1. Merseyside and Cheshire Cancer Network HEPATO BILIARY MULTIDISCIPLINIARY TEAM MEETING Referral to Specialist HPB (Liver) MDT, University Hospital, Aintree, with suspected Colorectal Liver Metastases PART 1: TO BE COMPLETED BY THE REFERRING UNIT. N.B. NO PATIENT WILL BE DISCUSSED WITHOUT FULL DETAILS Initial Referral Date / / Date Referred to UHA / / Referring Consultant Referring Hospital Referring Cancer Network SHA Forename Surname DOB GP NHS Number GP Tel.No PART 2: TO BE COMPLETED BY UHA Date of 1st MDT / / Number of Days on Pathway Presenting Consultant UHA 2 week rule Yes No Decision to Treat / / Treatment Start Date / / Initial colorectal cancer DateOperation performed Laparoscopic resection? Yes No TNM classification Tumour T0 T1 T2Node N0 N1 N2 Metastasis M0 M1 T3 T4 T5 MX Colon tumour localisation Right Transverse Left including sigmoid Rectum Chemotherapy post Number of cycles Drugs colectomy Yes No 5FU Yes No Oxaliplatin Yes No Irinotecan Yes No Other Yes No Name product …………………………….... Diagnosis of suspected Date Concomitant extra Synchronous Liver metastases hepatic disease Yes No Yes No Number Max size …………. mm Localisation: Unilateral Bilateral PLEASE ENCLOSE X-rays X-rays reportsPrimary cancerDetails of any co-morbidity WITH REFERRAL histology Date of last CEA CT/MR.……………. Date: …………….. Contact name and number Name Tel.No. FAX E-mail where Specialist HPB MDT can FAX the MDT decision back to referring team SEND PROFORMA WITH CT/MR AND X-RAY REPORTS TO: The Specialist HPB (Liver) UNIT, Room 19, GENERAL SURGERY, UNIVERSITY HOSPITAL AINTREE, LIVERPOOL, L9 7AL.TEL: 0151-529-8515 REFERRAL CANNOT BE ASSESSED WITHOUT CT/MR AND REPORTS / /

2. PART 3: TO BE COMPLETED BY UHA MDT Decision Potentially Resectable Mass Present Yes No Metastases Immediate Action Planning Ascites No action here Refer Back Vascular Yes Encasement Nodes Consultant Radiologists Dr Smethurst Dr White Dr O’Grady Dr Evans General Summary Further Investigation Date Booked Date Completed Days on Pathway Reason for Investigation CT MR CEA US EUS Other Date of 2nd MDT UHA Reason for Discussion General Summary Confirmed Diagnosis Treatment Outcome Resection Preoperative Chemotherapy Palliative Chemotherapy RFA OPD Admission Microwave Best Supportive / Palliative Care Trials Date of Recurrence /

3. Merseyside and Cheshire Cancer Network HEPATO BILIARY MULTIDISCIPLINIARY TEAM Referral to Specialist HPB (Liver) MDT, University Hospital, Aintree, with suspected primary liver cancer, including cholangiocarcinoma, gall bladder cancer PART 1: TO BE COMPLETED BY THE REFERRING UNIT. N.B. NO PATIENT WILL BE DISCUSSED WITHOUT FULL DETAILS Initial Referral Date / / Date Referred to UHA / / Referring Consultant Referring Hospital Forename Surname DOB Inpatient Outpatient Presenting Symptoms and Relevant History Bloods CLINICAL QUESTION ALK PHOS ALT CA19.9 AFP BILIRUBIN GGT CEA Histology (please include details of any relevant histology e.g. brushings). DO NOT BIOPSY LIVER LESIONS, REFER TO HPB SPECIALIST MDT FIRST ALL RELEVANT IMAGING (INCLUDING ERCP FILM) AND RADIOLOGISTS REPORTS ARE ENCLOSED WITH THIS REFERRAL PART 3: TO BE COMPLETED BY UHA SUMMARY OF MDT1 MDT Decision Potentially Resectable Mass Present Yes No Metastases Immediate Action Planning Ascites No action here Refer Back Vascular Yes Encasement Discussed by: Nodes Consultant Radiologists Dr Smethurst Dr White Dr O’Grady Dr Evans Contact Details of Referrer where MDT Decision can be faxed: Name:Fax:Tel No. SEND PROFORMA + REFERRAL LETTER WITH CT/MR/ERCP AND X-RAY REPORTS TO: The Specialist HPB (Liver) UNIT, Room 19, GENERAL SURGERY, UNIVERSITY HOSPITAL AINTREE, LIVERPOOL, L9 7ALTEL: 0151-529-8515 REFERRAL CANNOT BE ASSESSED WITHOUT CT/MR AND REPORTS PART 2: TO BE COMPLETED BY UHA Date of 1st MDT / / Number of Days on Pathway Presenting Consultant Yes No UHA GP 2 week rule Decision to Treat / / Treatment Start Date / / /

4. Further Investigation Date Booked Date Completed Days on Pathway Reason for Investigation CT US EUS EUS / FNA CT Biopsy US Biopsy OPD Admission Date of 2nd MDT UHA Reason for Discussion General Summary Confirmed Diagnosis Treatment Outcome Resection Neo/Adjuvant Chemotherapy Palliative Bypass Palliative Chemotherapy Photodynamic Therapy Chemoembolisation RFA Best Supportive / Palliative Care Trials Date of Recurrence / Resection Neo/Adjuvant Chemotherapy Palliative Bypass Palliative Chemotherapy Trials Date of Recurrence / Date of 3rd MDT UHA Reason for Discussion General Summary Confirmed Diagnosis Treatment Outcome