5 June 2017.
|
15
|
EMQ. Cervical cancer staging
|
|
16
|
EMQ. Parvovirus
|
|
17
|
SBA. Cowden syndrome
|
|
18
|
SBA. Caldicott guardian
|
|
19
|
EMQ. Borderline
ovarian tumours
|
|
20
|
Communication skills. Pre-pregnancy.
Brother has cystic fibrosis.
|
15. EMQ. Cervical cancer staging
This
question illustrates the problems surrounding staging. If you are not a cancer
specialist, it is not something that you think about very often, if ever. So
you have to put it into your list of things to revise in the days before the
exam. If you haven’t started this list, do so now.
Lead-in.
The following scenarios relate to cervical cancer staging.
For each, select the most appropriate staging.
Pick one option from the option list.
Each option can be used once, more than once or not at
all.
Option list.
Micro-invasive cervical cancer.
Stage Ia1
Stage Ia2
Stage Ia3
Stage Ib1
Stage Ib2
Stage Ib3
Stage IIa
Stage IIb
Stage IIc
Stage IIIa
Stage IIIb
Stage IIIc
Stage IVa
Stage IVb
Stage IVc
Stage Va
Stage Vb
Stage Vc
None of the above.
Scenario 1.
A woman of 25 has a cone
biopsy. The histology report shows squamous cell carcinoma penetrating to a
depth of 2 mm and 6 mm in width. The resection margins are tumour-free. There
is no evidence of spread outside the uterus. She is nulliparous and wishes to retain
her fertility.
Scenario 2.
A woman of 25 has a cone biopsy. The histology report
shows squamous cell carcinoma penetrating to a depth of 5 mm and 6 mm in width.
The resection margins are tumour-free. There is no evidence of spread outside
the uterus. She is nulliparous and wishes to retain her fertility.
Scenario 3.
A woman of 25 has a cone
biopsy. The histology report shows squamous cell carcinoma penetrating to a
depth of 5 mm and 6 mm in width. The resection margins are not tumour-free. There
is no evidence of spread outside the uterus. She is nulliparous and wishes to retain
her fertility.
Scenario 4.
A woman of 25 has a cone
biopsy. The histology report shows squamous cell carcinoma penetrating to a
depth of 6 mm and 3 cm in width. The resection margins are tumour-free. There
is no evidence of extension outside the uterus. She is nulliparous and wishes
to retain her fertility.
Scenario 5.
A woman of 25 has a cone
biopsy. The histology report shows squamous cell carcinoma penetrating to a
depth of 6 mm and 5 cm in width. The resection margins are tumour-free. She is
nulliparous and wishes to retain her fertility.
Scenario 6.
A woman of 38 has a cone
biopsy. The histology report shows squamous cell carcinoma penetrating to a
depth of 4 mm and 6mm in width. The resection margins are tumour-free. An MR
scan shows involvement of the lymphatic nodes in the left of the pelvis.
Scenario 7.
A woman of 45 has carcinoma of
the cervix. It extends into the parametrium, but not to the pelvic side-wall.
It involves the upper 1/3 of the vagina. There is MR evidence of para-aortic
node involvement.
Scenario 8.
A woman of 55 has carcinoma of
the cervix. It extends to the pelvic side-wall. It involves the upper 1/3 of
the vagina. She has a secondary on the end of her nose.
Scenario 9.
A woman of 55 has carcinoma of
the cervix. It involves the bladder mucosa.
Scenario 10.
A woman of 35 has a proven
cancer of the cervix with extension into the right parametrium, but not to the
pelvic side-wall. Left hydroureter and left non-functioning kidney are noted on
IVP and there is no other explanation for the findings. Cystoscopy shows
bullous oedema of the bladder mucosa.
Scenario 11.
A woman of 25 has a cone
biopsy. It shows malignant melanoma. The lesion invades to a depth of 3 mm and is
5 mm in width. The margins of the biopsy are clear. There is evidence of
lymphatic vessel involvement. There is no evidence of spread outside the
uterus.
16. EMQ.
Parvovirus
Lead-in.
The following scenarios relate to parvovirus infection
Abbreviations.
