ࡱ>  bjbj]] 7??g h h l& 8D":(<<<{}}}}}}$f]N<T<^<< <@JJJ<N{J<{JJJ}\Pu h@٠Bg0DZ,B,uu, \<<J<<<<<G<<<D<<<<,<<<<<<<<<h :  Guidelines for the Investigation and Management of Metastatic Malignant Disease of Unknown Primary Origin Version: 2.0 Author: Caroline Manetta Contributors: Rose Errington, Charlotte Moss, Antonia Creak Reviewed by Antonia Creak/ C Manetta/Charlotte Moss 10/06/ 2019. Histopatholgy section - reviewed by Catherine Guy May 2019 Acknowledgement: adapted (with permission) from original document by Cheshire & Merseyside Strategic Clinical Networks. Review Date: June 2021 Introduction Malignant disease of undefined origin (MUO) represents a very broad spectrum of presentations where evidence of a metastatic malignancy is apparent without a primary tumour identified. NICE Clinical Guideline 104 sets out clearly the definition (Table 1) for this entity and the two refinements of this diagnosis following further investigations; namely provisional and confirmed carcinoma of unknown primary (pCUP and cCUP)1. Historically, this clinical entity has been poorly managed with excessive and unnecessary investigation, poor information giving and delays in referral to oncology or palliative care1-3. The establishment of local CUP multi-disciplinary teams and a central specialist MDT should allow for the streamlining of investigative processes and timely triage to further specialist care. These guidelines provide a framework to facilitate the investigation and management of MUO and CUP presentations as defined in table 1. Two MUO syndromes are exempted from this pathway as they are best managed via different site-specific MDTs: Squamous cell carcinoma affecting the upper/mid cervical lymph nodes should be managed through the local head/neck MDT Adenocarcinoma of the axillary nodes should be managed through the local breast MDT The overarching feature of many MUO presentations is the futility of further investigations or treatment in a patient who is approaching the end of their life. Given, these factors, early holistic needs assessment and palliative care referral are important considerations. The document will be periodically reviewed in the light of experience and published evidence. Malignancy of undefined primary origin (MUO): Metastatic malignancy identified on the basis of a limited number of tests, without an obvious primary site, before comprehensive investigation. Provisional carcinoma of unknown primary (provisional CUP): Metastatic epithelial or neuroendocrine malignancy identified on the basis of histology/ cytology, with no primary site detected despite a selected initial screen of investigations, before specialist review and possible further specialised investigations. Confirmed carcinoma of unknown primary (confirmed CUP): Metastatic epithelial or neuroendocrine malignancy identified on the basis of final histology, with no primary site detected despite a selected initial screen of investigations, specialist review, and further specialised investigations as appropriate. To minimise the risk of delayed site-specific referral for patients who are suspected to have a specific primary, patients considered as having MUO are further defined as follows: Liver tumour(s) and other intra-abdominal masses identified as likely metastatic malignancy on initial imaging, without evidence of a probable primary site. Bone tumour(s) identified as likely metastatic malignancy on initial imaging and not immediately considered to be related to prostate cancer by digital rectal examination (DRE) or prostate-specific antigen (PSA). Brain tumour(s) identified as likely metastatic malignancy on initial imaging, without evidence of a probable primary site. Lung tumour(s) identified as likely metastatic malignancy on initial imaging, without evidence of a probable primary site. Pleural effusion(s) diagnosed as malignant on cytology, without evidence of a probable primary site. Malignant ascites diagnosed on cytology, without evidence of a probable primary site. Skin tumour(s) confirmed as malignant on histology when primary skin cancer excluded and no obvious primary from histology or imaging. Biopsy/FNA confirmed malignancy in inguinal lymph node(s) when no obvious primary from histology or imaging. Biopsy/FNA confirmed malignancy in cervical lymph node(s) when head and neck primary excluded and no obvious primary from histology or imaging These guidelines do not apply to this presentation Biopsy/FNA confirmed malignancy in axillary lymph node(s) when no obvious primary from histology or imaging. These guidelines do not apply to this presentationTable  SEQ Table \* ARABIC 1 Definitions of malignancy undefined origin and carcinoma of unknown primary Patient Pathway The majority of MUO presentations occur via an emergency admission to secondary care and the patients will be identified to the unit local CUP/AO teams. Outpatients may present through secondary care clinics, GP referrals or radiology flagging systems. Brighton and Sussex University Hospitals (BSUH) and East Sussex Healthcare