscopy.
Arrange MRI with contrast; CT only if MRI is not available quickly.
Give levetiracetam after a seizure; give dexamethasone only for symptomatic oedema.
Write driving advice after any seizure.

Suspected brain tumour: do not

Do not start steroids before a biopsy when lymphoma is possible and the patient is stable.
Do not give seizure prophylaxis to someone who has never had a seizure.
Do not start antituberculous treatment for a ring lesion without a plan to re-image and biopsy if it grows.
Do not treat recurrent morning vomiting in a child as acidity or worms without an examination.

Head and neck cancer

Same day or within 2 weeks

Refer urgently if

Same day: stridor or noisy breathing, bleeding from the mouth or throat, inability to swallow saliva or fluids, or rapidly progressive neck swelling.
Within 2 weeks: a mouth ulcer, white or red patch or lump persisting 2 weeks after removing any irritant; a neck lump in an adult (especially painless, hard or cystic); hoarseness over 3 weeks; persistent pain or difficulty swallowing, or earache with a normal ear.
A non-healing tooth socket, loosening teeth or an ill-fitting denture without a dental cause, numb lip or chin, or progressive trismus in an areca nut user.
Any new ulcer, lump, pain or bone exposure in a person treated for head and neck cancer.

Suspected head and neck cancer: do

Look under the tongue, in the cheeks and under dentures; palpate the neck.
Remove an obvious irritant and review in 2 weeks; refer if the lesion is still there.
For a neck lump: FNAC and referral for examination of the throat and larynx.
Advise stopping tobacco, gutka and areca nut; quitline 1800-11-2356.

Suspected head and neck cancer: do not

Do not give repeated courses of antibiotics or ointments for a non-healing ulcer.
Do not excise a neck node before the mouth, throat and larynx have been examined.
Do not start antituberculous treatment for a neck node without microbiological or histological proof.
Do not extract teeth in a patient who has had radiotherapy to the jaw without specialist advice (osteoradionecrosis).

Detailed notes for dentists, ENT and head and neck surgeons, general practitioners and physicians and general surgeons are under “Notes for specialists” below.

Sarcoma: lumps and bone pain

Same day or within 2 weeks

Refer urgently if

Same day: a bone or spinal tumour with new leg weakness, numbness or loss of bladder or bowel control (spinal cord compression); a fracture after a trivial injury with bone pain.
Within 2 weeks: a soft tissue lump larger than about 5 cm (bigger than a golf ball), deep to the fascia, growing, recurrent or painful; bone pain lasting weeks in a child, teenager or young adult, especially pain that wakes the child at night, or with a swelling or limp.
A growing, painless abdominal swelling with early satiety, leg swelling or weight loss (retroperitoneal sarcoma).
A bruise-like patch or nodules on a breast or chest wall treated with radiotherapy years ago, or purple nodules on a long-swollen arm, that persist beyond 2 weeks.
A lump already removed as a “lipoma” or “cyst” and reported as sarcoma or with positive margins: refer before any further operation.

Suspected sarcoma: do

Measure the lump, note whether it is deep or fixed, and ask for an MRI with contrast before any biopsy or excision.
For bone pain, ask for an X-ray of the whole bone, and an MRI if pain continues despite a normal film.
Refer to a sarcoma team, or one that works with one, before the first operation.
Ask about previous radiotherapy and about family cancers at a young age.

Suspected sarcoma: do not

Do not remove a large, deep or growing lump as a “lipoma” in a minor theatre without imaging.
Do not rely on FNAC alone, and do not take a benign FNAC as proof that a growing lump is harmless.
Do not call persistent limb pain in a child “growing pains”, and do not start antituberculous treatment for a bone lesion without tissue proof.
Do not curette a suspected bone sarcoma as if it were infection, and do not enucleate or debulk a retroperitoneal mass.

Detailed notes for surgeons, general practitioners, physicians and paediatricians and radiologists and pathologists are under “Notes for specialists” below.

Notes for specialists

Detailed referral notes for colleagues who usually make the diagnosis. Tap a card to open it.

For gastroenterologists and endoscopists: colorectal cancerWhen a cancer or malignant polyp is found: what to do at endoscopy, specific indications for oncology referral, and what to send6 steps9 indicationsSend · Do · Avoid

Many treatment decisions in colorectal cancer depend on what is done at the first colonoscopy and before any treatment starts. These notes summarise the colorectal module for endoscopists; final plans are made at the multidisciplinary tumour board.

1When you find a cancer at colonoscopy

1
Sample well
Several biopsies from the tumour edge (not the necrotic centre). Ask for mismatch-repair (MMR) immunohistochemistry on the biopsy.
2
Mark and measure
Tattoo colonic tumours for laparoscopic localisation. For rectal tumours, record the distance from the anal verge and do a rectal examination; agree rectal tattooing with the surgeon.
3
See the whole colon
Complete colonoscopy for synchronous cancers (3–5%) and polyps. If obstructing: CT colonography before surgery, or colonoscopy within 3–6 months after.
4
Stage before referral
CT chest-abdomen-pelvis, CEA, blood count and ferritin. MRI pelvis for every rectal cancer before any treatment. PET is not routine.
5
Ask about the family
Bowel, endometrial and other Lynch-type cancers in relatives. Anyone under 50 with colorectal cancer should be offered germline testing.
6
Treat emergencies first
Obstruction, perforation or heavy bleeding: same-day surgical review. A stent only as an agreed bridge in an experienced centre.

2Specific indications for oncology referral

Always / urgent refer every patient, usually before definitive treatment · Yes refer when the situation applies · Usually no specialist follow-up only

Colon adenocarcinoma, any stageAlways

Plan: Surgery first for most. Adjuvant chemotherapy for stage III and high-risk stage II: 3 months of CAPOX for low-risk stage III (IDEA); dMMR stage III: FOLFOX with atezolizumab (ATOMIC).
Points: Referral: MDT. Refer before surgery when CT suggests T4 or bulky disease: neoadjuvant chemotherapy (FOxTROT) or, if dMMR, immunotherapy (NICHE-2).

Rectal adenocarcinomaAlways

Plan: MRI-based risk groups; total neoadjuvant therapy for high-risk tumours; organ preservation (watch-and-wait) for selected complete responders (OPRA).
Points: Referral: Before any treatment. The MMR result must be known before chemoradiation: dMMR rectal cancer is treated with anti-PD-1 alone (Cercek 2022).

dMMR / MSI-high tumour, any stageAlways

Plan: Immunotherapy-based options at every stage; metastatic: nivolumab + ipilimumab or pembrolizumab (KEYNOTE-177, CheckMate 8HW).
Points: Lynch work-up: BRAF V600E or MLH1 promoter methylation testing for MLH1 loss; otherwise germline testing and cascade testing of relatives.