PvB19: parvovirus
B19
PvIgG: parvovirus B19 IgG
PvIgM: parvovirus B19 IgM
Option list.
There is none: make up your own
answers!
Scenario 1.
What type of virus is
parvovirus?
Scenario 2.
Is the title B19 something to do with the American B19
bomber, its potentially devastating bomb load and the comparably devastating
consequences of the parvovirus on human erythroid cell precursors?
Scenario 3.
PVB19 in the UK occurs in mini-epidemics at 3 – 4 year
intervals, usually during the summer months.
Scenario 4.
Which animal acts as the main
reservoir for infection?
Scenario 5.
What percentage of UK adults are immune to parvovirus
infection?
Scenario 6.
What names are given to acute
infection in the human?
Scenario 7.
What is the incubation period for parvovirus infection?
Scenario 8
What is the duration of infectivity for parvovirus
infection?
Scenario 9.
What are the usual symptoms of parvovirus infection in
the adult?
Scenario 10.
What is the incidence of parvovirus infection in
pregnancy?
Scenario 11.
How is recent infection diagnosed?
Scenario 12.
How long does PvIgM persist and why is this important?
Scenario 13.
What is the rate of vertical transmission of parvovirus
infection?
Scenario 14.
Are women with parvovirus infection who are asymptomatic
less likely to pass the virus to their fetuses?
Scenario 15.
To what degree is parvovirus infection teratogenic?
Scenario 16.
What proportion of pregnancies infected with parvovirus are
lost?
Scenario 17.
What is the timescale for the onset of hydrops?
Scenario 18.
Laboratories are advised to retain bloods obtained at
booking for at least 2 years for possible future reference. True or false?
Scenario 19.
What ultrasound features would trigger consideration of
cordocentesis?
Scenario 20.
Must suspected parvovirus infection be notified to the
authorities? Yes or No.
Scenario 21.
Possible parvovirus infection
does not need to be investigated after 20 week’s gestation. True or false?
Scenario 22
If serum is sent to the
laboratory from a woman with a rash in pregnancy for screening for rubella, the
laboratory should automatically test for parvovirus infection too. True or false?
17. EMQ.
Cowden syndrome
Cowden syndrome.
Scenario 1.
Lead in.
Which
feature is associated with Cowden syndrome?
Option list.
A. albinism
B. hamartoma
C. hammer-toe
D. hypertrichosis
E. stammer
Scenario 2.
Lead in. Which condition has the highest risk
of occurrence in women with Cs?
Option list.
A. breast
cancer
B. bowel
cancer
C. congenital
absence of Müllerian tract derivatives
D. hypertension
E. hypothyroidism
Scenario 3.
Lead in. Which gynaecological cancer is a
particular risk for women with Cs?
Option list.
A. Bartholin’s
gland cancer
B. cervical
cancer
C. choriocarcinoma
D. endometrial
cancer
E. vulval
cancer
Scenario 4.
Lead in. Which cancer is more common in men
with Cs?
Option list.
A. breast
cancer
B. colon
cancer
C. melanoma
D. renal
cancer
E. thyroid
cancer
F. all
of the above
18. EMQ.
Caldicott guardian
Question 1.
Lead-in
Which of
the following statements is true of the Caldicott Guardian?
Option List
|
A
|
it is a large lizard, unique to
the Galapagos Islands
|
|
B
|
it is the Trust Board member
responsible for child safeguarding procedures
|
|
C
|
it is the Trust Board member responsible
for complaint procedures
|
|
D
|
it is the person within a Trust
responsible for patient confidentiality in relation to information
|
|
E
|
it is the person within a Trust
responsible for dealing with bullying
|
Question 2.
Lead-in
The
Caldicott Report identified 6 basic principles. What are they?
Option list.
There is none. Imagine that there is information about
you stored on the computers of the local NHS Trust. What conditions would you
want to lay down about sharing of that information within the Trust, with other
NHS organisations and with non-NHS organisations?
Question 3.
Lead-in
The
Caldicott Report made numerous recommendations. Which was particularly
important for major NHS organisations such as Trusts?
