• Royal College of Pathologists minimum datasets for NMSC should be adhered to in order to improve patient care and help work-force planning in pathology departments. (G)

• Tumour depth is of critical importance in identifying high-risk cutaneous squamous cell carcinoma (cSCC), and should be reported in all cases. (R)

• Appropriate imaging to determine the extent of primary NMSC is indicated when peri-neural involvement or bony invasion is suspected. (R)

• In the clinically N0 neck, radiological imaging is not beneficial, and a policy of watchful waiting and patient education can be adopted. (R)

• Patients with high-risk NMSC should be treated by members of a skin cancer multidisciplinary team (MDT) in secondary care. (G)

• Non-infiltrative basal cell carcinoma (BCC) <2 cm in size should be excised with a margin of 4–5 mm. Smaller margins (2–3 mm) may be taken in sites where reconstructive options are limited, when reconstruction should be delayed. (R)

• Where there is a high risk of recurrence, delayed reconstruction or Mohs micrographic surgery should be used. (R)

• Surgical excision of low-risk cSCC with a margin of 4 mm or greater is the treatment of choice. (R)

• High-risk cSCC should be excised with a margin of 6 mm or greater. (R).

• Mohs micrographic surgery has a role in some high-risk cSCC cases following MDT discussion. (R)

• Delayed reconstruction should be used in high-risk cSCC. (G)

• Intra-operative conventional frozen section in cSCC is not recommended. (G)

• Radiotherapy (RT) is an effective therapy for primary BCC and cSCC. (R)

• Re-excision should be carried out for incompletely excised high-risk BCC or where there is deep margin involvement. (R)

• Incompletely excised high-risk cSCC should be re-excised. (R)

• Further surgery should involve confirmed marginal clearance before reconstruction. (R)

• P+ N0 disease: Resection should include involved parotid tissue, combined with levels I–III neck dissection, to include the external jugular node. (R)

• P+ N+ disease: Resection should include level V if that level is clinically or radiologically involved. (R)

• Adjuvant RT should include level V if not dissected. (R)

• P0 N+ disease: Anterior neck disease should be managed with levels I–IV neck dissection to include the external jugular node. (R)

• P0 N+ posterior echelon nodal disease (i.e. occipital or post-auricular) should undergo dissection of levels II–V, with sparing of level I. (R)

• Consider treatment of the ipsilateral parotid if the primary site is the anterior scalp, temple or forehead. (R)

• All patients should receive education in self-examination and skin cancer prevention measures. (G)

• Patients who have had a single completely excised BCC or low-risk cSCC can be discharged after a single post-operative visit. (G)

• Patients with an excised high-risk cSCC should be reviewed three to six monthly for two years, with further annual review depending upon clinical risk. (G)

• Those with recurrent or multiple BCCs should be offered annual review. (G)

• Comorbidity data should be collected as it is important in the analysis of survival, quality of life and functional outcomes after treatment as well as for comparing results of different treatment regimens and different centres. (R)

• Patients with hypertension of over 180/110 or associated target organ damage, should have antihypertensive medication started pre-operatively as per British Hypertension Society guidelines. (R)

• Rapidly correcting pre-operative hypertension with beta blockade appears to cause higher mortality due to stroke and hypotension and should not be used. (R)

• Patients with poorly controlled or unstable ischaemic heart disease should be referred for cardiology assessment pre-operatively. (G)

• Patients within one year of drug eluting stents should be discussed with the cardiologist who was responsible for their percutaneous coronary intervention pre-operatively with regard to cessation of antiplatelet medication due to risk of stent thrombosis. (G)

• Patients with multiple recent stents should be managed in a centre with access to interventional cardiology. (G)

• Surgery after myocardial infarction should be delayed if possible to reduce mortality risk. (R)

• Patients with critical aortic stenosis (AS) should be considered for pre-operative intervention. (G)

• Clopidogrel should be discontinued 7 days pre-operatively; warfarin should be discontinued 5 days pre-operatively. (R)

• Patients with thromboembolic disease or artificial heart valves require heparin therapy to bridge peri-operative warfarin cessation, this should start 2 days after last warfarin dose. (R)