Malignant polyp (pT1) with high-risk featuresYes

Plan: Oncological resection with lymph nodes when: piecemeal removal or margin <1 mm, poor differentiation, lymphovascular invasion, or high tumour budding.
Points: Referral: Surgeon ± MDT. Removed in one piece, clear margin ≥1 mm, grade 1–2, no lymphovascular invasion, low budding: surveillance colonoscopy only.

Liver or lung metastasesAlways

Plan: Curative intent if resectable or potentially resectable: surgery with perioperative or conversion chemotherapy; RAS, BRAF, HER2 and MMR testing guide drugs.
Points: Referral: Oncologist and liver surgeon together. The liver surgeon should see the scans before chemotherapy starts. Avoid percutaneous biopsy of a resectable liver lesion without MDT agreement.

Obstructing or bleeding cancerSame day

Plan: Resection, diversion, or a stent as a bridge to elective surgery in experienced hands; stents are avoided if bevacizumab is planned.
Points: Referral: Surgical review first, then oncology. Complete staging and colonoscopy after recovery; MMR on the resected tumour.

Anal canal squamous cell carcinomaAlways

Plan: Chemoradiation is the standard first treatment and usually preserves the anal sphincter; surgery is kept for residual or recurrent disease.
Points: Referral: Before any surgery. Biopsy, HIV test, examination of the groins, MRI pelvis. Not the same disease as rectal adenocarcinoma.

Young onset (<50), polyposis, Lynch, or IBD with dysplasiaGenetics ± oncology

Plan: Germline panel; cascade testing; syndrome-specific colonoscopy intervals; aspirin in Lynch carriers (CAPP2).
Points: Extent of colectomy is decided with the surgeon when Lynch syndrome or polyposis is known before surgery.

Rising CEA or a new lesion during surveillanceYes

Plan: CT (± PET) and MDT review for a curable relapse.
Points: Colonoscopy at 1 year after resection, then every 3–5 years if normal.

3What to send with the referral

Endoscopy report with photographs, tumour position, distance from the anal verge, tattoo site, completeness of the examination
Histology with grade, and MMR immunohistochemistry (or a note that it has been requested)
CT chest-abdomen-pelvis (report and images); MRI pelvis for rectal cancer
CEA, blood count, ferritin, liver and kidney tests
Performance status, comorbidities, anticoagulants and diabetes medicines
Family history of bowel, endometrial, gastric, ovarian or urinary tract cancers

Do

Request MMR testing on the first diagnostic biopsy.
Arrange MRI pelvis before any rectal treatment, including stenting or local excision.
Complete the colonoscopy, or plan when it will be done.
Refer every patient under 50 for genetic counselling.
Discuss stenting with the surgeon and oncologist first unless it is an emergency.

Avoid

Starting chemoradiation for rectal cancer before the MMR result is available.
Treating an ileocaecal mass as tuberculosis without biopsy.
Using CEA to diagnose or exclude cancer.
Barium enema instead of colonoscopy or CT colonography.
Percutaneous biopsy of a potentially resectable liver metastasis without MDT discussion.

Refer back, or re-discuss at the MDT, when

A new cancer or advanced adenoma on surveillance colonoscopy.
A rising CEA or new symptoms after treatment.
Relatives who need Lynch or polyposis screening.
Bowel dysfunction after rectal surgery (low anterior resection syndrome) or stoma problems.
Anaemia or bleeding after treatment.

For neurosurgeons: primary brain tumoursReferral to oncology and adjuvant treatment by integrated diagnosis: specific indications, timing, what to send6 steps19 indicationsSend · Do · Avoid

Almost every patient with a malignant primary brain tumour needs radiotherapy, chemotherapy or both after surgery, and several decisions depend on what is done (and saved) at the operation. Final plans are made at the neuro-oncology MDT.

1Before and at surgery: discuss with oncology when

1
Lymphoma is possible
Periventricular, homogeneous, diffusion-restricting, or immunosuppressed patient: stereotactic biopsy only, and hold steroids if the patient is stable.
2
A metastasis is likely
Known cancer, multiple lesions, or a smoker over 40: stage the body first; resect only large, symptomatic or diagnostic lesions.
3
Pineal or suprasellar mass
Serum and CSF AFP and β-hCG and a spine MRI before any operation: germ cell tumours may need no resection.
4
Deep, multifocal or frail
Agree biopsy versus resection, and the questions the tissue must answer (IDH, MGMT, H3).
5
Spine staging needed
Children, medulloblastoma, ependymoma, germ cell tumours: spine MRI before surgery avoids post-operative artefact.
6
After the operation
MRI within 24–48 hours; keep enough tissue and the paraffin blocks for the full integrated diagnosis.

2Adjuvant management by integrated diagnosis: specific indications

Always / urgent refer every patient, usually before definitive treatment · Yes refer when the situation applies · Usually no specialist follow-up only

Glioblastoma, IDH-wildtype, age ≤70, KPS ≥70Always

Plan: RT 60 Gy in 30 fractions with daily temozolomide, then 6 monthly cycles (EORTC/NCIC); tumour-treating fields optional (EF-14); lomustine–temozolomide for selected young, fit, MGMT-methylated patients (CeTeG/NOA-09)
Points: Referral: As soon as histology is known (do not wait for all molecular results. Start RT about 3–6 weeks after surgery once the wound has healed (common practice). Send MGMT. Weekly counts; PJP prophylaxis if on steroids.

Glioblastoma, age >70 or KPS 50–70Always

Plan: Short-course RT (40 Gy/15 or 25 Gy/5) with temozolomide if fit (Perry 2017); MGMT-methylated and frail: temozolomide alone (Nordic, NOA-08); unmethylated: short-course RT alone
Points: Referral: Choice depends on MGMT and function. Biopsy is enough when resection is unsafe; ask for MGMT on the biopsy. KPS <50: supportive and palliative care; discuss before surgery.

Astrocytoma, IDH-mutant, grade 2 — gross total resectionYes

Plan: Watchful waiting (MRI every 3–6 months) or vorasidenib
Points: Referral: For a shared decision. IDH sequencing if IHC negative and age <55; CDKN2A/B status needed.

IDH-mutant glioma, grade 2 (astrocytoma or oligodendroglioma) — residual tumour, seizures controlled, no mass effectYes

Plan: Vorasidenib to delay RT and chemotherapy (INDIGO: PFS 27.7 vs 11.1 months)
Points: INDIGO patients had non-enhancing measurable disease, no steroids, KPS ≥80. Monthly LFTs at first.