Option List
|
A.
|
the need
to appoint a Caldicott Guardian
|
|
B.
|
the need to create a Caldicott Register
|
|
C.
|
the need to create a Caldicott Police Department
|
|
D.
|
the need to create a link between the Caldicott
Department and the DOH
|
|
E.
|
none of the above.
|
Question 4.
Lead-in
What is
the definition of the key role deriving from the answer to question 3?
Option List
There is
none lest it give you the answer to question 3!
19. Borderline
ovarian tumours.
Some of these are not true EMQs
– they have more than one answer. I do this as it makes the document shorter
and saves me some typing.
Abbreviations.
BOT: borderline ovarian tumour.
Ca125: Ca125 as iu/ml.
EOT: epithelial ovarian tumour.
GCTO: germ cell tumour of the ovary.
IOC: invasive ovarian cancer.
MOV: mean ovarian volume.
POI: premature ovarian insufficiency.
RMI: Risk of Malignancy Index.
SOT: serous ovarian tumour.
US: ultrasound score.
Scenario 1.
Which, if any, of the following
statements are true in relation to BOTs?
Option list.
|
A
|
show more proliferation than benign ovarian tumours
|
|
B
|
stromal invasion is absent
|
|
C
|
stromal invasion is < 5 mm from the ovarian surface
|
|
D
|
comprise 10-15% of EOTs
|
|
E
|
comprise 10-15% of GCTOs
|
|
F
|
comprise 10-15% of SOTs
|
Scenario 2.
Which, if any, of the following
statements are true?
Option list.
|
A
|
BOTs constitute
5-10% of ovarian epithelial neoplasia
|
|
B
|
BOTs constitute 10-15% of ovarian epithelial neoplasia
|
|
C
|
BOTs constitute 15-20% of ovarian epithelial neoplasia
|
|
D
|
BOTs constitute
5-10% of ovarian germ-cell neoplasia
|
|
E
|
BOTs constitute 10-15% of ovarian germ-cell neoplasia
|
|
F
|
BOTs constitute 15-20% of ovarian germ-cell neoplasia
|
Scenario 3.
Which, if any, of the following
statements are true?
Option list.
|
A
|
BOTs are less common in women who have taken the COC
for > 5 years
|
|
B
|
BOTs are less common in women with a history of
lactation
|
|
C
|
BOTs are more common after the menopause
|
|
D
|
BOTs are more common in multiparous women
|
|
E
|
BOTs are more common in women with BRCA1 & 2
mutations
|
Scenario 4.
Which, if any, of the following
statements are true in relation to BOTs.
Option list.
|
A
|
p53 mutations are more common than in invasive ovarian
tumours
|
|
B
|
BRAF/KRAS mutations are common than in invasive ovarian
tumours
|
|
C
|
BRCA 1 & 2 mutations are more common in women with
BOTs
|
|
D
|
BOTs are more common in women from a Lynch syndrome
family with a known MSH6 mutation
|
|
E
|
BOTs are more common in women with red hair
|
Scenario 5.
Which, if any, of the following
statements are true in relation to BOTs.
Option list.
|
A
|
Brenner tumours are the most common
|
|
B
|
endometrioid tumours are the most common
|
|
C
|
mucinous tumours are the most common
|
|
D
|
serous tumours are the most common
|
|
E
|
< 10% are bilateral
|
Scenario 6.
Which, if any, of the following
statements are true in relation to mucinous BOTs.
Option list.
|
A
|
are subdivided into endocervical / Müllerian or
intestinal categories
|
|
B
|
are subdivided into endocervical / Müllerian,
intestinal or renal categories
|
|
C
|
are subdivided into endometrial or intestinal
categories
|
|
D
|
pseudomyxoma peritonei occurs in < 1% of cases
|
|
E
|
pseudomyxoma peritonei occurs in about 10% of cases
|
Scenario 7.
Which, if any, of the following
statements are true in relation to BOTs.
Option list.
|
A
|
↑ Ca
125 levels are rare, normally indicating malignancy
|
|
B
|
Ca 19-9 levels are often ↑ in mucinous BOTs
|
|
C
|
CEA levels are often ↑ in serous tumours
|
|
D
|
Ca 15-3 is commonly ↑ in both mucinous and serous BOTs
|
|
E
|
TVS and MRI are useful in the assessment of BOTs
|
Scenario 8.