• Cardiac drugs other than angotensin-converting enzyme inhibitors and angiotensin II antagonists should be continued including on the day of surgery. (R)

• Angotensin-converting enzyme inhibitors and angiotensin II antagonists should be withheld on the day of surgery unless they are for the treatment of heart failure. (R)

• Post-operative care in a critical care area should be considered for patients with heart failure or significant diastolic dysfunction. (R)

• Patients with respiratory disease should have their peri-operative respiratory failure risk assessed and critical care booked accordingly. (G)

• Patients with severe lung disease should be assessed for right heart disease pre-operatively. (G)

• Patients with pulmonary hypertension and right heart failure will be at extraordinarily high risk and should have the need for surgery re-evaluated. (G)

• Perioperative glucose readings should be kept within 4–12 mmol/l. (R)

• Patients with a high HbA1C facing urgent surgery should have their diabetes management assessed by a diabetes specialist. (G)

• Insulin-dependent diabetic patients must not omit insulin for more than one missed meal and will therefore require an insulin replacement regime. (R)

• Patients taking more than 5 mg of prednisolone daily should have steroid replacement in the peri-operative period. (R)

• Consider proton pump therapy for patients taking steroids in the peri-operative phase if they fit higher risk criteria. (R)

• Surgery within three months of stroke carries high risk of further stroke and should be delayed if possible. (R)

• Patients with rheumatoid arthritis should have flexion/extension views assessed by a senior radiologist pre-operatively. (R)

• Patients at risk of post-operative cognitive dysfunction and delirium should be highlighted at pre-operative assessment. (G)

• Patients with Parkinson's disease (PD) must have enteral access so drugs can be given intra-operatively. Liaison with a specialist in PD is essential. (R)

• Intravenous iron should be considered for anaemia in the urgent head and neck cancer patient. (G)

• Preoperative blood transfusion should be avoided where possible. (R)

• Where pre-operative transfusion is essential it should be completed 24–48 hours pre-operatively. (R)

• An accurate alcohol intake assessment should be completed for all patients. (G)

• Patients considered to have a high level of alcohol dependency should be considered for active in-patient withdrawal at least 48 hours pre-operatively in liaison with relevant specialists. (R)

• Parenteral B vitamins should be given routinely on admission to alcohol-dependent patients. (R)

• Smoking cessation, commenced preferably six weeks before surgery, decreases the incidence of post-operative complications. (R)

• Antibiotics are necessary for clean-contaminated head and neck surgery, but unnecessary for clean surgery. (R)

• Antibiotics should be administered up to 60 minutes before skin incision, as close to the time of incision as possible. (R)

• Antibiotic regimes longer than 24 hours have no additional benefit in clean-contaminated head and neck surgery. (R)

• Repeat intra-operative antibiotic dosing should be considered for longer surgeries or where there is major blood loss. (R)

• Local antibiotic policies should be developed and adhered to due to local resistance patterns. (G)

• Individual assessment for venous thromboembolism (VTE) risk and bleeding risk should occur on admission and be reassessed throughout the patients' stay. (G)

• Mechanical prophylaxis for VTE is recommended for all patients with one or more risk factors for VTE. (R)

• Patients with additional risk factors of VTE and low bleeding risk should have low molecular weight heparin at prophylactic dose or unfractionated heparin if they have severe renal impairment. (R)

• • Recent evidence synthesis from National Institute for Health and Care Excellence suggests that the following brief interventions for smoking cessation work should be used:

  • ○ Ask smokers how interested they are in quitting (R)

  • ○ If they want to stop, refer them to an intensive support service such as National Health Service Stop Smoking Services (R)

  • ○ If they are unwilling or unable to accept a referral, offer a stop smoking aid, e.g. pharmacotherapy. (R)

• • Brief interventions are effective for hazardous and harmful drinking. (R)

• • Specialist interventions are effective in people with alcohol dependence. (R)

• • Most people with alcohol dependence can undergo medically assisted withdrawal safely at home, after risk assessment. (R)

• • Management of leukoplakia is not informed by high-level evidence but consensus supports targeted use of biopsy and histopathological assessment. (R)

• • The management of biopsy proven dysplastic lesions favours:

  • ○ advice to reduce known environmental carcinogens such as tobacco and alcohol (R)

  • ○ surgical excision when the size of the lesions and the patient's function allows (R)

  • ○ long-term surveillance. (R)

• • Fanconi anaemia patients should:

  • ○ be followed up in a multidisciplinary specialist Fanconi anaemia clinic (G)

  • ○ have quarterly screening for head and neck squamous cell carcinoma and an aggressive biopsy policy (G)

  • ○ receive prophylactic vaccination against high risk human papilloma virus (G)

  • ○ receive treatment for head and neck squamous cell carcinoma with surgery alone where possible. (G)

• All cancer patients should meet a clinical nurse specialist at the point of diagnosis. (R)

• Clinical nurse specialists must act as gate keeper to the patients' cancer pathway to provide a seamless journey. (R)

• Holistic needs assessment should be completed at different stages of the patient's pathway to reflect the changes of the patients' needs. (R)

• Clinical nurse specialists to be part of local and national initiatives for health promotion and raising awareness in the public domain. (G)

• Clinical nurse specialists should lead in redesigning of services and policies to ensure they are responsive to patient's needs for the future. (G)

• Treatment summaries should become part of practice to provide good communication between primary and secondary care to enable continuity of care for the patient. (G)

• Audit of information supplied to patients and carers should be conducted on an annual basis to update and review content and media presentation. (G)

• Patients and carers should be invited to discuss treatment options and relate possible outcomes to functional retention or loss to provide a patient-centred approach. (G)

• Clinical staff should inspect their systems of assessment to make them sensitive enough to identify patients with psychological difficulties. (G)

• Flexibility, rather than rigid formulation is required to assess patients frequently, and to allow for change in circumstances to be noted. (G)

• Multidisciplinary teams should determine the supportive care services available and commission extra assistance to provide patients and carers with timely information, education or brief supportive advice. (G)

• Multidisciplinary teams need to inspect specialist services for mental health interventions at structured and complex levels for the small proportion of patients with more serious, but rarer, psychological difficulties. (G)

• Clinical staff at all levels should receive communication skills training to raise and maintain consultation expertise with difficult patient and/or carer interactions. (G)

• All patients with more than one of: chronic otalgia, bloody otorrhoea, bleeding, mass, facial swelling or palsy should be biopsied. (R)

• Magnetic resonance and computed tomography imaging should be performed. (R)

• Patients should undergo audiological assessment. (R)

• Carotid angiography is recommended in select patients. (G)

• The modified Pittsburg T-staging system is recommended. (G)

• The minimum operation for cancer involving the temporal bone is a lateral temporal bone resection. (R)

• Facial nerve rehabilitation should be initiated at primary surgery. (G)

• Anterolateral thigh free flap is the workhorse flap for lateral skull base defect reconstruction. (G)

• For patients undergoing surgery for squamous cell carcinoma, at least a superficial parotidectomy and selective neck dissection should be carried out. (R)

• Cross-sectional imaging with computed tomography of the head, neck and chest is necessary for all patients; magnetic resonance imaging of the primary site is useful particularly in advanced disease; and computed tomography and positron emission tomography to look for distant disease. (R)

• Careful evaluation of the upper and lower extents of the disease is necessary, which may require contrast swallow or computed tomography and positron emission tomography imaging. (R)

• Formal rigid endoscopic assessment under general anaesthetic should be performed. (R)

• Nutritional status should be proactively managed. (R)

• Full and unbiased discussion of treatment options should take place to allow informed patient choice. (G)

• Early stage disease can be treated equally effectively with surgery or radiotherapy. (R)

• Endoscopic resection can be considered for early well localised lesions. (R)

• Bulky advanced tumours require circumferential or non-circumferential resection with wide margins to account for submucosal spread. (R)

• Offer primary surgical treatment in the setting of a compromised larynx or significant dysphagia. (R)

• Midline lesions require bilateral neck dissections. (R)

• Consider management of silent nodal areas usually not addressed for other primary sites. (G)

• Reconstruction needs to be individualised to the patients’ needs and based on the experience of the unit with different reconstructive techniques. (G)