IDH-mutant glioma, grade 2 — uncontrolled seizures, growth, mass effect or enhancementYes

Plan: RT (50.4–54 Gy) plus chemotherapy: PCV (RTOG 9802, median survival 13.3 vs 7.8 years) or 12 cycles of temozolomide
Points: Referral: Promptly. Chemotherapy alone only when the RT field would be very large (bihemispheric oligodendroglioma).

Astrocytoma, IDH-mutant, grade 3Always

Plan: RT 59.4 Gy, then 12 cycles of adjuvant temozolomide (CATNON final); concurrent temozolomide adds little
Points: No role for vorasidenib outside trials at grade 3.

Astrocytoma, IDH-mutant, grade 4 (including CDKN2A/B-deleted)Always

Plan: RT with temozolomide (glioblastoma-style, or 12 adjuvant cycles)
Points: Report CDKN2A/B status: it changes the grade even without necrosis.

Oligodendroglioma, IDH-mutant, 1p/19q-codeleted, grade 3Always

Plan: RT 59.4 Gy plus PCV (or temozolomide if PCV cannot be given) (EORTC 26951/RTOG 9402: survival about doubled)
Points: Whole-arm 1p/19q by NGS/methylation preferred to FISH alone.

Diffuse midline glioma, H3 K27-altered (thalamus, brainstem, cord)Always

Plan: Focal RT (about 54–60 Gy); clinical trials; dordaviprone at progression (ONC201)
Points: Resection usually not possible; stereotactic biopsy in an experienced centre.

Ependymoma, adultYes

Plan: Grade 3, or grade 2 with residual: focal RT. Grade 2 after gross total resection: RT or observation, individualised
Points: Stage with MRI of the whole spine (ideally before surgery) and CSF cytology about 2 weeks after surgery.

Meningioma, grade 1Usually no

Plan: Gross total resection: observe. Subtotal: observe, or RT/radiosurgery if growing or symptomatic
Points: Referral: Neurosurgical follow-up. MRI at 3–6 months, then yearly; per EANO meningioma guidance.

Meningioma, grade 2 (atypical)Yes

Plan: Subtotal resection: adjuvant RT. Gross total resection: RT or close MRI surveillance (randomised trials ongoing)
Points: Referral: Radiation oncology. Discuss at MDT; no proven chemotherapy.

Meningioma, grade 3 (anaplastic)Always

Plan: Adjuvant RT (about 60 Gy) whatever the extent of resection
Points: High recurrence risk; trials for recurrence.

Circumscribed gliomas: pilocytic astrocytoma, PXA, gangliogliomaIf residual or recurrent

Plan: Gross total resection: observe. Residual or progressive: re-resection, RT, or targeted therapy if BRAF V600E (ROAR)
Points: Ask for BRAF V600E (VE1) and BRAF fusion testing.

Primary CNS lymphoma (suspected)Urgent

Plan: Stereotactic biopsy only; then methotrexate-based chemotherapy and consolidation (autologous transplant or RT) under haemato-oncology
Points: Referral: Before definitive surgery. Withhold steroids before biopsy if the patient is stable; resection does not help. HIV test, eye (slit-lamp) and CSF studies.

Medulloblastoma or other embryonal tumour (adult or child)Always

Plan: Craniospinal RT with boost plus cisplatin-based chemotherapy (risk-adapted); infants: chemotherapy to delay RT
Points: Spine MRI and CSF staging; molecular group (WNT, SHH, group 3/4); germline testing for SHH.

Pineal or suprasellar mass (possible germ cell tumour)Before surgery

Plan: Germinoma: chemotherapy and/or RT, no radical resection; raised serum/CSF AFP or markedly raised β-hCG: chemotherapy first without biopsy
Points: Check serum and CSF AFP and β-hCG and spine MRI before any operation.

Resected brain metastasisAlways

Plan: Cavity SRS rather than whole-brain RT (Mahajan, N107C), plus systemic therapy for the primary
Points: Referral: Radiation and medical oncology. Cavity SRS within about a month of surgery (3–4 weeks may lower side effects). Send tissue for EGFR/ALK/HER2/BRAF as relevant.

Any brain tumour in a childAlways

Plan: By type: focal or craniospinal RT, chemotherapy, BRAF/MEK inhibitors for BRAF-altered LGG (Bouffet 2023)
Points: Referral: To a paediatric neuro-oncology team. Avoid RT under 3 years where possible; fertility, endocrine and school planning.

3What to send with the referral

Integrated pathology report: histology, CNS WHO grade, IDH (sequencing if IHC negative and under 55), ATRX, p53, 1p/19q, CDKN2A/B, Ki-67
MGMT for every glioblastoma; H3 K27M (midline), H3 G34 (young, hemispheric), BRAF V600E where relevant; blocks kept available
Pre-operative MRI and post-operative MRI within 24–48 hours (images, not just reports) for radiotherapy planning
Operation note: extent of resection, residual tumour and its location, eloquent areas, CSF leak or wound concerns
KPS or ECOG, deficits, seizures and the current antiseizure drug, steroid dose and taper plan, VTE prophylaxis or events
What the patient and family understand; for young adults, whether fertility has been discussed

Do

Refer high-grade tumours the same week the diagnosis is known; molecular results can follow.
Taper dexamethasone to the lowest dose that controls symptoms; H2-blocker rather than routine PPI.
Use levetiracetam for patients who have had seizures; stop perioperative prophylaxis if there were none (SNO/EANO).
Give post-operative VTE prophylaxis; treat clots with a DOAC or LMWH after CT excludes bleeding.
Start radiotherapy about 3–6 weeks after surgery once the wound has healed (common practice).
Write driving advice after any seizure.

Avoid

Steroids before biopsy when lymphoma is possible and the patient is stable.
Enzyme-inducing antiseizure drugs (phenytoin, carbamazepine, phenobarbital): they lower temozolomide, targeted drug and dexamethasone levels.
A late post-operative MRI (after about 72 hours): surgical enhancement hides residual tumour.
Reporting "glioma grade 2" without IDH and 1p/19q, or using up all tissue on frozen section.
Re-operating for early new enhancement within 3–6 months of chemoradiation without MDT review: often pseudoprogression.

Refer back, or re-discuss at the MDT, when

New or enlarging enhancement after treatment (pseudoprogression, recurrence or radiation necrosis).
Recurrence that may be resectable: re-resection, re-irradiation and systemic options are planned together.
Growth or new enhancement of a low-grade glioma under surveillance or on vorasidenib.
Steroid dependence or refractory oedema (bevacizumab option), uncontrolled seizures, or new VTE.
Hydrocephalus or a wound problem during radiotherapy.

Head and neck cancer: notes for Dentists and oral surgeons · Ent and head and neck surgeons · General practitioners and physicians · General surgeons.