Trust (ESHT) patients are discussed in the Network CUP MDT which acts as both local and specialist MDT. Western Sussex patients from Worthing are discussed in a local MDT and selected patients (with final diagnoses of MUO & cCUP and those complex MUOs) are discussed at the Network CUP MDT acting as specialist MDT. Western Sussex patients from Chichester are managed by the Queen Alexandra NHS Trust CUP team. Outpatient CUP MDT Assessment All local CUP MDTs should develop their own procedures to manage MUO presentations in an outpatient setting. Most referrals will come from other site-specific MDTs or secondary care clinicians. Primary care referrals may be accepted by local arrangement with the local CUP MDT, host Trust and CCG. Inpatient CUP MDT Assessment Inpatient referrals should be seen within one working day and it is expected that review will be by the local inpatient Acute Oncology Service. An overview of patient flow is shown in Figure 1. Concomitant with a thorough medical assessment, the patients holistic needs should also be assessed. Symptom control and psychological support should be offered and appropriate referrals made. The patients and carers understanding of the situation should be assessed and information given in a clear and sympathetic manner. These processes are active and ongoing throughout the patients journey and the CUP nurse specialist role here is fundamental. A patient information leaflet should be provided. It is common for Specialist Palliative Care to be brought in during the diagnostic stage and for the majority of patients this will remain the most important intervention during their illness. Many patients can be managed as outpatients once the above needs have been met and therefore every attempt should be made to facilitate discharge. Following specialist oncology review, a management plan will be implemented and it is expected that the patient will be discussed at the CUP MDT. Outcomes following review and/or further investigation will fall into four groups: MUO/pCUP/cCUP, fit for active therapy and requiring further investigation or treatment MUO/pCUP/cCUP, not fit for further therapy and requiring best supportive care Primary identified, needing review at site-specific MDT Non-malignant diagnosis, requiring onward referral  SHAPE \* MERGEFORMAT  Approach to Investigation The assessment of any MUO patient begins with a thorough history and physical examination. Most patients will be referred having had some imaging which is highly suggestive or confirmatory of malignancy. Routine blood tests should include: FBC, U&E, LFTs, Calcium, LDH. The decision to embark on further tests from here will very much be influenced by the mode of presentation and the condition of the patient4. It should be borne in mind that most oncology decisions can be made utilising three fundamental pieces of information The condition, functional status and co-morbidities of the patient (history and examination) The stage of the cancer (cross-sectional imaging) The type of cancer (histology) The use of blood tumour markers is not recommended except in a limited number of circumstances (Table 2)5-8. However other tumour markers including CA19-9, CA153 & CEA should be considered if felt to be of useful in certain cases by the individual Oncologist. Gastrointestinal endoscopy should only be considered when a GI primary is hinted to on imaging or symptoms and where it is felt this will alter further management9-12. There is currently no routine role for positron emission tomography unless the patient has isolated cervical lymphadenopathy and is suitable for radical treatment13,14 and should be considered on an individual basis. Gene expression based profiling has no current routine use and is not currently funded by NHS, however the use of this technique will be discussed at the CUP MDM when appropriate and can be considered if patients wish to self-fund. a-FP and b-HCGIf germ cell tumour suspected: men with midline lymph node metastasesa-FPIf hepatocellular carcinoma suspected: evidence of chronic liver diseasePSAMen >40 with bone metastasesCA125Women with peritoneal or pelvic metastases, ascites, pleural effusionsTable  SEQ Table \* ARABIC 2 Indications for the ordering of blood tumour markers Specific Presentations Presentations that may benefit from radical (potentially curative) treatment: Squamous carcinoma involving upper or mid neck nodes; refer patients presenting with upper or mid-neck squamous cell carcinoma and an unidentified primary tumour to a Head & Neck MDT for evaluation and treatment. Adenocarcinoma involving axillary nodes: refer to breast cancer MDT for evaluation and treatment. Squamous carcinoma involving inguinal nodes: refer patients with squamous carcinoma confined to inguinal nodes to a specialist surgeon in an appropriate MDT to consider treatment with curative intent. Possible sites of origin of malignant groin nodes: malignant melanoma or scc skin of lower leg or lower trunk; carcinoma of external genitalia, anus, vaginal, cervix, ovary. Offer