Urgent suspicion of cancer (USC) referral

Children:

In most cases the first contact for children with suspected cancer is general paediatrics. This may take the form of a phone call for emergency and very urgent concerns. Local guidelines should be followed as referral pathways differ across Scotland.

Young people:

The referral pathway may be more complex for young people with suspected cancer. The person may need clear guidance to understand different appointments, to avoid missed scans/failed attendances. For some young people, consideration should be given to sharing information with parents/guardians. Adult guidelines should be followed, where appropriate, bearing in mind that the more common cancer types seen in this age group, are different to those in older adults.

Clinical features that can be associated with cancer in children and young people:

While many CYP cancers present with non-specific symptoms, the majority of CYP presenting with these symptoms will not have cancer. The guidance aims to support clinicians in identifying those at higher risk while avoiding unnecessary investigations.

The following is not an exhaustive list of clinical features - it is important to remember that children and young people can present atypically.^91-93

Leukaemia

fever
recurrent or persistent infection
pallor
fatigue
generalised bone pain and/or limp
hepatosplenomegaly
lymphadenopathy
bleeding
petechiae
any of the features found in NHL (see below)

Lymphoma: Hodgkin’s

lymphadenopathy typically progressing over weeks-months
fever
sweats (drenching and at night)
pruritus
weight loss
breathlessness

Lymphoma: non-Hodgkin’s (NHL)

lymphadenopathy (particularly cervical)
splenomegaly
abdominal distension
sweats
fever
pruritus
weight loss
breathlessness

Lymphoma (either type)

Lymphoma can present with a mediastinal mass (see good practice) causing:

airway compromise – wheeze, stridor, orthopnoea
superior vena cava obstruction – breathing difficulty with facial swelling

Brain tumour

See – Better Safe Than Tumour – for age specific symptoms

persistent/recurrent headache
persistent/recurrent vomiting
behaviour change, confusion, or lethargy
developmental regression or reduced school performance
seizures
loss of balance
papilloedema
head tilt, wry neck, or stiff neck
focal neurological deficit
abnormal eye movements
new squint
blurred or loss of vision
co-ordination or walking issues
increasing head circumference crossing the centiles
delayed or arrested puberty

Neuroblastoma

abdominal mass,
unexplained neurological symptoms
hypertension
periorbital bruising
Horner’s syndrome
skin lesions in infants (‘blueberry muffin’ appearance)
systemic symptoms (bone pain, pallor, bruising, fever, fatigue, irritability, lymphadenopathy)

Renal tumours (nephroblastoma)

palpable abdominal mass (can be painful),
haematuria (can be visible or persistent non-visible)
hypertension
associated fever

Soft tissue sarcoma

soft tissue mass anywhere on the body (firm/hard, tethered, non-tender, enlarging)
proptosis
nasal or ear obstruction or discharge (persistent or recurrent, bloody/purulent)
urinary retention
scrotal swelling, vaginal discharge (blood stained)
back pain, lower limb pain or weakness (see good practice for malignant spinal cord compression)
can be associated with enlarged draining lymph nodes and weight loss

Bone tumours

persistent localised bone pain (pain can be at rest)
bony mass or swelling
spontaneous or minor trauma fracture
back pain including a painful scoliosis
unexplained limp
can cause malaise and fever

Liver tumours

hepatomegaly
abdominal pain
systemic upset (fever, fatigue, loss of appetite)
rarely jaundice

Retinoblastoma

white or absent pupillary red reflex
new onset squint

Germ cell tumours

scrotal swelling (testis)
abdominal mass (ovary)
neurological symptoms (CNS involvement)
can be associated with gynaecomastia, virilisation, and/or precocious puberty

Germ cell tumours (continued)

Germ cell tumours can present with a mediastinal mass (see good practice) causing:

airway compromise – wheeze, stridor, orthopnoea;
superior vena cava obstruction – breathing difficulty with facial swelling

Langerhans cell histiocytosis

Bone (pain, swelling, multiple lesions on X-ray and can be lytic)
posterior pituitary features (polydipsia/polyuria)
skin (rash, which is unusual, fluctuant, persistent, can look like eczema unresponsive to treatment, severe cradle cap, persistent/recurrent otitis externa, anal excoriation)

Haemophagocytic lymphohistiocystosis

systemic upset
fever
splenomegaly
pallor
fatigue
bruising and /or bleeding