Investigation of a metastasis or metastases from an unknown primary
Descriptor
The local protocol for the (imaging) investigation of patients presenting with a metastasis or metastases from an unknown primary.
Background
This audit is worth carrying out because patients presenting with a metastasis or metastases from an unknown primary account for 5–10% of those with malignant disease. CT scans of the abdomen and pelvis together with a CXR or CT thorax will identify the primary site in 30-35% of patients. Except in a few specific tumour types, the demonstration of the primary tumour does not provide a survival advantage. The management emphasis is best placed on identification of the tissue type and then (after a limited selection of focused investigations) commencing the appropriate treatment. Adopting a local protocol for investigation is not only sensible but also minimises the distress to the patient.
A local imaging protocol might be as follows (initial diagnostic phase):
• CT chest, abdomen and pelvis
• Mammogram
• Testicular ultrasound in males (if presentation suggestive of germ-cell tumour)
• Biopsy of the metastasis where appropriate
• Further investigations as indicated depending on the histology and after discussion with the oncologist or the consultant looking after the patient (secondary diagnostic phase)
The Cycle
The standard:
The local protocol for the (imaging) investigation of patients presenting with a metastasis or metastases from an unknown primary should be adhered to in all cases
Target:
100%
Assess local practice
Indicators:
Percentage of patients investigated as per the agreed protocol.
Data items to be collected:
Details of all imaging investigations performed on each patient before and after biopsy.
Suggested number:
Ten consecutive patients.
Suggestions for change if target not met
• Circulate the protocol to the relevant clinicians
• Organise a meeting to agree that the protocol is adopted as hospital-wide policy
• Discuss those requests that do not conform to the protocol with the individual referrer
• Repeat date for commencing the next audit (following change): six months
• Identify staff member responsible for introducing change
Resources
• Audit clerk to review notes and imaging records
• Consultant radiologist
• Consultant oncologist
• Six hours for audit clerk to review notes and two hours for each consultant
References
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Husband JES, Reznek RH. Imaging in oncology (2nd Edition) London: Informa Health Care 2004, ISBN 1841844217.
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Schapira DV. The need to consider survival, outcome and expense when evaluating and treating patients with unknown primary carcinoma. Arch Intern Med 1995; 155: 200-54.
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Van de Pol M et al. Brain metastases from an unknown primary tumour: which diagnostic procedures are indicated? Journal of Neurology, Neurosurgery and Psychiatry 1996; 61: 321-3.
Editor’s comments
The local protocol should be drawn up jointly between the radiologists and the oncologists. This is a multidisciplinary audit and this regular audit for governance is best carried out in conjunction with the clinical oncology department.
Submitted by
Taken from Clinical Governance and Revalidation 2000 RCR, updated by D Howlett