patients with operable disease either superficial lymphadenectomy and consider post-lymphadenectomy radiotherapy for patients with risk factors for residual disease (eg multiple involved nodes or extra-capsular spread) or simple excision of clinically involved nodes followed by radiotherapy. A solitary, apparent metastasis. Do not investigate tumour inappropriately because this may make radical treatment ineffective. For example, biopsy of a primary bone tumour may mean that the patient needs more extensive surgery than usual. Percutaneous biopsy of a potentially resectable liver metastasis may compromise outcome. Consider that an apparent metastasis could be an unusual primary tumour. Refer patients with a solitary tumour in the liver, brain, bone, skin or lungs to the appropriate MDT to consider radical local treatment. Patterns requiring urgent specific action: Spinal cord compression: requires urgent assessment and referral to metastatic spinal cord compression co-ordinator (on call Oncology Registrar at BSUH). Superior vena cava obstruction: requires urgent referral to respiratory for consideration of stenting. Men with midline disease: requires urgent referral to germ cell cancer specialist oncologist. Suspected lymphoma, myeloma, plasmacytoma: requires urgent referral to haematology. Liver lesions The finding of isolated liver metastases is a common MUO presentation and nearly half of all MUO patients will have liver involvement2. A retrospective review of carcinoma unknown primary presenting to the MD Anderson in Texas identified hepatic involvement as an independent adverse prognostic feature15. A full staging CT scan of thorax, abdomen and pelvis should be performed after history taking and physical examination. A serum a-fetoprotein should be checked if there is a suspicion of hepatocellular carcinoma. If the distribution of metastatic disease is confined to the liver and cross-sectional imaging suggests that it may be resectable (e.g. unilobar) then a referral to the hepatobiliary MDT is recommended prior to an image-guided biopsy. If it is likely to be resectable then colonoscopy, PET CT and MRI of liver should be performed to more accurately define the extent of disease prior to surgery. Most presentations are unlikely to be resectable and if tissue is needed an image-guided percutaneous biopsy of a lesion should be arranged. Brain lesions These are the presenting feature of around 10% of MUO presentations2. They typically present as an emergency with stroke-like symptoms and are identified on CT/MRI brain. Immediate management with dexamethasone typically provides some relief. The key determinants of prognosis are performance status, neurological deficit following trial of dexamethasone and extent of extracranial disease. Solitary lesions should be discussed with the BSUH neurosurgical team and at the Neuroscience MDM. If the lesion is technically unresectable, a biopsy should be discussed (if it is solitary and in absence of disease suitable for biopsy extracranially). Stereotactic radiosurgery should also be considered (for patients who meet the NHSE commissioning criteria i.e expected prognosis of 6 months or more, KPS 70 or more, absent/controlled/controllable extracranial disease, total brain tumour volume <20cc). Patients of good PS with multiple brain metastases should be considered for whole brain radiotherapy. Bone lesions Bone lesions are seen in about a third of MUO presentations and are typically lytic in nature. They typically present as an emergency with significant skeletal events such as pathological fracture, spinal cord compression or uncontrolled pain. In many situations therefore it is imperative to arrange radiotherapy before any further investigations can be undertaken. Men over the age of 40 should have a digital rectal examination and a PSA checked. All patients with lytic bone lesions should have serum protein electrophoresis and serum light chains checked. If the patient presents with a pathological fracture and is scheduled for internal fixation then ensure that you request that the surgeon sends reamings to the laboratory for histological analysis. Bone biopsies should be arranged via the local orthopaedic services/ interventional radiology. If there is a suspicion of primary bone sarcoma on imaging then the images should be reviewed by the sarcoma MDT prior to an attempt at biopsy. Lung lesions If there is any suspicion of a lung primary, such patients should be managed by lung MDT. Where the distribution and appearances suggest metastatic spread, tissue can be obtained either by percutaneous needle biopsy or bronchoscopically. Consider referral for video assisted thoracic surgery if no tissue is obtained via these routes, after discussion at lung MDM. Peritoneal carcinomatosis This typically presents with vague abdominal symptoms and ascites. In women it is reasonable to check a CA125 but it should be borne in mind that this will be invariably elevated even in non-malignant causes for ascites. Diagnosis can often be made on the presence of malignant cells in peritoneal fluid, particularly if a cell block is prepared, but sometimes a biopsy is required. If an image guided procedure cannot access tissue then the patient should be referred for a laparoscopy via the gynaecologists. 