Suspected haematological cancer

Harrogate and District NHS Foundation Trust

Definition/Description

Suspected haematological cancer including myeloma pathway. 

Red Flag Symptoms

Urgently telephone Haematology consultant at HDFT and make 2 week referral if 

  • Blood Count or film suggestive of acute leukaemia or chronic myeloid leukaemia

Guidelines on Management

If unsure whether patient needs referring, further advice can be sought via Advice and Guidance, or if urgent the on-call haematologist via HDFT switchboard

Referral Criteria/Information

Refer as a USC haematology referral if has:

 

Lymphadenopathy

Particularly if:

  • Present >6 weeks
  • >2cm in size
  • Enlarging
  • Widespread
  • If associated with splenomegaly
  • If associated with drenching night sweats
  • If associated with weight loss

Consider other causes of lymphadenopathy eg infection and other malignancies eg cancer of head and neck which should be referred to ENT

Drenching, persistent night sweats

ONLY If associated with symptoms such as:

  • Weight loss
  • Lymphadenopathy or splenomegaly
  • Unexplained, persistent cytopenias eg Hb <105; neutrophils <1; platelets <100
  • Hypercalcaemia
  • Persistent lymphocytosis

Other causes incl: infections, inflammatory disorders, hormonal disorders, drugs, alcohol and should not be referred to haematology

Unexplained splenomegaly

If associated with symptoms such as:

  • Drenching night sweats
  • Weight loss
  • Unexplained cytopenias eg Hb<105, neutrophils <1, platelets <100
  • Persistent lymphocytosis

Myeloma

Where myeloma is suspected:

  • Paraprotein (usually IgG or IgA) associated with any of the following:
    • Unexplained anaemia
    • Unexplained renal dysfunction
    • Hypercalcaemia
    • Malignant type bone pain (persistent unexplained bony pain particularly occurring at rest/nocturnal pain) and associated x-ray/scan appearances suggestive of myeloma.
  • IgM paraproteins can sometimes be associated with lymphoproliferative disorders. Refer as 2 week wait if associated with any of following symptoms; drenching night sweats, unexplained weight loss, lymphadenopathy, splenomegaly, unexplained cytopenia (Hb<105, neutrophils <1, platelets <100), hypercalcaemia.

NB: paraproteins too faint to quantify with above features are very rarely associated with myeloma. There is usually an alternative underlying diagnosis. However, if there is overwhelming evidence to suggest cause is myeloma e.g. scans, blood film, then refer as 2 week wait. Further advice on paraproteins can be found on ICE under serum electrophoresis.

Immediate action if:

  • Paraprotein present / abnormal SFLC ratio
    AND
  • Signs / symptoms of spinal cord compression (SCC) - follow trust SCC pathway
    OR
  • AKI - d/w haematologist on-call

USC referral if:

  • moderate concentration  of paraprotein (IgG>15g/L, Ig A or IgM>10g/L)
  • any level IgD or IgE paraprotein
  • SFLC ratio <0.1 or >0.7
  • any IgG or IgA paraprotein/abnormal SFLC ratio  AND CRAB criteria (any one of: hypercalcaemia, new onset significant anaemia not secondary to other causes, new and significant renal deterioration, new and severe bone pain esp nocturnal not secondary to other causes. Please note bone pain and renal dysfunction common in the elderly.
  • any IgM paraprotein AND B symptoms, lymphaenopathy, organomegally, new significant anaemia, or hyperviscosity symptoms refer as 2WW; otherwise refer routinely
  • note normal SFLC ratio in CKD 1.66 - 3.1

Routine referral if: 

  • all other papraprotein concentration (not including  too low to quantify WITHOUT CRAB criteria, or if IgM paraprotein WITHOUT B symptoms, lymphaenopathy, organomegally, new significant anaemia, or hyperviscosity symptoms
  • bence jones protein present without CRAB criteria

No action if:

  • normal myeloma screen
  • patients with life expectancy <5 years and PP <5g/Lwith no CRAB criteria
  • paraproteins too low to quanitfy should not be referred. Consider rechecking 6-12 monthly

Additional Resources & Reference

Reporting Policy for Monoclonal Proteins and Serum Free Light Chains

Associated Policies

There are no associated policies.

Specialties

Haematology North Yorkshire Urgent Suspected Cancer North Yorkshire

Places covered by

  • North Yorkshire

Hospital Trusts

  • Harrogate and District