Which, if any, of the following
statements are true in relation to BOTs.
Option list.
|
A
|
the 5-year survival rate is approximately 80% for stage
I disease
|
|
B
|
the 5-year survival rate is approximately 95% for stage
I disease
|
|
C
|
the 5-year survival rate is approximately 50% for stage
III disease
|
|
D
|
the 5-year survival rate is approximately 60% for stage
III disease
|
|
E
|
the overall 10-year survival rate is approximately 75%
|
Scenario 9.
Which, if any, of the following
statements is true in relation to calculation of the RMI score?
Option list.
|
A
|
uses the formula age x Ca125 x US
|
|
B
|
uses the formula Ca125 x MS x MOV
|
|
C
|
uses the formula (Ca125 + MS) x US
|
|
D
|
uses the formula Ca125 + MS + US
|
|
E
|
uses the formula Ca125 x MS x US
|
|
F
|
none of the above
|
Scenario 10.
Which, if any, of the following
describes the formula used for the calculation of the MOV as used in the RMI
score?
Option list.
|
A
|
total ovarian volume / 2
|
|
B
|
total ovarian volume / average ovarian number
|
|
C
|
total ovarian volume /
ovarian number
|
|
D
|
total volume of the larger ovary
|
|
E
|
p
x (mean diameter)3 / 4 of the larger ovary
|
|
F
|
none of the above
|
Scenario 11.
Which, if any, of the following
as used in the calculation of the MS as used in the RMI score
Option list.
|
A
|
prepubertal: score = 0
|
|
B
|
1ry. amenorrhoea: score = 1
|
|
C
|
POI: score = 2
|
|
D
|
perimenopausal:
score = 3
|
|
E
|
menopausal:
score = 4
|
|
F
|
none of the above
|
Scenario 12.
Which, if any, of the following
statements is true in relation to calculation of the RMI score?
Option list.
|
A
|
uses the formula age x Ca125 x US
|
|
B
|
uses the formula Ca125 x MS x MOV
|
|
C
|
uses the formula (Ca125 + MS) x US
|
|
D
|
uses the formula Ca125 + MS + US
|
|
E
|
uses the formula Ca125 x MS x US
|
|
F
|
none of the above
|
Scenario 13.
Which, if any, of the following
statements are true in relation to the RMI and BOTs.
Option list.
|
A
|
the RMI is particularly useful and should always be
considered in the early assessment
|
|
B
|
the RMI is not particularly useful in the majority of
possible BOTs
|
|
C
|
the strength of the RMI in the assessment of possible
BOTs lies with the elevated Ca125 levels
|
|
D
|
weakness of the RMI in the assessment of possible BOTs
is, in part, due to the wide range of Ca125 levels found with BOTs
|
|
E
|
none of the above
|
Scenario 14.
Which, if any, of the following
statements are true in relation to the measurement of Ca125 in calculating a
RMI score.
Option list.
|
A
|
the units used are mg/L
|
|
B
|
the units used are mg/mL
|
|
C
|
the units used are mol/L
|
|
D
|
the units used are mol/mL
|
|
E
|
the units used are iu/L
|
|
E
|
the units used are iu/ml
|
Scenario 15.
Which, if any, of the following
are part of the measurement of US?
Option list.
|
A
|
ascites
|
|
B
|
hydrothorax
|
|
C
|
multilocular cysts
|
|
D
|
↑
ovarian blood flow
|
|
E
|
↑ ovarian number
|
|
E
|
↑ ovarian volume
|
Scenario 16.
Which, if any, of the following
statements describes the best management of BOTs.
Option list.
|
A
|
the best management is hysterectomy + BSO + infracolic
omentectomy + lymphadenectomy + appendicectomy + excision of extra-ovarian
lesions
|
|
B
|
the best management is hysterectomy + BSO + infracolic
omentectomy + appendicectomy
|
|
C
|
the best management is hysterectomy + BSO +
appendicectomy
|
|
D
|
the best initial management is ovarian cystectomy +
histology of frozen section
|
|
E
|
chemotherapy should be offered when the stage is > I
|
Scenario 17.
Which, if any, of the following
statements describes the recommended management of BOT in the woman who does
not wish to retain her fertility?