5.0 Imaging and Histological Assessment 5.1 Imaging Assessment Offer to patients with MUO when clinically appropriate, guided by symptoms: CT chest, abdomen and pelvis Bone scan MRI Do not offer mammography routinely to women with MUO unless clinical or pathological features are compatible with breast cancer. Do not offer PET-CT routinely unless the patient has isolated cervical lymphadenopathy and/or is suitable for radical treatment. 5.2 Histological Assessment It is incumbent on the local Acute Oncology teams to work closely with their local pathology laboratories to provide sufficient background information to facilitate appropriate immunohistochemical analysis. For some patients the confirmation of cancer may be sufficient on haematoxylin and eosin (H&E) staining whereas others will require a more comprehensive immunohistochemical panel to categorise the tumour: a. undifferentiated malignancies. The panel of investigations will be influenced by the age and sex of the patient, the site of biopsy and morphological assessment of the H&E stained sections. In general, consider: i. initial panel to cover possibilities of lymphoma, carcinoma, melanoma (LCA, AE1/AE3, S-100) and germ cell tumour (OCT3/4 and PLAP) ii. second line panel depending on results of (i). If probable lymphoma the case will be referred to one of the local specialist haematopathologists for work up, if carcinoma the site of biopsy and the morphology of the tumour must be considered, and a panel of immunohistochemical stains constructed (locally available markers include: CK7, CK20, CDX2, CA125, PSA, PSAP, TTF-1, ER, napsin-A, Pax-8, Gata-3, EMA, CEA, p53, p40, p63, p16, synaptophysin, chromogranin, CD56, alpha-feta protein, CD30, inhibin, WT-1, GCDFP-15, ER, PR, DOG-1, CK5/6, RCC, CD10, CD117, Cam 5.2, vimentin, racemase, hepatocellular marker and vimentin, Her-2 breast and gastric type), if melanoma (pan-melanin, sox10, melan-A and HMB45) if sarcoma (the antibodies selected decided upon in concert with a local specialist soft tissue pathologist, or the case sent to an expert centre such as the Royal Marsden Hospital). b. metastatic adenocarcinoma. If proven, or likely lung adenocarcinoma, analysis for EGFR and ALK and PDL1 status must be arranged and if possibly from a colorectal origin micro satellite instability immunohistochemistry undertaken. c. metastatic squamous cell carcinoma. Markers of squamous differentiation are not entirely specific but consider p63, 34BE12. Site-specific markers for origin of squamous cell carcinoma are of very limited value, however p16 immunohistochemistry should routinely be performed, and analysis for EBER be considered. d. Identification of predictive markers of therapeutic response. After MDT discussion, consideration should be given to requesting additional biomarkers if any of the following are suspected but only if it will have a bearing on therapy: i. Breast: ER/Her2/BRAC 1 and 2 ii. Lung: EGFR mutation, ALK translocation and PD-L1 expression testing. iii. Colorectal: K-RAS mutational status, MSI iv. Gastric and Breast: Her2 v. Gastrointestinal stromal tumours: Kit and PDGFRA mutational sequencing vi. High grade serous ovarian: BRCA 1 and 2 vii. Breast : Endopredict analysis Options for Systemic Treatment of cCUP The evidence base for optimal systemic treatment of those patients with confirmed CUP is poor16-18. The initial decision to treat will be based on the patients performance status and co-morbidity but there is no evidence to dictate the use of one regimen over another in cCUP. The regimen used in practice therefore typically is a best guess approach based on where the suspected origin of the cancer, often this involves a first-line platinum-doublet chemotherapy regimen. There is clear need to develop an evidence base here and where possible patients should be managed in clinical trials. As a guide some common presentations are highlighted here with suitable regimens. Liver or lung metastases adenocarcinoma or poorly differentiated carcinomaGemcitabine and platinum Gemcitabine alone ECX/ECF EOXSquamous cell carcinomaCisplatin and 5-FU/capecitabinePoorly differentiated carcinoma with predominant midline distributionECX/ECF BEP (if male)- under care of germ cell tumour teamWomen with predominant peritoneal adenocarcinomaCarboplatin and paclitaxel Carboplatin monotherapy (under care of Gynae-oncology team)Poorly differentiated neuroendocrine carcinomaPlatinum and etoposide 7. Ongoing Care The CUP team will be involved in the patients care until the patients is: Taken over by a site specific consultant Diagnosed with a non-malignant condition Declines further input/Taken over by the Palliative care team 8. Data collection and Clinical Audit All MUO/CUP presentations to the local CUP teams will be registered on Somerset. The local teams have responsibility for management and analysis of the core dataset. Scope and timelines of future audit projects will be set by the Acute Oncology and CUP Network Group. 