For dentists and oral surgeons: mouth cancer and patients treated with radiotherapySpotting and biopsying suspicious lesions, urgent referral, and dental care before and after head and neck radiotherapy6 steps6 indicationsSend · Do · Avoid

Dentists see the mouth more often than any other clinician and are often the first to find an oral cancer or a potentially malignant lesion. They are also central to preventing osteoradionecrosis after radiotherapy. These notes summarise the head and neck module; final plans are made at the tumour board.

1When you see a suspicious lesion

1
Remove the irritant, review in 2 weeks
Smooth a sharp tooth, adjust or remove an ill-fitting denture, treat obvious infection and see the patient again in 2 weeks. Do not prescribe repeated courses of ointments or antibiotics.
2
Biopsy or refer if it persists
Any ulcer, white or red patch or lump still present at 2 weeks: incisional biopsy of the most suspicious (reddest, thickest or ulcerated) area, or same-week referral to a head and neck team. Do not excise a suspicious lesion completely before there is a diagnosis.
3
Examine the whole mouth and neck
Lateral and ventral tongue, floor of mouth, buccal mucosa, retromolar area, palate and under dentures; palpate both sides of the neck. Field change makes second lesions common in tobacco and areca nut users.
4
Do not extract a loose tooth beside a mass
A loose tooth or a non-healing socket in an area of swelling, ulceration or numbness needs imaging and a biopsy, not an extraction, which delays diagnosis and seeds the socket.
5
Record and photograph
Site, size, colour, induration, habits (tobacco, areca nut, alcohol) and a clinical photograph help the receiving team and later comparison.
6
Advise on tobacco and areca nut
Brief advice at every visit; free quitline 1800-11-2356.

2Specific situations

Always / urgent refer every patient, usually before definitive treatment · Yes refer when the situation applies · Usually no specialist follow-up only

Non-healing ulcer, red patch or indurated lump beyond 2 weeksUrgent

Plan: Biopsy, or refer to a head and neck surgeon or oncologist.
Points: Referral: Within 2 weeks. Induration, fixity, bleeding, earache and numbness are red flags.

Leukoplakia, erythroplakia, oral submucous fibrosisYes

Plan: Biopsy the worst area; dysplasia needs specialist management; stop tobacco and areca nut.
Points: Referral: Biopsy first. Erythroplakia carries the highest risk. Follow up every 3–6 months for life; no drug prevents cancer outside trials.

Unexplained tooth mobility, non-healing socket, numb lip or chinUrgent

Plan: OPG and biopsy; refer.
Points: Referral: Within 2 weeks. Numbness suggests nerve invasion by a gingival or mandibular tumour.

Progressive or one-sided trismusYes

Plan: Examine and image (CT or MRI) if mouth opening is falling.
Points: May be submucous fibrosis, a masticator space tumour, or both.

Patient about to start head and neck radiotherapyAlways

Plan: Dental assessment and OPG; extract unsalvageable teeth at least 10–14 days before RT; scaling; fluoride trays.
Points: Referral: Before radiotherapy. Extractions after RT are the main trigger for osteoradionecrosis.

Extraction needed in a jaw that has had radiotherapyAlways

Plan: Discuss with the oncology team first; atraumatic extraction by an experienced oral surgeon; prefer root treatment where possible.
Points: Referral: Before any extraction. Exposed bone that has not healed after 3 months is osteoradionecrosis: refer.

3What to send with the referral

Clinical photograph and a sketch of the lesion site and size
Duration, habits and treatments already tried
Biopsy report, and slides or block if a biopsy was done
OPG or other imaging
Medical history and medicines (antithrombotics, bisphosphonates)
Phone numbers of the patient and a relative

Do

Biopsy or refer at 2 weeks
Look under dentures
Palpate the neck
Give fluoride and 6-monthly reviews after RT
Reassure patients that a biopsy does not spread cancer

Avoid

Repeated ointments, gels or antibiotics for a non-healing lesion
Extracting a loose tooth beside a mass
Extractions in an irradiated jaw without oncology advice
Complete excision of a suspicious lesion before a diagnosis

Refer back, or re-discuss at the MDT, when

A new ulcer, lump, pain or exposed bone in a treated patient
Decay progressing despite fluoride
Trismus or denture problems after treatment
Before any dental surgery in an irradiated area

For ENT and head and neck surgeons: workup, surgery and referral to oncologyEndoscopy and staging, what to record at surgery, and when to involve medical and radiation oncology6 steps6 indicationsSend · Do · Avoid

Most head and neck cancers are diagnosed by ENT surgeons. Early disease is usually treated with a single modality; locally advanced disease needs two or three, so oncology should see the patient before definitive treatment. Final plans are made at the tumour board.

1At diagnosis

1
Biopsy and map
Biopsy the primary; panendoscopy under anaesthesia when the extent is unclear. Record subsites, cord mobility and the relation to the midline and anterior commissure.
2
Neck: FNAC, not excision
FNAC or core biopsy of a neck mass; never open-biopsy a node before the primary search. Unknown primary: p16 and EBER on the node, PET-CT before examination under anaesthesia, then bilateral tonsillectomy and directed biopsies.
3
Image before biopsying deep tumours
Contrast CT (cartilage, bone) or MRI (tongue, perineural spread, nasopharynx); CT chest for all; PET-CT for stage III–IV.
4
Ask for the right pathology
p16 for every oropharynx cancer (HPV DNA/RNA if decisions depend on it); EBER for undifferentiated or nasopharyngeal cancer; PD-L1 CPS (22C3) for resectable stage III–IVA and recurrent disease.
5
Prepare the patient
Dental assessment, nutrition (feeding plan if weight loss or dysphagia), speech and swallow baseline, audiogram and creatinine clearance if cisplatin is likely, tobacco and alcohol cessation.
6
Tumour board before treatment
Especially for oropharynx, larynx and hypopharynx cancers, where organ preservation and surgery are both options.

2When to involve oncology

Always / urgent refer every patient, usually before definitive treatment · Yes refer when the situation applies · Usually no specialist follow-up only

Early glottic, oral or oropharyngeal cancer (T1–T2 N0)If radiotherapy is an option

Plan: Single modality: surgery (laser, transoral or open) or RT. Discuss with radiation oncology when RT is a reasonable alternative.
Points: Choose the route least likely to need all three modalities.

Locally advanced (T3–T4 or N+), resectableAlways

Plan: Medical and radiation oncology review before surgery; perioperative pembrolizumab is an option if PD-L1 CPS is 1 or more (KEYNOTE-689).
Points: Referral: Before surgery. Start adjuvant RT within 6 weeks of surgery; plan reconstruction and dental work early.