Option list.
|
A
|
the best management is hysterectomy + BSO + infracolic
omentectomy + lymphadenectomy + appendicectomy + excision of extra-ovarian
lesions
|
|
B
|
the best management is hysterectomy + BSO + infracolic
omentectomy + appendicectomy
|
|
C
|
the best management is hysterectomy + BSO +
appendicectomy
|
|
D
|
the best initial management is ovarian cystectomy +
histology of frozen section
|
|
E
|
none of the
above
|
Scenario 18.
Which, if any, of the following
statements describes the recommended additional management of BOT in the woman
who does not wish to retain her fertility and whose tumour is mucinous?
Option list.
|
A
|
appendicectomy
|
|
B
|
appendicectomy after histology of frozen section
|
|
C
|
removal of the other ovary
|
|
D
|
removal of the other ovary after histology of frozen
section
|
|
E
|
bilateral salpingectomy
|
Scenario 19.
What advice is usually given in
relation to the use of clomifene in women treated for BOTs?
Option list.
|
A
|
clomifene is contraindicated
|
|
B
|
only offer treatment to women < 35 years
|
|
C
|
only offer treatment to women who have screened –ve for
BRCA 1 & 2
|
|
D
|
only offer treatment to women with stage 1 & 2
disease
|
|
E
|
restrict the number of treatment cycles
|
Scenario 20.
What is the role of chemotherapy
in the management of women with BOTs?
Option list.
|
A
|
chemotherapy should be offered routinely after surgery
as for invasive disease
|
|
B
|
pre-operative chemotherapy reduces recurrence rates
|
|
C
|
routine chemotherapy is of unproven benefit
|
|
D
|
the main role for chemotherapy is for recurrent disease
|
|
E
|
the main role for chemotherapy is for recurrent disease
unsuitable for surgery
|
Scenario 21.
Which, if any, of the following
statements are true in relation to restaging in the management of women with
BOTs?
Option list.
|
A
|
should be offered routinely if definitive surgery is
not performed initially
|
|
B
|
restaging improves 5-year recurrence rates
|
|
C
|
restaging improves 10-year survival
|
|
D
|
restaging may be appropriate for those with invasive
implants
|
|
E
|
restaging may be appropriate for those with DNA
aneupooidy
|
Scenario 22.
What advice is usually given in
relation to the management of women found unexpectedly to have a BOT on
histology?
Option list.
|
A
|
further surgery, if needed, to remove the ovary and
tube
|
|
B
|
adjuvant chemotherapy
|
|
C
|
pelvic radiotherapy
|
|
D
|
close follow-up
|
|
E
|
none of the above
|
Scenario 23.
What is the role of laparoscopy
in women with actual or suspected BOT?
Option list.
|
A
|
laparoscopy has replaced laparotomy in most cases
|
|
B
|
concerns about the risk of recurrence limit its use
|
|
C
|
concerns about worse survival limit its use
|
|
D
|
concerns about port metastasis limit its used
|
|
E
|
none of the above
|
20. Communication
skills. Pre-pregnancy.
Brother has cystic fibrosis.
Candidate's Instructions.
This is a roleplay station. You are a year 4 SpR and are
in the gynaecology clinic.
The consultant has just left you in charge as she is
feeling unwell and has gone to lie down.
Your task is to deal with the patient as you would in
real life.
GP referral letter.
Best
Medical Centre,
High Road,
Anytown.
Phone: 01882
78998.
Practice Manager: Mary Wright. B.SC., RGN.
Phone: 01882 78998 ext. 23.
E-mail: besthealth@gmail.com
Re. Mrs.
Bonnie Black,
25 Low
Road,
Anytown.
DOB: 28 January 1990.
Phone:
07889 888 132.
Dear
Doctor,
Please see
Mrs Black who is planning her first pregnancy. Her main concern is that her
brother has cystic fibrosis.
This was
the first time I had met her although she has been registered with us for 5
years – her health is good and she has no history of serious illness or
surgery.
I have
explained that I don’t know much about the implications of the brother’s cystic
fibrosis for her potential pregnancies and that she needs to talk to an expert.
Yours
sincerely,
John P.
Clatter.
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