9. Organisation of Services 9.1 The CUP Team Every acute Trust should have a CUP Team, ensuring that patients and health care professionals have access to it when MUO is diagnosed. This team should comprise the following health care professionals as a minimum: An oncologist A palliative care physician A CUP specialist nurse/key worker (this may be performed by person who also has another role eg acute oncology or site-specific role). 9.2 The CUP MDT The CUP MDT should comprise those listed above in the CUP Team plus: A radiologist A histopathologist A patient pathway co-ordinator 10. References NICE Clinical Guideline 104: Diagnosis and management of metastatic malignant disease of unknown primary origin Singh G, Henry J, Evans M, Forsythe D, Ahmed E Griffiths RW. The impact of an acute oncology service on the management of malignancy of undefined origin.. National Cancer Research Institute Cancer Conference Abstract B41. 2011 National Confidential Enquiry into Patient Outcome and Death. Systemic Anti-Cancer Therapy: For better, for worse?.2008 Schapira DV, Jarrett AR. The Need to Consider Survival, Outcome, and Expense When Evaluating and Treating Patients with Unknown Primary-Carcinoma. Archives of Internal Medicine 1995;155(19):2050-4. Losa Gaspa F, Germa JR, Albareda JM, Fernandez-Ortega A, Sanjose S Fernandez Trigo V. Metastatic cancer presentation. Validation of a diagnostic algorithm with 221 consecutive patients. Rev.Clinica Espana 2002;202(6):313-9. Tsukushi S, Katagiri H, Kataoka T, Nishia Y, Ishiguro N. Serum Tumor Markers in Skeletal Metastasis. Japanese Journal of Clinical Oncology 2006;36(7):439-444.Topic 3 Mottolese M, Venturo I, Donnorso RP, Curcio CG, Rinaldi M, Natali PG. Use of selected combinations of monoclonal antibodies to tumor associated antigens in the diagnosis of neoplastic effusions of unknown origin. European Journal of Cancer & Clinical Oncology 1988;24(8):1277-84. Koch M, Mcpherson TA. Carcinoembryonic antigen levels as an indicator of the primary site in metastatic disease of unknown origin. Cancer 1981;48(5):1242-4. Katagiri H, Takahashi M, Inagaki J, Sugiura H, Ito S, Iwata H. Determining the site of the primary cancer in patients with skeletal metastasis of unknown origin: a retrospective study. Cancer 1999;86(3):533-7. Kirsten F, Chi CH, Leary JA, Ng ABP, Hedley DW, Tattersall WHN. Metastatic adeno or undifferentiated carcinoma of unknown primary site - natural history and guidelines for the identification of treatable subsets.. Quarterly Journal of Medicine 1987;62(238):143-161. Yamada K, Holyoke ED, Elias EG. Endoscopy in patients with malignant conditions of the gastrointestinal tract. Surgery, Gynecology & Obstetrics 1975;141(6):903-6. Schapira DV, Jarrett AR. The Need to Consider Survival, Outcome, and Expense When Evaluating and Treating Patients with Unknown Primary-Carcinoma. Archives of Internal Medicine 1995;155(19):2050-4. Kwee TC, Kwee RM. Combined FDG-PET/CT for the detection of unknown primary tumors: systematic review and meta-analysis. European radiology 2009;19(3):731-44 Joshi U, van der Hoeven JJ, Comans EF, Herder GJ, Teule GJ, Hoekstra OS. In search of an unknown primary tumour presenting with extracervical metastases: the diagnostic performance of FDG-PET. British Journal of Radiology 2004;77(924):1000-6. Abbruzzese JL, Abbruzzese MC, Hess KR, Raber MN, Lenzi R, Frost P. Unknown primary carcinoma: natural history and prognostic factors in 657 consecutive patients. Journal of Clinical Oncology 1994;12(6):1272-80. Adenis A Fert C Penel N. Phase II trials in patients with carcinoma of unknown primary: a pooled data analysis.. Invest New Drugs 2009 Briasoulis, E., et al., Carboplatin plus paclitaxel in unknown primary carcinoma: a phase II Hellenic Cooperative Oncology Group Study. Journal Of Clinical Oncology: Official Journal Of The American Society Of Clinical Oncology, 2000. 18(17): p. 3101-3107 Golfinopoulos V, Pentheroudakis G, Salanti G, Nearchou AD, Ioannidis JPA, Pavlidis N. Comparative survival with diverse chemotherapy regimens for cancer of unknown primary site: Multiple-treatments meta-analysis. Cancer Treatment Reviews 2009. Appendix One Electronic Cancer of Unknown Primary MDM referral proforma Criteria for referral: New suspected diagnosis of metastatic cancer of unidentified primary site seen on imaging including: a) Plain XR or MRI reported demonstrating likely bone metastases b) USS or CT demonstrating evidence of metastatic disease with no readily identifiable primary site. Please note: Patients with symptoms suggestive of malignancy (without a radiological diagnosis of cancer) e.g. weight loss, anaemia etc. should be referred for investigation under the appropriate medical/surgical teams in the usual way. Patients with an obvious primary on imaging/examination should be referred to the appropriate site-specific