Larynx or hypopharynx, candidate for larynx preservationAlways

Plan: Discuss cisplatin chemoradiation or induction chemotherapy versus laryngectomy at the tumour board; salvage surgery must be available.
Points: Referral: Before laryngectomy. T4a with cartilage destruction or a non-functioning larynx usually does better with laryngectomy.

After resection: positive margin or ENEUrgent

Plan: Postoperative RT with cisplatin; for HPV-negative disease, nivolumab can be added (NIVOPOSTOP).
Points: Referral: Within 2 weeks of surgery. Send the full synoptic pathology report.

After resection: pT3–T4, PNI, LVI, 2 or more nodes, close marginYes

Plan: Postoperative RT alone.
Points: In early oral cancer, re-excise a close margin rather than relying on RT.

Unresectable, recurrent or metastatic diseaseAlways

Plan: Chemoradiation, re-irradiation, salvage surgery or systemic therapy guided by PD-L1 CPS; early palliative care.
Points: Biopsy every recurrence and test CPS.

3What to send with the referral

Endoscopy findings with a diagram (subsites, cord mobility, extent)
Biopsy report with p16, EBER and PD-L1 CPS where relevant
CT/MRI neck and CT chest or PET-CT images
Operation note and synoptic pathology (margins in mm, DOI, PNI, LVI, nodes, ENE)
Dental, nutrition and swallow assessments
Comorbidities, creatinine clearance, audiogram

Do

Present every new case at the tumour board before treatment
Measure DOI and report margins in millimetres
Mark close margins for the radiation oncologist
Plan postoperative RT to start within 6 weeks

Avoid

Open biopsy of a neck node before the primary search
Watching close or involved margins without a plan
Trimodality treatment when a single-modality plan was possible
Laryngectomy before larynx preservation has been discussed for a suitable T3 tumour

Refer back, or re-discuss at the MDT, when

Residual disease on PET-CT 12 weeks after chemoradiation (neck dissection or salvage surgery)
Local or neck recurrence that may be salvageable
Airway problems, fistula or stricture
Second primary tumours found on follow-up

For general practitioners and physicians: recognising head and neck cancer and caring for survivorsRed flags and time limits, what to avoid, and long-term care after treatment6 steps6 indicationsSend · Do · Avoid

Most patients with head and neck cancer first see a general practitioner or physician, often with a symptom that looks like an infection. Early referral is the biggest single step towards cure. These notes also cover the long-term problems that survivors bring back to their family doctor.

1When you suspect head and neck cancer

1
Look in the mouth and feel the neck
In every tobacco, areca nut or alcohol user with a mouth or throat symptom: look under the tongue, in the cheeks and under dentures, and palpate both sides of the neck.
2
Apply the time limits
Mouth ulcer or patch beyond 2 weeks; hoarseness beyond 3 weeks; one-sided blocked ear, nasal block or bleeding beyond 3 weeks; painful or difficult swallowing; earache with a normal ear.
3
Neck lump in an adult: FNAC
A hard, painless or cystic neck lump in an adult is cancer until FNAC shows otherwise; refer for examination of the throat. Start TB treatment only on microbiological or histological proof.
4
Refer rather than treat again
One course of treatment for an obvious infection is reasonable; after that, refer to ENT or a head and neck team.
5
Same-day referral
Stridor or noisy breathing, bleeding from the mouth or throat, inability to swallow saliva, rapidly enlarging neck swelling.
6
Start prevention now
Tobacco and areca nut cessation advice; free quitline 1800-11-2356.

2Common situations

Always / urgent refer every patient, usually before definitive treatment · Yes refer when the situation applies · Usually no specialist follow-up only

Hoarseness beyond 3 weeks in a smokerUrgent

Plan: Refer for laryngoscopy.
Points: Referral: Within 2 weeks. Do not give repeated antibiotics or steroid inhalers for hoarseness without the cords being seen.

Neck lump in an adultUrgent

Plan: FNAC and referral for throat examination.
Points: Referral: Within 2 weeks. Do not have the node excised before the primary search.

One-sided blocked ear or fluid behind the eardrum in an adultIf it lasts beyond 3 weeks

Plan: Refer for nasoendoscopy.
Points: Nasopharyngeal cancer can present this way; ask about neck lumps and nosebleeds.

Survivor with new pain, ulcer, lump, hoarseness or swallowing changeUrgent

Plan: Refer back to the treating team.
Points: 80–90% of recurrences occur in the first 2–3 years; second primaries continue for life.

Survivor after neck radiotherapyUsually no

Plan: Check TSH every 6–12 months and treat hypothyroidism.
Points: Referral: Family doctor care. Hypothyroidism is common and silent after neck RT.

Survivor with cough on eating or repeated chest infectionsYes

Plan: Refer for a swallow assessment (videofluoroscopy or FEES).
Points: Late radiation dysphagia with silent aspiration can appear years later.

3What to send with the referral

Symptom, duration and treatment already tried
Tobacco (smoked and chewed), areca nut and alcohol history
FNAC report if done
Medical history and medicines (kidney function, hearing, diabetes)
Phone numbers of the patient and a relative

Do

Look in the mouth and feel the neck
Refer when the time limits are passed
Check TSH every 6–12 months after neck RT
Support tobacco cessation at every visit
Screen survivors for depression

Avoid

Repeated antibiotics, ointments or antacids for persistent symptoms
Empirical TB treatment for a neck node
Tooth extraction in an irradiated jaw without specialist advice
Steroids before a diagnosis when lymphoma is possible

Refer back, or re-discuss at the MDT, when

New ulcer, lump, pain, bleeding, hoarseness or swallowing change after treatment
Weight loss or aspiration
Exposed jaw bone
Breathing difficulty or problems with a tracheostomy or laryngectomy stoma

For general surgeons: neck lumps, biopsies, the airway and feeding accessWhat to do with an adult neck mass, why open node biopsy harms, airway emergencies and gastrostomy6 steps5 indicationsSend · Do · Avoid

General surgeons often see an adult with a neck lump, or a patient who needs urgent airway or feeding access. A few steps at this point protect the chance of cure and of keeping the voice box.

1When you see an adult neck lump

1
Think head and neck cancer first
A hard, painless or cystic lateral neck lump in an adult (a smoker or areca nut user, or a younger non-smoker with a cystic level II node) is metastatic squamous carcinoma until proven otherwise.
2
FNAC or core biopsy, not excision
Ultrasound-guided FNAC or core biopsy; ask for p16 and EBER on squamous carcinoma.
3
Find the primary before any open procedure
Refer to ENT or a head and neck team for endoscopy and imaging (PET-CT for an unknown primary) before considering open biopsy.
4
If the node was already excised
Send the specimen for p16, EBER and HPV testing and refer at once; record the incision for the radiation oncologist.
5
"Branchial cyst" in an adult
A presumed branchial cyst after the age of about 40 is a cystic metastasis until cytology shows otherwise.
6
Thyroid and salivary masses
Follow their own pathways and refer to the appropriate specialist.