• Consider tumour bulk reduction with induction chemotherapy prior to definitive radiotherapy. (R)

• Consider intensity modulated radiation therapy where possible to limit the consequences of wide field irradiation to a large volume. (R)

• Use concomitant chemotherapy in patients who are fit enough and consider epidermal growth factor receptor blockers for those who are less fit. (R)

• Ultrasound scanning (USS) of the nodule or goitre is a crucial investigation in guiding the need for fine needle aspiration cytology (FNAC). (R)

• FNAC should be considered for all nodules with suspicious ultrasound features (U3–U5). If a nodule is smaller than 10 mm in diameter, USS guided FNAC is not recommended unless clinically suspicious lymph nodes on USS are also present. (R)

• Cytological analysis and categorisation should be reported according to the current British Thyroid Association Guidance. (R)

• Ultrasound scanning assessment of cervical nodes should be done in FNAC-proven cancer. (R)

• Magnetic resonance imaging (MRI) or computed tomography (CT) should be done in suspected cases of retrosternal extension, fixed tumours (local invasion with or without vocal cord paralysis) or when haemoptysis is reported. When CT with contrast is used pre-operatively, there should be a two-month delay between the use of iodinated contrast media and subsequent radioactive iodine (I131) therapy. (R)

• Fluoro-deoxy-glucose positron emission tomography imaging is not recommended for routine evaluation. (G)

• In patients with thyroid cancer, assessment of extrathyroidal extension and lymph node disease in the central and lateral neck compartments should be undertaken pre-operatively by USS and cross-sectional imaging (CT or MRI) if indicated. (R)

• For patients with Thy 3f or Thy 4 FNAC a diagnostic hemithyroidectomy is recommended. (R)

• Total thyroidectomy is recommended for patients with tumours greater than 4 cm in diameter or tumours of any size in association with any of the following characteristics: multifocal disease, bilateral disease, extrathyroidal spread (pT3 and pT4a), familial disease and those with clinically or radiologically involved nodes and/or distant metastases. (R)

• Subtotal thyroidectomy should not be used in the management of thyroid cancer. (G)

• Central compartment neck dissection is not routinely recommended for patients with papillary thyroid cancer without clinical or radiological evidence of lymph node involvement, provided they meet all of the following criteria: classical type papillary thyroid cancer, patient less than 45 years old, unifocal tumour, less than 4 cm, no extrathyroidal extension on ultrasound. (R)

• Patients with metastases in the lateral compartment should undergo therapeutic lateral and central compartment neck dissection. (R)

• Patients with follicular cancer with greater than 4 cm tumours should be treated with total thyroidectomy. (R)

• I131 ablation should be carried out only in centres with appropriate facilities. (R)

• Serum thyroglobulin (Tg) should be checked in all post-operative patients with differentiated thyroid cancer (DTC), but not sooner than six weeks after surgery. (R)

• Patients who have undergone total or near total thyroidectomy should be started on levothyroxine 2 µg per kg or liothyronine 20 mcg tds after surgery. (R)

• The majority of patients with a tumour more than 1 cm in diameter, who have undergone total or near-total thyroidectomy, should have I131 ablation. (R)

• A post-ablation scan should be performed 3–10 days after I131 ablation. (R)

• Post-therapy dynamic risk stratification at 9–12 months is used to guide further management. (G)

• Potentially resectable recurrent or persistent disease should be managed with surgery whenever possible. (R)

• Distant metastases and sites not amenable to surgery which are iodine avid should be treated with I131 therapy. (R)

• Long-term follow-up for patients with differentiated thyroid cancer (DTC) is recommended. (G)

• Follow-up should be based on clinical examination, serum Tg and thyroid-stimulating hormone assessments. (R)

• Patients with suspected medullary thyroid cancer (MTC) should be investigated with calcitonin and carcino-embryonic antigen levels (CEA), 24 hour catecholamine and nor metanephrine urine estimation (or plasma free nor metanephrine estimation), serum calcium and parathyroid hormone. (R)

• Relevant imaging studies are advisable to guide the extent of surgery. (R)

• RET (Proto-oncogene tyrosine-protein kinase receptor) proto-oncogene analysis should be performed after surgery. (R)