MDM Does the patient have IMAGING suggestive of a diagnosis of Metastatic cancer yes/no What does it show? : -Plain Xray: Comments box -Ultrasound: Comments box -CT: Comments box -MRI: Comments box -Other: Comments box Current symptoms: free text Past history (including any previous cancer history): free text Current medications: free text Any relevant blood results: free text Question you want the MDT to answer? WHO PS drop down box -1 to 4 Is the patient aware of your suspicion of a cancer diagnosis? Y/N Is the patient known to the palliative care team Y/N If yes drop down box Martletts, St P&J, St Catherines, St Barnabas, other     Sussex Cancer Centre Page  PAGE 1 of  NUMPAGES 18Guidelines for the investigation and management of metastatic malignant disease of unknown primary originVersion 2.0Review Date: May 2021 updated by Dr C Guy May 2019 Active Therapy Figure  SEQ Figure \* ARABIC 1 Patient flow for new presentations of malignancy of undefined origin Malignancy of Undefined Primary Origin (MUO) Do not order tumour markers or further investigations unless genuine clinical need Provisional CUP consider at any point in pt pathway for symptom management PS 0-2 Appropriate for systemic therapy By Fax By email By electronic form 1/2 Care Referral Refer through to site specific oncologist/MDT Primary Identified Urgent Referral to Local CUP/AO Team Ward Referral Radiology Flag ASSESSMENT IP8CXgop|    ! ] a º¤™͑vnbWh hOJQJh<-h6OJQJh OJQJhLhLOJQJhGOJQJh ROJQJhOJQJhwhCOJQJhwhLOJQJhwhwOJQJh\EOJQJhwhGOJQJhK OJQJhLh9 CJ0OJQJaJ0h / hCJ0OJQJaJ0hLCJ$OJQJaJ$"opqrstuvwxyz{|! gdG$a$gd{egdL$a$gd! ] # QL$$&`#$/7$8$H$Ifa$gdTN$&`#$/7$8$H$IfgdTN$ & F dhxxa$gdf]$dhxxa$gdf]$dhxxa$gdTN & F gd / gdLgdG^gd8I2a 4 6 ^ ` a c   ! " # V l ~ zrrg\r\hf]hf]OJQJh h<OJQJhf]OJQJhOJQJhGOJQJh hOJQJh huFOJQJhTNhTNH*OJQJhTNH*OJQJh h((OJQJh hOJQJh9 h9 H*OJQJh h AOJQJh hOJQJh hOJQJh2 OJQJ$ PQLKMN}k_PDhf]CJOJQJaJh hf]CJOJQJaJhTNCJOJQJaJ"h hTN6CJOJQJ]aJhf&CJOJQJ]aJh hTNCJOJQJaJh hTNCJOJQJ]aJh hTN5CJOJQJaJh AOJQJh h6OJQJh hOJQJh hYlOJQJh h((OJQJhf]OJQJh hf]OJQJLM6$ZN*$ & F 8$&`#$/7$8$H$If^`a$gdTN$&`#$/7$8$H$IfgdTN$$&`#$/7$8$H$Ifa$gdTN~$%&.63źxlaVaVKChj OJQJh hMOJQJh h']OJQJh h((OJQJh<-h((6OJQJh<-h86OJQJ hf]hf]hTNOJQJh@OJQJmHnHujhTNhTNOJQJUhTNhTNOJQJh hTNOJQJhf]hTNCJOJQJaJhf]CJOJQJaJh hTNCJOJQJaJhf]hf]5CJOJQJaJ%&6fa\M>$dhxxa$gdf] & F dhxxgdf]gdf]gdTNnkd$$Ifl8@ 6`064 laytTN*$ & F 8$&`#$/7$8$H$If^`a$gdf],5?@z;U9efƻvk`U`h h NOJQJh hOJQJh h2 OJQJh hqWqOJQJhJbOJQJhqWqOJQJh hYlOJQJh2 hYl5OJQJh hOJQJhOJQJh h']OJQJh/POJQJhf&hf&OJQJhf&OJQJhj hj B*OJQJphhj OJQJhCOJQJ;f"v##$S$$$$$&$dhxxa$gd & F dhxxgd$a$gd8$ & Fdhxxa$gdf]$dhxxa$gdf]$ & F dhxxa$gdf]$hdhxx^ha$gdf] !=!!!"""""###!#u#v#$$$$$$$$$$ϞϦ}y}k]U}Qh8jh,~Ujh AUmHnHujhtv UmHnHuh Ajh AUjh,~UmHnHuh htv OJQJhj OJQJh h8OJQJhf&OJQJh h((OJQJh hJ3<OJQJhsXOJQJh hx#OJQJh hOJQJh hMOJQJh2 OJQJ$$%%%%%Y&Z&&&'''''(')()+),)6)@)B)J)T)p))) *Z*j**z++++ݾݳɳɢ{skkschq|6OJQJhOJQJhf&OJQJh{eh{eH*OJQJhj OJQJh{eOJQJh / h>IkOJQJh{eH*OJQJhOJQJh / h\tJOJQJh / hJ3<OJQJh+0h+0H*OJQJhCOJQJh / h'LOJQJh / h8OJQJh<-h86OJQJ$&0'b''++,,,$-Skd$$IfTl0= t0644 laytT $$Ifa$gd$dhxxa$gd U$ & Fdhxxa$gd ++++,8,,,. . .. .!.".X.Y.p../e/f/j/m////004444556Ȼװ~sgs\s\hghN(OJQJhgh#+A5OJQJhgh#+AOJQJhCOJQJhf&OJQJhgh;OJQJhgh9:OJQJhgh\tJ6OJQJhghJ3<OJQJh@OJQJmHnHujhghq|6OJQJUhghq|6OJQJhj OJQJh / hq|6OJQJh2 hq|6OJQJ#$-&-.-h-tt $$Ifa$gdkd$$IfTl0= t0644 laytTh-j-v-.tf $$$Ifa$gd $$Ifa$gdkd$$$IfTl0= t0644 laytT..X.Y.p..////{vgbZQZQ^gd; & Fgd9:gd9: & F dhxxgdgd\tJgdm%kd$$IfTl0= t0644 laytT /00p1q122/404444455H6666d9>;$dhxxa$gd & F dhxxgd^gd-B & FgdN(gd; & Fgd;^gd; & Fgd9:666071737777888 9 9b9d9;;;<<x<|<<=;=<=J=P=߼߱uj^jjSSHh / hCOJQJh / h?OJQJhhH*OJQJh / hCOJQJh / h\tJOJQJhhhOJQJh / hWXOJQJhCOJQJhOJQJh2 hhOJQJh / hhOJQJh}h}H*OJQJh / h qOJQJh{eh{eH*OJQJh / hY1OJQJhgh\tJOJQJhgh-BOJQJ>;;;???BCCCC1E2ELEKGLGtGG dhxxgdBhdhxx^hgdqdhxx^gd/x$dhxxa$gdq$dhxx^a$gdl & F dhxxgd$dhxxa$gdP=V=W=^======7>Z>[>\>j>>>>>X?Y?[?d?o????? @>AAAAAϼϴϴϴϝϝ|q|i^hwh -OJQJh -OJQJh / hdOJQJh / hOJQJh / h\tJOJQJh-BhlOJQJh / h<OJQJh8I2hf&6hf&hf&OJQJhOJQJh / h7nOJQJh7nOJQJh / hCOJQJh / h?OJQJh / hCOJQJhCOJQJ AAAAABB C#C@CMCCCCCDDD^D_DE0E1E2ELEOEE7F=FkFuF{FFFF2GIG׹ױąĐĐzooodooo\hBOJQJh / hx#OJQJh / hq|6OJQJh / hqOJQJh / h7nOJQJh / h+OJQJh / h\tJOJQJh / h/xOJQJhOJQJh / h6OJQJh7nOJQJh / h?OJQJh / hdOJQJhf&OJQJhwh -OJQJhwhf&OJQJ$IGJGKGLGtGwGGI I I!I"I#IUUUUV˿ymiaL?/h2 sh<-5CJOJQJaJh/x5CJOJQJaJ)h/xh<-5CJOJQJ\]^JaJ *h8I2h4Mh4Mh8I2hWX6OJQJ+jh4M0J56OJQJU\]^Jh4MhWX6OJQJh4MhBOJQJh4MhB56OJQJh2 shBOJQJh2 shB6OJQJh/xhB56OJQJh/x6OJQJh<-hqOJQJhq|6OJQJh / hq|6OJQJGGGGHHHHI#IJKALOPR SnSSeTTNUUUUgd/xgd8I2gd4M dhxxgdB & FgdBgdBVVVVuVzVVVV,W>WdWeWoWpWWWWWXXXXX&Y?Y@YCYDY]YkYoY|Y~YYYYʾʶʫʫzzozdzzh / hx#OJQJh / hOJQJh / hm%OJQJhqOJQJh / h/xOJQJh{OJQJh=h=OJQJh / h{OJQJh=OJQJh Uh UH*OJQJh / hJ3<OJQJh2 sh/x5CJOJQJaJh<-CJOJQJaJh<-h<-CJOJQJaJ$UVVXXX Y&Y8Y@YDY $$Ifa$gd$a$gd{$dhxxa$gdgd/x & F gd8I2 DYEY]Y}Yuu $$Ifa$gd}kd2$$Ifl09 9 t0644 lalytx#}Y~YYYYuuu $$Ifa$gd}kd$$Ifl09 9 t0644 lalytx#YYYYYYZcZdZZZZZZZZ-[.