2Specific situations

Always / urgent refer every patient, usually before definitive treatment · Yes refer when the situation applies · Usually no specialist follow-up only

Adult neck lump, squamous carcinoma on FNACUrgent

Plan: Refer to the head and neck team for the primary search.
Points: Referral: Within 2 weeks. No open biopsy and no neck dissection without a tumour-board plan.

Stridor from a laryngeal or hypopharyngeal tumourSame day

Plan: Secure the airway with ENT and anaesthesia (awake tracheostomy by an experienced team, or tumour debulking).
Points: Biopsy at the same time if possible; plan definitive treatment within days.

Feeding access during head and neck treatmentYes

Plan: Gastrostomy (endoscopic or radiological) when swallowing fails or weight is falling.
Points: Use the radiological or open route if tumour obstructs the pharynx.

Bleeding from a neck wound, stoma or tumourSame day

Plan: Pressure, airway and resuscitation; emergency interventional radiology or surgery.
Points: A small "sentinel" bleed after RT or in recurrent disease can precede carotid blow-out.

Node suspected to be lymphoma or TBIf FNAC is non-diagnostic

Plan: Core biopsy, or excision biopsy after the throat has been examined.
Points: Excision is appropriate once squamous cancer has been excluded.

3What to send with the referral

FNAC or core biopsy report
Ultrasound or CT images
Operation note and pathology if an excision was done
Airway, swallowing and weight status
Phone numbers of the patient and a relative

Do

FNAC or core biopsy for an adult neck lump
Ask for p16 and EBER on squamous carcinoma
Arrange endoscopy before any open procedure
Involve ENT early for airway problems

Avoid

Open excision of a neck node before the primary search
Calling a cystic neck mass in an adult a branchial cyst without cytology
Emergency tracheostomy through tumour without an experienced team when there is time to transfer

Refer back, or re-discuss at the MDT, when

Feeding tube problems
Wound, fistula or stoma complications
New neck masses after treatment

Sarcoma: notes for General, orthopaedic, plastic and gynaecological surgeons · General practitioners, physicians and paediatricians · Radiologists and pathologists.

For general, orthopaedic, plastic and gynaecological surgeons: lumps, bone lesions and suspected sarcomaWhat to do before an excision or biopsy, after an unplanned excision, and when to involve a sarcoma team6 steps7 indicationsSend · Do · Avoid

Most sarcomas are first seen by a surgeon who expects a benign lump, a bone cyst or a fibroid. What happens before and at that first operation decides whether the limb can be kept and whether the cancer is cured. These notes summarise the sarcoma module; final plans are made at the sarcoma tumour board.

1When you see a lump or a bone lesion

1
Apply the size, depth and growth rule
A lump over 5 cm, deep to the fascia, growing, painful or recurrent needs an ultrasound and, if it stays suspicious, an MRI with contrast before any excision. Pain does not separate benign from malignant lumps.
2
Image first, biopsy second
Do the MRI before the biopsy, because post-biopsy oedema confuses the picture, and tell the radiologist where the incision will be.
3
Core biopsy along the future incision
Image-guided core needle biopsy with several cores, by or planned with the team that will operate: a longitudinal track on a limb, no transverse incision, no drain far from the wound. FNAC alone is not enough, and a benign FNAC does not exclude sarcoma.
4
Ask for expert pathology
FNCLCC grade, immunohistochemistry and a molecular test (for example MDM2 FISH for fatty tumours), with review by a sarcoma pathologist.
5
Stage before treatment
CT chest for everyone, and extra imaging by subtype (spine MRI and CT abdomen for myxoid liposarcoma). For bone: X-ray and MRI of the whole bone, CT chest, and PET-CT or a bone scan.
6
Plan reconstruction early
Involve plastic surgery before radiotherapy and wide resection; vascular grafts and nerve repair are part of limb salvage.

2Specific situations

Always / urgent refer every patient, usually before definitive treatment · Yes refer when the situation applies · Usually no specialist follow-up only

Presumed lipoma that is large (over 5 cm), deep or growingUrgent

Plan: Ultrasound, then MRI with contrast, and referral to a sarcoma team before the knife.
Points: Referral: Before any excision. A well-differentiated liposarcoma of the thigh can feel identical to a lipoma; MDM2 FISH separates them.

Unplanned excision already done (“whoops”)Always

Plan: Do not re-operate yet. Collect the histology and blocks, arrange MRI of the site and CT chest, and refer. Re-excision of the scar and tumour bed follows, with radiotherapy where re-excision would cost function.
Points: Referral: Urgent. Residual tumour is found in about half of cases; the scar, drain track and haematoma are contaminated and enlarge the field.

Retroperitoneal mass found at laparotomy or on CTAlways

Plan: CT chest-abdomen-pelvis and percutaneous posterior core biopsy (unless a classic well-differentiated liposarcoma is going straight to surgery); refer to a high-volume centre.
Points: Referral: Before any operation. Never enucleate, morcellate or “debulk”: the first operation is the best chance of cure.

Bone lesion with an aggressive X-ray: sunburst, Codman triangle, permeative pattern or a soft tissue massAlways

Plan: MRI of the whole bone, CT chest and PET-CT or bone scan; biopsy at, or planned with, the treating centre.
Points: Referral: Before biopsy. A badly placed biopsy track can turn limb salvage into amputation.

Fever, raised ESR and a lytic bone lesion in a young personUrgent

Plan: Core biopsy for histology and culture together before any antituberculous or antibiotic course.
Points: Ewing sarcoma mimics osteomyelitis and tuberculosis; never curette a suspected sarcoma as infection.

Rapidly growing fibroid, or a fibroid with suspicious features (gynaecologists)Yes

Plan: Avoid power morcellation; image the uterus (MRI) and refer if features are suspicious; send the specimen for expert review.
Points: Referral: If suspicious. Uterine leiomyosarcoma is often found after a presumed fibroid is removed, and morcellation can spread it.

Persistent bruise-like patch or nodules on an irradiated breast or chest wallUrgent

Plan: Multiple punch biopsies from the darkest area, then refer.
Points: Referral: Within 2 weeks. Radiation-associated angiosarcoma is skin-led and wider than it looks; a small excision does not cure it.