• All patients with known or suspected MTC should have serum calcitonin and biochemical screening for phaeochromocytoma pre-operatively. (R)

• All patients with proven MTC greater than 5 mm should undergo total thyroidectomy and central compartment neck dissection. (R)

• Patients with MTC with lateral nodal involvement should undergo selective neck dissection (IIa–Vb). (R)

• Patients with MTC with central node metastases should undergo ipsilateral prophylactic lateral node dissection. (R)

• Prophylactic thyroidectomy should be offered to RET-positive family members. (R)

• All patients with proven MTC should have genetic screening. (R)

• Radiotherapy may be useful in controlling local symptoms in patients with inoperable disease. (R)

• Chemotherapy with tyrosine kinase inhibitors may help in controlling local symptoms. (R)

• For individuals with anaplastic thyroid carcinoma, initial assessment should focus on identifying the small proportion of patients with localised disease and good performance status, which may benefit from surgical resection and other adjuvant therapies. (G)

• The surgical intent should be gross tumour resection and not merely an attempt at debulking. (G)

• Preventative oral care must be delivered to patients whose cancer treatment will affect the oral cavity, jaws, salivary glands and oral accessibility. (G)

• Close working and communication between the surgeons, oncologists and restorative dental specialists is important in ensuring optimal oral health outcomes. (G)

• Intensity-modulated radiotherapy has been shown to reduce long-term xerostomia and should be offered to all appropriate patients. (R)

• If patients are deemed at risk of trismus they should be warned and its progressive and potentially irreversible nature explained. (G)

• Where it is known that adjuvant radiotherapy will be given, extractions should take place at primary surgery to maximise the time for healing and minimise the number of surgical events for patients. (G)

• Osseointegrated implants should be considered for all patients having resection for head and neck cancer. (G)

• Radiotherapy (RT) and transoral laser microsurgery (TLM) are accepted treatment options for T1a–T2a glottic carcinoma. (R)

• Open partial surgery may have a role in the management of selected tumours. (R)

• Radiotherapy, TLM and transoral robotic surgery are reasonable treatment options for T1–T2 supraglottic carcinoma. (R)

• Supraglottic laryngectomy may have a role in the management of selected tumours. (R)

• Most patients with T2b–T3 glottic cancers are suitable for non-surgical larynx preservation therapies. (R)

• Concurrent chemoradiotherapy should be regarded as the standard of care for non-surgical management. (R)

• Subject to the availability of appropriate surgical expertise and multi-disciplinary rehabilitation services, TLM or open partial surgical procedures ± post-operative RT, may be also be appropriate in selected cases. (R)

• In the absence of clinical or radiological evidence of nodal disease, elective treatment (RT or surgery ± post-operative RT) is recommended to at least lymph node levels II, III and IV bilaterally. In node positive disease, it is recommended that lymph node levels II–V should be treated on the involved side. If level II nodes are involved, then elective irradiation of ipsilateral level Ib nodes may be considered. (R)

• Most patients with T3 supraglottic cancers are suitable for non-surgical larynx preservation therapies. (R)

• Concurrent chemoradiotherapy should be regarded as the standard of care for non-surgical management. (R)

• Subject to the availability of appropriate surgical expertise and multi-disciplinary rehabilitation services, TLM or open partial surgical procedures ± post-operative RT, may also be appropriate in selected cases. (R)

• In the absence of clinical or radiological evidence of nodal disease, elective treatment (RT or surgery ± post-operative RT) is recommended to at least lymph node levels II, III and IV bilaterally. In node positive disease, lymph node levels II–V should be treated on the involved side. (R)

• As per the PET-Neck clinical trial, patients with N2 or N3 neck disease who undergo treatment with chemoradiotherapy to their laryngeal primary and experience a complete response with a subsequent negative post-treatment positron emission tomography combined with computed tomography (PET–CT) scan do not require an elective neck dissection. In contrast, patients who have a partial response to treatment or have increased uptake on a post-treatment PET–CT scan should have a neck dissection. (R)

• Larynx preservation with concurrent chemoradiotherapy should be considered for T4 tumours, unless there is tumour invasion through cartilage into the soft tissues of the neck, in which case total laryngectomy yields better outcomes. (R)