[[[[[*\5\\\ڻⳫ{i_UKUhOJQJ^Jh<-OJQJ^JhOJQJ^J#h<-h<-5CJOJQJ^JaJh<-5CJOJQJaJh*EVOJQJh / h<-OJQJh<-h<-5CJOJQJaJh<-OJQJh{OJQJh / h7nOJQJhm%OJQJh / hm%5OJQJh7nOJQJh / hm%OJQJh / h{OJQJhwOJQJYZ1ZLZdZZuuuu $$Ifa$gd}kdL$$Ifl09 9 t0644 lalytx#ZZZZuu $$Ifa$gd}kd$$Ifl09 9 t0644 lalytx#ZZZZZZ.[W[[[[[yyyyynnnbb $^a$gd<- $ & Fa$gd<-$a$gd{}kdf$$Ifl09 9 t0644 lalytx# [[\\]]]^!^^^^^^^__"_A_B_$dhxxa$gd 3$ & Fdhxxa$gd 3$dhxx^a$gd/x$ & Fdhxxa$gd 3$dhxxa$gdq\\\\]]]]]^^^^^__A_B_C_G_ɷɥwowdSB hLl56CJOJQJ^JaJ hq56CJOJQJ^JaJh / h 3OJQJh*EVOJQJh 3OJQJh/xOJQJ^Jh 3OJQJ^J#h/xh5CJOJQJ^JaJ#h/xh9:5CJOJQJ^JaJ#h/xh 35CJOJQJ^JaJ h/xh 3CJOJQJ^JaJ#h/xh5CJOJQJ^JaJh=OJQJ^JhqOJQJ^JG_Q_R___Z`[``aab&bDcEcccldmdeeeeeeqfrf_gggbhchhiǽǽrrrrerXh}h{eOJQJ^Jh{ehTNOJQJ^Jh{eh{eOJQJ^Jh{eh+0OJQJ^Jh+0OJQJ^Jh+0h+0OJQJ^Jh+0hTNOJQJ^JhTNhTNOJQJ^JhTNOJQJ^Jh}OJQJ^Jh9 OJQJ^J h9 56CJOJQJ^JaJ&h2 h*EV56CJOJQJ^JaJ B_R__`aabicdeefgchiijOkPlDm$ & F7$8$H$a$gdq$ & F7$8$H$a$gd}$ & F7$8$H$a$gd{e$ & F7$8$H$a$gd+0 $ & Fa$gd+0 $a$gdLliiii5j6jjjjjjjjjjjHkIkMkNkkkNlOlllBmCmDmEmkmvmmmmmmʽxj_j_j_h#5>*CJaJhv@h#5>*CJaJh#CJ OJQJ^Jh*EVCJ OJQJ^JhqCJOJQJ^JaJhqhqOJQJhqOJQJ^JhqWqOJQJ^JhqhqOJQJ^JhqOJQJh}OJQJh}h}OJQJh}h}^J h{eh{eh}h{eOJQJ$DmEmFmGmHmImJmKmLmMmNmOmPmQmRmSmTmUmVmWmXmYmZm[m\m]mjmkmmgd#$a$gd{mmmm)nknnno-pppppppqq#qcqqqqq]gd# & F]gd#^gd# hh^h`hgd# & Fgd#gd#mmmmmmmmmmmmn n nnEnYnnnunwnnnnnnoo,pppqqq.rrrrø~vkvv`v`vh0Xh#CJaJhv@h#CJaJh#CJaJhh#CJaJ#h=h#56B* CJaJphh=h#56CJaJh=h#B* CJaJphh=h#CJaJ2h=h#5>*B* CJOJQJ\^JaJphh=h#5>*CJ\aJ&h=h#5>*B* CJ\aJph%qqqqq2rhrrrrrrrrrrrrrrrrrrrrrgd$a$gd{ & Fgd#]gd#rrrrrrrrrrrrrrrrrrrrrrss s svs~ssssssssssssμymyymycjh4M0JUh=CJOJQJaJhf&CJOJQJaJ!hqCJOJQJaJmHnHu%jh Uhf&CJOJQJUaJh Uhf&CJOJQJaJhf&#hf&B*CJOJQJ^JaJphfffh98jh98Uh / h#CJ OJQJ^Jh#CJ OJQJ^Jhv@h#CJaJ&rrrrrrrrrr svss $Ifgd$If$a$gdcgd ssssssrllcc $Ifgdh$Ifkd$$Ifl4,F< ``06    4 layt Ussssssssss7trmkkiikak\gdtv $a$gd Agd Ukd$$Ifl4F<  06    4 layt U sssssssssssss6t7t8tettttttuu u1u2uTuUuVuiujukuРۘ}nnbShP8hf&CJOJQJaJhf&CJOJQJaJh,~hf&CJOJQJaJhf&CJOJQJaJh!;hf&CJOJQJaJhf&OJQJ'h / hf&CJOJQJaJmHnHuhf&OJQJmHnHujh / hf&OJQJUh / hf&OJQJhf&h9Bhf&5OJQJhf&5OJQJh98h4Mhs 7t8tetttttuu uu1u2u9uBuUuVujukuuuuuuuuuuugd<$a$gd<kuuuuuuuuuuuuuuuuuuvU_ik !"/019:;̼̓̓th!;hf&OJQJhf&OJQJhhf&5OJQJhhf&5OJQJhf&CJOJQJaJhZhf&CJOJQJaJUhZhf&5CJOJQJaJhEhf&5>*OJQJh!;hf&5OJQJhf&h9Bhf&5OJQJhf&5OJQJ-uui!"01:;KLgd%9? & Fgd<h^hgd$a$gd<gd<$a$gd< within one working day of referral. Seen on ward. Patient to remain under care of admitting clinician OP within 14 days of referral. REFERRAL OUTCOMES CUP Team/AO Review Local CUP Team Organise appropriate investigations Symptom control Inform patient Early discharge planning Non-malignant Refer on Confirmed CUP Specialist CUP MDT Referral to palliative care for ongoing supportive care consider at any point in patient pathway for symptom management ;JKL^_`ο滬h / h#CJ OJQJ^Jh98h,~hf&CJOJQJaJhf&CJOJQJaJhEhf&5OJQJhf&h9Bhf&5OJQJhf&5OJQJ L_`$a$gd{gd<gd$a$gd< 5 01h:p . A!"#$% $$If!vh#v@ :V l8 6`065@ 4ytTNDd  6  3 @$$If!vh#v=#v:V l t065=5ytT$$If!vh#v=#v:V l t065=5ytT$$If!vh#v=#v:V l t065=5ytT$$If!vh#v=#v:V l t065=5ytT$$Ifl!vh#v9#v:V l t06595alytx#$$Ifl!vh#v9#v:V l t06595alytx#$$Ifl!vh#v9#v:V l t06595alytx#$$Ifl!vh#v9#v:V l t06595alytx#$$Ifl!vh#v9#v:V l t06595alytx#$$If!vh#v#v#v:V l4,06++5554ayt U$$If!vh#v#v#v:V l406++5554ayt U^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH Z@Z  Heading 1$<@&5CJ KH OJQJ\^JaJ \@\  Heading 2$<@& 56CJOJQJ\]^JaJV@V WX Heading 3$<@&5CJOJQJ\^JaJDA D Default Paragraph FontRi@R  Table Normal4 l4a (k (No List 8"@8 dCaption5CJ\aJjj q|6 Table Grid7:V04@4 Header  B#6o!6  Header CharCJaJ4 @24 Footer  B#6oA6  Footer CharCJaJH@RH 6 Balloon TextCJOJQJ^JaJNoaN 6Balloon Text CharCJOJQJ^JaJ4U`q4 } Hyperlink >*phB'`B CComment ReferenceCJaJ<@< C Comment TextCJaJ:: CComment Text Char@j@@ CComment Subject5\FoF CComment Subject Char5\D`D4M0RevisionCJ_HaJmH sH tH PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] x Ir#3bq{l$H(),./1257;@ILx Ir#3bq{ Creak, Antonia!>lCAv ruG"l ##a $+6P=AIGVY\G_imrsku;;>?ACEFHMOPQSW\]_bdhjm! L&$-h-./>;GUDY}YYZZ[B_Dmmqrss7tuL<=@BDGIJKLNRTUVXYZ[^`acefgikn $$!$l T_ T(/16AD!.0 @ AN@H 0(  @M<(   k+m8 3  "0?`  c $X99?k+m8b  # 3"`?4k+)P   "`&#(P   "`&R(b  # 3"`?R*k+m8\    3"`?,X.b   # 3"`?Rk+P    "`(h\    3"`? O  \   3"`?TO j \   3"`?!@ 2( P   "` p' n  C "`A %'  P   "`X 9 n  C "`&A%( z  C 3"`?&$"q*n' z  C 3"`?q*%/ z  C 3"`?<!' z  C 3"`? @ /  z  C  3"`?+.  n  C  "`|&%)  n  C  "`  P   "`%%fB  s *DjJ fB B s *DjJ $fB ! s *DjJ1 v#wfB " s *DjJ%fB #B s *DjJ] 9 (&zB % s *DjJ#" ?(/zB &B s *DjJ#" ?(+z ( C  (3"`?1 j   z ) C  )3"`?g!" (   zB * s *DjJ#" ?  zB +B s *DjJ#" ? , S ,S"`a : P -  "`'&C*7 . C .c"$`?% ~  / C /c"$`? *, zB 0B s *DjJ#" ?2`5n 1 C 1"`w% n 2 C 2"`  \ 4  3"`? '"(z 5 C 53"`?&:) \ 6  3"`?a ,"-z 7 C 73"`?$,- zB 8B s *DjJ#" ?(,zB 9 s *DjJ#" ?9 &\ :  3"`?/#1z ; C ;3"`?/#Q1 zB = s *DjJ#" ?!!R&&\ ?  3"`?`5$7 @ S @3"`?&)0*4 B AB 6DjJ#" ?#'''B BB 6DjJ#" ?#0'0B CB 6DjJ#" ?$6'6zB DB s *DjJ#" ? 9 &P K  "`&$BX*!n I C I"`#*! z L C L3"`?%  zB MB s *DjJ#" ?R''h $ C $#" `? t H s *"? B S  ?l$*/2tH2#3t#2t v >g!>g!._cz~ ''e,q,:/B/337799=:K:>>??@@AAAAjB}BBBC'CD"DIHJHJJKK(L,LV%VVVVVVVVWW#W0W5WWWWWWWWWWWWWXXiXrXvX}XXXXXXXYYZ&ZBZIZr\|\\\c]g]l]p]]]^^^"^2^7^^^______O`Y`Pa]asaza~aaaaeeggggggggggggggggg hhhhhhhiill /9 U\!! ''??