3What to send with the referral

MRI and CT images (not only the reports)
Biopsy report, slides and paraffin blocks
Operation note, with the drain site and incision marked if a lump was already excised
Clinical photograph and a sketch of the scar
Previous radiotherapy, and family cancers at a young age
Phone numbers of the patient and a relative

Do

Get an MRI before the biopsy
Plan the biopsy track with the operating team
Ask for MDM2 FISH on fatty tumours
Keep the specimen and blocks
Discuss at a sarcoma tumour board before definitive surgery

Avoid

Excising a large or deep lump as a lipoma without imaging
Transverse incisions or drains placed far from the wound
FNAC as the only test
Enucleation or debulking of a retroperitoneal mass
Curettage of a suspected bone sarcoma

Refer back, or re-discuss at the MDT, when

Wound problems after preoperative radiotherapy
A positive margin on the final histology
A new lump in or near the scar
Need for flap cover, vascular or nerve reconstruction

For general practitioners, physicians and paediatricians: lumps, bone pain and survivorsRed flags, the first tests to order, what to avoid, and shared care after treatment6 steps7 indicationsSend · Do · Avoid

Most lumps are benign and most bone pain in children is not cancer, which is why the few sarcomas are missed. Recognising the red flags and arranging an MRI or X-ray before any excision is the biggest single step towards cure and towards keeping the limb.

1When you suspect a sarcoma

1
Examine and measure
Record the size, depth (mobile over muscle or fixed), skin changes and regional nodes of any lump. For bone pain, look for a swelling, a limp or night pain.
2
Apply the red flags
A lump over about 5 cm, deep, growing, recurrent or painful; bone pain lasting weeks, waking the child, or with swelling or a limp; a bruise-like patch on an irradiated breast lasting over 2 weeks; a growing painless abdominal swelling with early satiety or leg swelling.
3
Order the right first test
Ultrasound for a lump (MRI if it stays suspicious) and an X-ray of the whole bone for bone pain. A normal early X-ray does not exclude a bone tumour: re-image if the pain persists.
4
Refer before any excision or biopsy
Refer to a sarcoma team; do not arrange removal “to be safe”, and do not accept a benign FNAC alone for a growing lump.
5
Do not call it growing pains
Pain that wakes a child, lasts for weeks or comes with swelling or a limp needs an X-ray.
6
Prepare the family early
Treatment is long and often far from home. Talk about travel, lodging and schemes such as PM-JAY and state schemes at the start, to prevent abandonment.

2Common situations

Always / urgent refer every patient, usually before definitive treatment · Yes refer when the situation applies · Usually no specialist follow-up only

Lump over 5 cm, deep, growing or recurrentUrgent

Plan: MRI with contrast and referral to a sarcoma team before excision.
Points: Referral: Within 2 weeks. Pain does not separate benign from malignant lumps; size, depth and growth do.

Child or teenager with persistent bone pain, night pain, swelling or a limpUrgent

Plan: X-ray of the whole bone; refer if abnormal, or get an MRI if pain continues despite a normal film.
Points: Referral: Within 2 weeks. Night pain in a teenager is not growing pains.

A bone lesion labelled infection or TB without tissue proofUrgent

Plan: Stop empirical treatment that is not working and refer for biopsy, sent for histology and culture.
Points: Ewing sarcoma can cause fever and a raised ESR.

Painless, growing abdominal swelling with early satiety or a swollen legUrgent

Plan: Ultrasound and CT abdomen-pelvis; refer before any laparotomy.
Points: Referral: Within 2 weeks. Retroperitoneal sarcomas are silent until they are large (often about 15 cm).

Bruise-like patch on a breast treated with radiotherapyUrgent

Plan: Punch biopsies, then refer to the cancer team.
Points: Referral: Within 2 weeks. Radiation-associated angiosarcoma is often called a haematoma or cellulitis.

Survivor after sarcoma treatmentUsually no

Plan: Keep to the follow-up schedule and ask about a new lump in or near the scar, cough, and bone pain.
Points: Referral: Shared care. Most relapses occur in the first 2–3 years; late effects follow anthracyclines, cisplatin, alkylators and radiotherapy.

Young patient with a sarcoma and cancers at a young age in the familyGenetics

Plan: Refer for genetic counselling (TP53, NF1, RB1).
Points: Cascade testing of relatives; avoid unnecessary CT in young survivors.

3What to send with the referral

Duration, growth and associated symptoms
Measurements and a photograph of the lump
X-ray, ultrasound and any MRI (images, not only reports)
Previous biopsy or operation reports
Previous radiotherapy, and family cancers at a young age
Phone numbers of the patient and a relative

Do

Re-examine and re-image persistent symptoms
Refer before excision
Ask about previous radiotherapy
Support rehabilitation and the return to school or work
Share the Telugu–English handouts once approved

Avoid

Repeated courses of painkillers for persistent bone pain
Empirical antituberculous treatment for a bone lesion
Reassuring a family on the basis of one normal X-ray or FNAC
Removing a lump without imaging

Refer back, or re-discuss at the MDT, when

A new lump in or near the scar
A new cough or breathlessness
Fever or wound problems during treatment
Breathlessness, hearing loss or kidney problems that may be late effects

For radiologists and pathologists: imaging, biopsy and reporting of suspected sarcomaTriage and MRI protocol, planning the biopsy track, tissue handling, and the tests that change treatment6 steps6 indicationsSend · Do · Avoid

Sarcoma is diagnosed by imaging, a well-planned biopsy and expert pathology with a molecular test. Misdiagnosis is common outside reference centres, so the steps below protect the patient from an avoidable change of treatment.

1From the first scan to the final report

1
Triage soft tissue lumps
Small, superficial, homogeneous fatty lesions can be watched; anything else goes to MRI with contrast (T1, T2 or STIR, and fat-suppressed post-gadolinium).
2
Report what the surgeon needs
Compartments, the neurovascular bundle, bone involvement and peritumoural oedema. For a fatty abdominal mass, say whether there is a solid non-fatty nodule (dedifferentiation).
3
Plan the biopsy track with the surgeon
Image-guided core biopsy after MRI with several cores, a single longitudinal track within the future excision (posterior approach in the retroperitoneum), and a recorded track position.
4
Send tissue for the right tests
Fresh or frozen tissue for molecular confirmation (for example Ewing sarcoma); histology and culture together when infection is possible.
5
Report grade and subtype
FNCLCC grade, and subtype by morphology plus immunohistochemistry plus a molecular test (FISH, RT-PCR or NGS). A small core can under-call grade, and the resection specimen re-grades the tumour.
6
Offer or seek expert review
Discordance with the sarcoma pathologist is common; ask for review when the subtype will change treatment.

2Tests and findings that change management

Always / urgent refer every patient, usually before definitive treatment · Yes refer when the situation applies · Usually no specialist follow-up only

Deep or large (over 5 cm) fatty lesion with thick septa or nodulesYes

Plan: MRI, then core biopsy of the non-fatty area, and MDM2 FISH to separate lipoma from well-differentiated liposarcoma.
Points: Referral: MDM2 FISH. MDM2 also separates dedifferentiated liposarcoma from UPS: test any retroperitoneal “UPS”.

