Referral to emergency

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

    • unwell, acute breathlessness, rapidly enlarging abdominal distension, rapidly enlarging lymphadenopathy, distended veins/ venous congestion of upper chest or face suggestive of superior vena cava (SVC) obstruction
    • if lymphoma or other solid malignancy is considered likely, contact the on call Paediatric Haematology Oncology team for an urgent clinic review or refer to emergency; do not wait for, or do extensive blood work-up
    • all mediastinal masses

Please contact the on-call registrar to discuss your concerns prior to referral.

For clinical advice, please telephone the relevant specialty service.

Women's and Children's Health Network

Inclusions

  • lymphadenopathy, acute and chronic, not infectious in nature
  • suspected or confirmed lymphoma

Exclusions

  • incidental chest x-ray findings which may be more appropriately referred to respiratory
  • lymphadenopathy which is likely to be infectious in nature — refer to infectious diseases. An example of these includes rapidly growing solitary tender lymph node which may be red and associated with a fever

Triage categories

Category 1 (appointment clinically indicated within 30 days)

  • progressive enlargement of lymph nodes over weeks or months with no obvious cause, night sweats, unexplained weight loss, fevers, pruritus or increasing breathlessness over time.
  • single lymph node >2cm in diameter AND any of the following:
    • absence of a clear infectious cause
    • persistence of significantly enlarged nodes (>2cms diameter) for 6 weeks or more with no decrease in size
    • widespread distribution
    • abnormal consistency, firm or hard or non-mobile
    • absence of pain
  • supraclavicular lymph nodes, associated splenomegaly, night sweats, bone pain or limp or presence of mediastinal widening on chest radiograph.
  • progressive respiratory symptoms of unknown aetiology, with systemic symptoms such as fever, night sweats, loss of weight.

Although generally seen within 48 to 72 hours given urgency of most paediatric cancers.

Category 2 (appointment clinically indicated within 90 days)

  • chronic lymphadenopathy (> 6 weeks) of unknown cause and not meeting criteria listed in category 1

Category 3 (appointment clinically indicated within 365 days)

  • nil

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

  • family history
  • important psychosocial history or other barrier to accessing care
  • relevant medical history
  • history:
    • characteristics of lymph node including onset, size, duration, pain, and distribution
    • recent infections including sore throat, earache, rash
    • constitutional symptoms including fever, night sweats, weight loss
    • respiratory symptoms
  • blood results
    • complete blood examination (CBE)
    • liver function tests (LFTs)
    • lactate dehydrogenase (LDH)
    • electrolytes, urea, creatinine (EUC)
    • c-reactive protein (CRP)
    • calcium
    • phosphate
    • uric acid
  • serology
    • Epstein-Barr virus (EBV)
    • Cytomegalovirus (CMV)
  • examination
    • lymph node – size, site, colour, tender/non- tender, mobile, distribution, fluctuant, consistency
  • chest x-ray
  • results of all prior relevant investigations

Additional information to assist triage categorisation

  • ultrasound (US) or computed tomography (CT) scan if completed

Clinical management advice

In South Australia, cancer care for individuals aged <18 years is centralised to Women’s and Children’s Hospital

Enlarged lymph nodes are common and usually the result of inflammation or inflammatory processes.

Concern regarding possible malignancy warrants careful assessment and referral.

Lymph nodes < 2cm in diameter, reducing or fluctuating in size are unlikely to be associated with malignancy in the absence of other suspicious features

Please do not arrange for a fine needle aspirate (FNA) of any paediatric lymph node (because FNA lacks sensitivity and provides insufficient information for accurate histological diagnosis in lymphoma).

Please do not commence steroids even if respiratory compromise, unless discussed with the team prior. This can mask the diagnosis, lead to tumour lysis syndrome and compromise definitive diagnosis and treatment.

Reason for request

  • to establish a diagnosis
  • for treatment or intervention
  • for advice and management
  • for specialist to take over management
  • for a specified test/investigation the General Practitioner cannot order
  • for other reason (e.g. rapidly accelerating disease progression)
  • transfer of care from another tertiary service
  • clinical judgement indicates a referral for specialist review is necessary.

Patient demographic details

  • full name, including aliases
  • date of birth
  • residential and postal address
  • telephone contact number/s – home, mobile and alternative
  • Medicare number, where eligible
  • name of the parent or caregiver, if appropriate
  • preferred language and interpreter requirements
  • identifies as Aboriginal and/or Torres Strait Islander

Clinical modifiers

  • impact on employment
  • impact on education
  • impact on home
  • impact on activities of daily living
  • impact on ability to care for others
  • impact on personal frailty or safety
  • identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery, where surgery is a likely intervention.
  • Choice to be treated as a public or private patient.
  • Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
  • Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
  • Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  • Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
  • A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
  • All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.

Adolescents transitioning from paediatric to adult specialist services require a formal handover from paediatric specialist clinician to adult specialist clinician as well as a formal referral from the referring specialist to ensure initial transfer of care is completed.

The General Practitioners role in this process is to provide support to patients as part of holistic care. All ongoing referrals to specialists can subsequently be provided by the General Practitioner once the transfer of care has occurred.