• In the absence of clinical or radiological evidence of nodal disease, elective treatment (RT or surgery ± post-operative RT) is recommended to bilateral lymph node levels II, III, IV, V and VI. (R)

• A specialist dietitian should be part of the multidisciplinary team for treating head and neck cancer patients throughout the continuum of care as frequent dietetic contact has been shown to have enhanced outcomes. (R)

• Patients with head and neck cancer should be nutritionally screened using a validated screening tool at diagnosis and then repeated at intervals through each stage of treatment. (R)

• Patients at high risk should be referred to the dietitian for early intervention. (R)

• Offer treatment for malnutrition and appropriate nutrition support without delay given the adverse impact on clinical, patient reported and financial outcomes. (R)

• Use a validated nutrition assessment tool (e.g. scored Patient Generated–Subjective Global Assessment or Subjective Global Assessment) to assess nutritional status. (R)

• Offer pre-treatment assessment prior to any treatment as intervention aims to improve, maintain or reduce decline in nutritional status of head and neck cancer patients who have malnutrition or are at risk of malnutrition. (G)

• Patients identified as well-nourished at baseline but whose treatment may impact on their future nutritional status should receive dietetic assessment and intervention at any stage of the pathway. (G)

• Aim for energy intakes of at least 30 kcal/kg/day. As energy requirements may be elevated post-operatively, monitor weight and adjust intake as required. (R)

• Aim for energy and protein intakes of at least 30 kcal/kg/day and 1.2 g protein/kg/day in patients receiving radiotherapy or chemoradiotherapy. Patients should have their weight and nutritional intake monitored regularly to determine whether their energy requirements are being met. (R)

• Perform nutritional assessment of cancer patients frequently. (G)

• Initiate nutritional intervention early when deficits are detected. (G)

• Integrate measures to modulate cancer cachexia changes into the nutritional management. (G)

• Start nutritional therapy if undernutrition already exists or if it is anticipated that the patient will be unable to eat for more than 7 days. Enteral nutrition should also be started if an inadequate food intake (60 per cent of estimated energy expenditure) is anticipated for more than 10 days. (R)

• Use standard polymeric feed. (G)

• Consider gastrostomy insertion if long-term tube feeding is necessary (greater than four weeks). (R)

• Monitor nutritional parameters regularly throughout the patient's cancer journey. (G)

• Pre-operative:

○ Patients with severe nutritional risk should receive nutrition support for 10–14 days prior to major surgery even if surgery has to be delayed. (R)

○ Consider carbohydrate loading in patients undergoing head and neck surgery. (R)

• Post-operative:

○ Initiate tube feeding within 24 hours of surgery. (R)

○ Consider early oral feeding after primary laryngectomy. (R)

• Chyle Leak:

○ Confirm chyle leak by analysis of drainage fluid for triglycerides and chylomicrons. (R)

○ Commence nutritional intervention with fat free or medium chain triglyceride nutritional supplements either orally or via a feeding tube. (R)

○ Consider parenteral nutrition in severe cases when drainage volume is consistently high. (G)

• Weekly dietetic intervention is offered for all patients undergoing radiotherapy treatment to prevent weight loss, increase intake and reduce treatments interruptions. (R)

• Offer prophylactic tube feeding as part of locally agreed guidelines, where oral nutrition is inadequate. (R)

• Offer nutritional intervention (dietary counselling and/or supplements) for up to three months after treatment. (R)

• Patients who have completed their rehabilitation and are disease free should be offered healthy eating advice as part of a health and wellbeing clinic. (G)

• Quality of life parameters including nutritional and swallowing, should be measured at diagnosis and at regular intervals post-treatment. (G)

• Microsurgical free flap reconstruction should be the primary reconstructive option for most defects of the head and neck that need tissue transfer. (R)

• Free flaps should be offered as first choice of reconstruction for all patients needing circumferential pharyngoesophageal reconstruction. (R)

• Free flap reconstruction should be offered for patients with class III or higher defects of the maxilla. (R)

• Composite free tissue transfer should be offered as first choice to all patients needing mandibular reconstruction. (R)