Small round blue cell tumourAlways

Plan: CD99 (membranous) and NKX2.2, then EWSR1 FISH or an RNA-based panel.
Points: Referral: Fresh tissue. CIC- and BCOR-rearranged sarcomas are separate, more aggressive entities.

Spindle cell tumourYes

Plan: Synovial sarcoma: TLE1 and SS18::SSX testing. Leiomyosarcoma: desmin, SMA, h-caldesmon. MPNST: loss of H3K27me3.
Points: UPS is a diagnosis of exclusion after the panel is negative.

Vascular lesion in an irradiated breastYes

Plan: CD31 and ERG for angiosarcoma, and MYC amplification.
Points: MYC amplification helps separate post-radiation angiosarcoma from an atypical vascular lesion.

Bone lesion with aggressive features on X-rayAlways

Plan: Whole-bone MRI and CT chest; biopsy at, or planned with, the treating centre.
Points: Referral: Before biopsy. Recognisable fat inside a bone lesion usually means it is benign.

Resection specimen after preoperative chemotherapy for osteosarcomaAlways

Plan: Report percentage necrosis and margins.
Points: Referral: Report necrosis. Necrosis of 90% or more is a good response; response is judged on necrosis, not on shrinkage of the mass.

3What to send with the referral

Complete clinical details: site, size, duration, previous radiotherapy or surgery
Slides and paraffin blocks for expert review
Imaging and a note of the planned biopsy track
Fresh or frozen tissue for molecular tests
Contact details of the treating clinician

Do

Report grade, necrosis and margins clearly
Ask for molecular confirmation when the subtype will change treatment
Keep unstained slides and blocks
Request review by a sarcoma pathologist

Avoid

Treating a benign FNAC as conclusive
Relying on a small core for grade alone
Calling every round cell tumour Ewing sarcoma without a molecular test
Using up all the tissue on immunohistochemistry

Refer back, or re-discuss at the MDT, when

The diagnosis differs at expert review
The grade changes on the resection specimen
More tissue is needed for molecular testing
Imaging and pathology do not agree

Routine referral

Strong family history (or a known BRCA1/2, PALB2 or TP53 variant) for genetic counselling and high-risk screening.
Survivors with late effects (lymphoedema, bone loss on aromatase inhibitors, menopausal symptoms) or difficulty continuing endocrine therapy.
Second opinions on a diagnosis or treatment plan.

What to send with the patient

Imaging films or CDs and reports · biopsy report and the paraffin blocks or slides · ER/PR/HER2 report (breast) or EGFR/ALK/PD-L1 and NGS reports (lung) · sputum TB results and any antituberculous treatment given · operation notes and discharge summaries · list of medicines · brief referral letter with the question you want answered.

To refer to Dr. Haritha Chiramana (C.R. Reddy Cancer Center, Nellore, Andhra Pradesh, India): phone 0861 232 5344 · WhatsApp +91 79896 42272 · info@drharitha.co.in. For emergencies, send the patient to the nearest emergency department first.

Quarterly trial digest October 2026 edition

Practice-changing breast cancer trials from the past year, read critically: the question, the result, what it changes, and what it means for Indian practice. Updated every quarter.

DESTINY-Breast05

QuestionResidual HER2+ disease after neoadjuvant therapy (node-positive or initially inoperable): trastuzumab deruxtecan vs T-DM1?

Result3-year invasive disease-free survival 92% vs 84% (HR 0.47); interstitial lung disease 9.6% vs 1.6%.

What it changesTrastuzumab deruxtecan becomes the preferred adjuvant option for high-risk residual disease; T-DM1 remains acceptable.

Indian practiceCost and access decide in many Indian centres; screen for ILD symptoms and keep T-DM1 as a valid choice.

Read on PubMed →

ASCENT-04

QuestionFirst-line PD-L1-positive (CPS ≥10) metastatic TNBC: sacituzumab govitecan + pembrolizumab vs chemotherapy + pembrolizumab?

ResultProgression-free survival improved (HR 0.65), with similar rates of severe adverse events.

What it changesSacituzumab + pembrolizumab is a preferred first-line option for PD-L1-positive metastatic TNBC.

Indian practiceCheck PD-L1 (22C3) on the metastatic biopsy; access to both drugs may be limited.

Read on PubMed →

monarchE (overall survival)

QuestionDoes 2 years of abemaciclib with endocrine therapy improve survival in high-risk node-positive HR+/HER2− early cancer?

ResultAt 7 years, overall survival 86.8% vs 85.0% (HR 0.84); invasive disease-free survival 77% vs 71%.

What it changesConfirms abemaciclib for high-risk patients meeting monarchE criteria.

Indian practiceWeigh a ~2% absolute survival gain against diarrhoea, monitoring and cost.

Read on PubMed →

NSABP B-51

QuestionBiopsy-proven N1 disease that becomes ypN0 after neoadjuvant chemotherapy: is regional nodal radiotherapy needed?

ResultNo reduction in invasive recurrence or breast cancer death with nodal radiotherapy (HR 0.88, not significant).

What it changesNodal radiotherapy can usually be omitted when nodes are cleared by neoadjuvant therapy.

Indian practiceReduces lymphoedema and machine time; whole-breast radiotherapy after conservation still applies.

Read on PubMed →

INSEMA

QuestionSmall HR+/HER2−, clinically and sonographically node-negative cancers having breast conservation: can sentinel-node biopsy be omitted?

ResultOmitting axillary surgery was non-inferior for invasive disease-free survival, with less arm morbidity.

What it changesSupports omitting the sentinel node in selected older, low-risk women (with SOUND).

Indian practiceRequires good-quality axillary ultrasound and planned whole-breast radiotherapy.

Read on PubMed →

HYPORT-Adjuvant (India)

QuestionCan one-week radiotherapy include the regional nodes? (Tata Medical Center, Kolkata)

ResultQuality of life after one-week nodal radiotherapy was no worse than with the 3-week schedule (Radiother Oncol 2026); disease-control results are awaited.

What it changesStrengthens the case for 1-week schedules, including nodes, pending outcome data.

Indian practiceDirectly relevant to Indian radiotherapy capacity and patients travelling long distances.

Read on PubMed →

Trials from Case of the week shortlisted for the January 2027 digest

FLAURA2 final overall survival — Yes: median overall survival 47.5 vs 37.6 months (HR 0.77), with more haematological toxicity. (case of 09 Oct)

Prepared by Dr. Haritha Chiramana for health professionals. General guidance only; use clinical judgement and local pathways. Next digest: January 2027.