@@hAnADDEExJJJJZU\UVVVVWWqYtYZZZZ[[[[\\R]V]^^__5`7```bbFdKdggggggggghhhhhiij&k'k4kikkllll3333333333333333333333333333333333333qq\ ? !"-"5"@"""" $"$e%f%j%m%..//00;2<2030373Z3[3\3]3]3j3j3o3v3w333Y4[4[4d4o46666660:0:>>!>JJJJJKKKKKKTLTLdLeLoLpLLLQQQQSSffgggggggggg hhhhh8iiiiiiiijjj j j1j1j2j2jUjUjVjYjjjjjkjkjjjjjjjjjjjjjjjjjjjjjjjUk_kkkkkkkkkkkkkkkkkkkkk!l!l"l"l0l0l1l1l9l9l:l:l;l;lKlKlLl^l_l`llllllllqq\ ? !"-"5"@"""" $"$e%f%j%m%..//00;2<2030373Z3[3\3]3]3j3j3o3v3w333Y4[4[4d4o46666660:0:>>!>JJJJJKKKKKKTLTLdLeLoLpLLLQQQQSSffgggggggggggg~hhhhhhijkkllllS& ,qj3 ,q/ ˨@IN Xd[8ltmy<X1x%&hG,( ,q~c42R58.g8Y;aW'C4pp'I ,q)JZRE9\L;XI*mPZ`BgQ ,qR,4S4BC\T$I\-:.R^ ,q|+,oXoa.ro"4gYp.%D!Rp>fȔ {|LiE(}N4z}Xh 7^7`o(hH.hS^S`5o(hH..h SS^S`o(hH...h SS^S`o(hH.... h  ^`o(hH ..... h  X@ ^ `Xo(hH ...... h  ^ `o(hH....... h 8x^`8o(hH........ h `H^``o(hH.........h 7^7`o(hH.hS^S`5o(hH..h SS^S`o(hH...h SS^S`o(hH.... h  ^`o(hH ..... h  X@ ^ `Xo(hH ...... h  ^ `o(hH....... h 8x^`8o(hH........ h `H^``o(hH.........h^`OJQJo(hHhp^p`OJQJ^Jo(hHoh@ ^@ `OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHhP^P`OJQJ^Jo(hHoh ^ `OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHhp^p`OJQJ^Jo(hHoh@ ^@ `OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHhP^P`OJQJ^Jo(hHoh ^ `OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohp^p`OJQJo(hHh@ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohP^P`OJQJo(hH88^8`OJPJQJ^Jo(-^`OJQJ^Jo(hHopp^p`OJQJo(hH@ @ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoPP^P`OJQJo(hH88^8`CJOJQJaJo(hH^`OJQJ^Jo(hHopp^p`OJQJo(hH@ @ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoPP^P`OJQJo(hH 7^7`o(hH.S^S`5o(hH.. SS^S`o(hH... SS^S`o(hH....  ^`o(hH .....  X@ ^ `Xo(hH ......  ^ `o(hH.......  8x^`8o(hH........  `H^``o(hH.........h^`OJQJo(hHhp^p`OJQJ^Jo(hHoh@ ^@ `OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHhP^P`OJQJ^Jo(hHoh ^ `OJQJo(hHh^`OJQJo(hH ^`hH. pp^p`hH. @ @ ^@ `hH. ^`hH. ^`hH. ^`hH. ^`hH. PP^P`hH.h^`OJQJo(hHhp^p`OJQJ^Jo(hHoh@ ^@ `OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHhP^P`OJQJ^Jo(hHoh ^ `OJQJo(hHh88^8`OJQJo(hH^`OJQJ^Jo(hHo  ^ `OJQJo(hH  ^ `OJQJo(hHxx^x`OJQJ^Jo(hHoHH^H`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH 7^7`o(hH.S^S`5o(hH.. SS^S`o(hH... SS^S`o(hH....  ^`o(hH .....  X@ ^ `Xo(hH ......  ^ `o(hH.......  8x^`8o(hH........  `H^``o(hH.........h^`OJQJo(hHh ^`o(hH.hpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHh ^`o(hH.hpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh88^8`OJQJo(hH^`OJQJ^Jo(hHo  ^ `OJQJo(hH  ^ `OJQJo(hHxx^x`OJQJ^Jo(hHoHH^H`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH 7^7`o(hH.S^S`5o(hH.. SS^S`o(hH... SS^S`o(hH....  ^`o(hH .....  X@ ^ `Xo(hH ......  ^ `o(hH.......  8x^`8o(hH........  `H^``o(hH.........h ^`hH.h ^`hH.h pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.h^`OJQJo(hHhp^p`OJQJ^Jo(hHoh@ ^@ `OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHhP^P`OJQJ^Jo(hHoh ^ `OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hH88^8`OJPJQJ^Jo(-^`OJQJ^Jo(hHo  ^ `OJQJo(hH  ^ `OJQJo(hHxx^x`OJQJ^Jo(hHoHH^H`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH 7^7`o(hH.S^S`5o(hH.. SS^S`o(hH... SS^S`o(hH....  ^`o(hH .....  X@ ^ `Xo(hH ......  ^ `o(hH.......  8x^`8o(hH........  `H^``o(hH.........^`o(. o^o`hH. ? L^? `LhH.  ^ `hH. ^`hH. L^`LhH. ^`hH. O^O`hH. L^`LhH.h^`OJQJo(hHhp^p`OJQJ^Jo(hHoh@ ^@ `OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHhP^P`OJQJ^Jo(hHoh ^ `OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hH^`^J.^`^J.pL^p`L^J.@ ^@ `o(.^`^J.L^`L^J.^`^J.^`^J.PL^P`L^J.h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hH88^8`OJPJQJ^Jo(-^`OJQJ^Jo(hHopp^p`OJQJo(hH@ @ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoPP^P`OJQJo(hHI\!Rpz}1x%yW'C*mP)JS&E9\LRG,(.R^p'Ij3BgQIN gYpBC\iE(}Y;4S|+,o[8~c4/a.ro {58                                             Ne        u`                                                                                Ne        h                             ֞                        ]uYEI i:+3.uYER sM LJLqJqR sMI i:E=![LqJq]u+3.u|z LJ(7|z{uJb}7n(( / 2 9 2 tv G Y^ .x#uh7C,#m%f&YQ'#Z+<-u-+08I2~u56/6q|6 <J3<%9? A#+ACEH\tJ'L R U*EVsXZ']f]ec`mtbgj>IkLlnop qqqWq2 svyz,~;DLo9 \EWXY1Ylc+sss/x#hTN/P8X]HTB~=lbJ98uFgFhN(fBW(Mj S&<dq-B@?4M8 3w1<PLA{{eK -gaH9:8;N Ngg@X"#$./kl@*,\@8t@@Unknown G.[x Times New Roman5Symbol3. .[x Arial7..{$ Calibri?OptimaLTStd5. .[`)Tahoma?= .Cx Courier New;WingdingsA$BCambria Math"1h[yg[ygEG}IX5}IX524gg 3qHX ?+2!xx >C:\Users\Richard\Work Folder\Acute Oncology\MUO Guidelines.dot!Clatterbridge Centre for OncologyRichardBurgoyne, Kevin                         Oh+'0p   , 8 DPX`h$Clatterbridge Centre for OncologyRichardMUO GuidelinesBurgoyne, Kevin2Microsoft Office Word@^в@~n @qh@qh}IX՜.+,0  hp  WHIS5g "Clatterbridge Centre for Oncology Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnoqrstuvwyz{|}~Root Entry F hData p1TablexWordDocument 7SummaryInformation(DocumentSummaryInformation8MsoDataStoreh h5CLUGF5PNNA==2h hItem  PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q