• Patients undergoing salvage total laryngectomy should be offered vascularised flap reconstruction to reduce pharyngocutaneous fistula rates. (R)

• At-risk individuals should be warned about the correlation between ultraviolet radiation (UVR) exposure and skin cancer, and should be given advice on UVR protection. (R)

• Dermatoscopy can aid in the diagnosis of cutaneous melanoma. (R)

• Histological examination after biopsy is essential to confirm the diagnosis and the tumour thickness. (G)

• Excisional biopsy is method of choice. (G)

• Staging investigations can be performed for both regional and distant disease. (R)

• Scanning (computed tomography (CT) and/or magnetic resonance imaging) is recommended for patients with high-risk melanoma. (G)

• Patients with signs or symptoms of disease relapse should be investigated by imaging. (R)

• Imaging of the brain should be performed in patients who have stage IV disease. (G)

• Patients with melanoma of unknown primary should be thoroughly examined and investigated for a potential primary source. (R)

• Primary cutaneous invasive melanoma should be excised with a surgical margin of at least 1 cm. (G)

• The maximum recommended excision margin is 3 cm. (R)

• The actual margin of excision depends upon the depth of the melanoma and its anatomical site. (G)

• Ultrasound-guided fine needle aspiration (FNA) or core biopsy of suspected lymphadenopathy is more accurate than ‘blind’ biopsy. (R)

• Open biopsy should only be performed if FNA or core biopsy is inadequate or equivocal. (R)

• Prior to lymph node dissection, staging by CT scan should be carried out. (R)

• If parotid disease is present without neck involvement, both parotidectomy and neck dissection should ideally be performed. (R)

• There is no role for elective lymph node dissection. (R)

• Sentinel lymph node biopsy (SLNB) can be considered in stage IB and above by specialist skin cancer multidisciplinary teams. (G)

• Patients should be made aware that SLNB is a staging procedure, and should understand that it has, as yet, no proven therapeutic value. (R)

• All patients with cutaneous melanoma should have their original tumour checked for BRAF gene status, and their subsequent targeted biological therapy based on this. (R)

• Patients who develop brain metastases should be considered for stereotactic radio-surgery. (R)

• Offer appropriate radiological imaging, based on tumour extent, site and local expertise, to stage tumours and plan treatment for patients diagnosed with head and neck cancer. (G)

• Consider positron emission tomography combined with computed tomography (PET–CT) imaging if conventional cross-sectional imaging identifies no primary site. (R)

• Offer PET–CT imaging 12 weeks after non-surgical treatment to detect residual disease. (R)

• All theatre staff should participate in the World Health Organization checklist process. (R)

• Post-operative airway management should be guided by local protocols. (R)

• Patients admitted to post-operative care units with tracheal tubes in place should be monitored with continuous capnography. Removal for tracheal tubes is the responsibility of the anaesthetist. (R)

• Anaesthetists should formally hand over care to an appropriately trained practitioner in the post-operative or intensive care unit. (G)

• Intensive care unit staff looking after post-operative tracheostomies must be clear about which patients are not suitable for bag-mask ventilation and/or oral intubation in the event of emergencies. (R)

• • All patients presenting with confirmed cervical lymph node metastatic squamous cell carcinoma and no apparent primary site should undergo:

  • ○ Positron emission tomography-computed tomography whole-body scan. (R)

  • ○ Panendoscopy and directed biopsies. (R)

  • ○ Bilateral tonsillectomy. (R)

• • Tongue base mucosectomy can be offered if facilities and expertise exists. (G)

• • Concomitant chemotherapy with radiation should be considered in patients with an unknown primary. (R)

• • Concomitant chemotherapy with radiation should be offered to suitable patients in the post-operative setting, where indicated. (R)

• • Neo-adjuvant chemotherapy can be used in gross ‘unresectable’ disease. (R)

• • Patients should be followed up at least two months in the first two years and three to six months in the subsequent years. (G)

• • Patients should be followed up to a minimum of five years with a prolonged follow up for selected patients. (G)

• • Positron emission tomography–computed tomography scan at three to four months after treatment is a useful follow-up strategy for patients treated by chemoradiation therapy. (R)