OSCE Flashcards
You have been referred a 35 yo HPV 16+ve with SCC on CST. Please discuss your assessment and initial investigation
I would arranged to clinically review and examine the patient. Prior to review I would review their previous screening history as well as general medical, surgical and other history provided. I would ensure that a recent set of bloods has been taken and review prior to consultation.
On history I would note RF for cervical cancer, as well as confirm medical and surgical history, any GA issues and social issues that will affect treatment. I would also confirm the patients obstetric history and fertility desires as well as previous fertility issues.
On examination I would undertake a colposcopy vaginal / rectal examination. I would also undertake a biopsy of the cervix. I would aim to formulate a clinical stage by the end of the examination.
For investigations I would ensure that the EUC, LFT and FBC are done with an FE studies. For imaging I would undertake a CT + PET CT. If the lesion appeared to be surgically resectable I would undertake a pelvic MRI.
Fertility sparing - as she is under 35 I would discuss the implications of this cancer on her fertility if desired. If she has a strong desire for fertility I would arrange a rapid assessment by a fertility specialist.
By the end of the consultation I would have identified the most likely treatment recommendation for the patient and discussed the options with them. I would arrange for histopathology and imaging to be reviewed at the MDT. If required I would book the patient for an EUA and involve the urology, colorectal and radiation oncology team as needed. I would involve the social worker and offer a clinical psychologist. The CNC would also review the patient.
You have been referred a 55 yo with an abnormal cervix on examination after presenting to her GP with PMB. A HPV test was done (no cytology) and HPV was negative. Please discuss your assessment and initial investigation.
I would arranged to clinically review and examine the patient. Prior to review I would review their previous screening history as well as general medical, surgical and other history provided. I would ensure that a recent set of bloods has been taken and review prior to consultation. In this case I would expect imaging has been done and I would review that.
On history I would note the patients PHx as well as her Hx of PMB, Menopause, RF for Endometrial and cervical cancer as well as confirm medical and surgical history, any GA issues and social issues that will affect treatment.
On examination I would undertake a colposcopy vaginal / rectal examination. I would also undertake a biopsy of the cervix as well as an ECC and pipelle if possible. If not I would arrange an EUA with HD&C + ECC +/- LLETZ if needed and consider Urology, Colorectal and Rad Onc involvement if needed based on my examination.
For investigations I would ensure that the EUC, LFT and FBC are done with an FE studies. Depending on my suspicion I would add a CA125 and CEA. For imaging I would undertake a pelvic US if not done and a CT C/A/P at this point whilst I await the tissue diagnosis.
By the end of the consultation I would have identified the most likely diagnosis and potential treatment plans and have briefly discussed them with the patient. I would involve social work and psychology if needed.
I would arrange for histopathology and imaging to be reviewed at the MDT. And a follow up either for the EUA or after the MDT.
X is a 34 yo P0 who is 28 weeks pregnant. She presented with an APH on the BG of a LLP. Cervix evaluation was abnormal and a CST followed by a biopsy identified a HPV related SCC Cervix. Discus your assessment and initial investigations
I would arranged to clinically review and examine the patient. Prior to review I would review previous screening history as well as OBSTETRIC, general medical, and surgical history. I would ensure that a recent set of bloods has been taken and review prior to consultation. In this case I would expect imaging has been done and I would review that.
On history I would note the patients obstetric history and ensure that routine obstetric investigations especially morphology scanning has been done. IF the foetus has a condition that makes it non-viable this affects the treatment plan. I will confirm her medical and surgical history, any GA issues and social issues that will affect treatment.
On examination I would undertake a colposcopy vaginal / rectal examination aiming to clinically stage the lesion.
For investigations I would ensure that the EUC, LFT and FBC are done with an FE studies. I would arrange an abdo/ Pelvis MRI. By the endo of the consultation I would have a provisional idea of:
- Patient’s wishes regarding the pregnancy and cancer management
- Clinical stage of the lesion
- The patients suitability for surgery / chemotherapy / radiotherapy
I would involve social work and psychology if needed.
I would arrange for histopathology and imaging to be reviewed at the MDT and include her obstetrician / MFM at the MDT.
The histopathology returned a HPV related SCC of the cervix with LVSI. A PET CT did not identify any disease outside of the cervical Lesion. The MRI and clinical examination indicate that the lesion is 3cm in size. On MRI there is no parametrial invasion.
Patient strongly wishes to preserve fertility.
What is your treatment recommendation and why?
I would ensure that this case has been reviewed at the MDT prior to discussion with the patient. Especially given the fertility question.
This patients has a stage IB2 SCC of the cervix with LVSI. Lesions > 2cm in size, especially with LVSI are not considered suitable for fertility preserving treatment due to their increased risk of recurrence. The Recent FERTISS trial identified that the only significant factor related to an increased risk of recurrence was the size of the lesion and recurrences were three times more likely > 2 cm in size (6 - 18 %).
My treatment recommendation for this patient would be a radical hysterectomy with sentinel nodes and a bilateral pelvic node dissection. In the case of an SCC of the cervix I would recommend leaving the ovaries in situ. I would also discuss oocyte harvesting post-surgery.
In the event that the patient declines this treatment I would investigate whether there is a clinical trial or prospective trial that she can be involved in.
There is evidence that cisplatin based NACT can be used in these cases and fertility preserving surgery attempted if there is complete resolution of the lesion or <1cm of tumor left (based on data from Marie plante). I would recommend a sentinel lymph node biopsy and Pelvic lymph node dissection prior to commencing chemotherapy.
In the case of surgery after chemotherapy the data suggest that a simple trachelectomy or cone biopsy provide equivalent oncological outcomes and improved fertility outcomes.
I would reiterate that the data behind this is limited and the standard of care would be definitive surgery.
The foetus is morphologically normal and the patients first baby.
Clinical examination and MRI identify a 5cm lesion on the cervix. There is concern about myometrial invasion on the left side. There are no palpable LN. The MDT has confirmed a stage 2B based on the MRI finding.
What is your recommendation for treatment and why?
This patient has a locally advanced cervix cancer at 28 weeks gestation. Outside of pregnancy the standard of care would be for combined chemotherapy and radiotherapy.
Options:
Surgery - A caesarean section followed by CCRT when the patient has recovered. The benefit of this option is that it will allow the patient to receive comprehensive treatment asap. The major disadvantage is the extreme prematurity of the baby.
Radiotherapy - With the fetus in situ would terminate the pregnancy. This would also be the last pregnancy the patient could carry. The benefit of this option is that treatment would start straight away. The disadvantage is the significant emotional trauma. The requirement to deliver the fetus abdominally which can affect oncological treatment.
NACT to allow fetal maturity followed by CS. Then treatment. There is some surgery of variable quality of the use of NACT prior to surgery in cervix cancer. Most of this is prior to fertility sparing surgery. Most patients who have chemotherapy have a complete or partial response to treatment. Some will not respond to treatment…. This is my preferred course of action. I would recommend a platinum based chemotherapy.
This would be continued with regular reviews to monitor response to treatment. MDT discussion to decide duration and time to delivery.
I would expect around 36 weeks. I would review the patient prior to see overall response to treatment. I would undertake the CS as planned. I would repeat imaging investigations and if needed biopsy their cervix. Based on this I would re-present the case at the MDT to decide whether the previous plan for CCRT was appropriate. I would also have to take into consideration the patients fertility wish regarding ovarian preservation.
You have a XXX cancer…. Will I die?
You have an advanced cancer that has yet to be treated.
Most cancers like yours are treatable, some for a long time, but most are not curable.
It is not possible before you start treatment to say how well your cancer will respond to treatment and for how long it will respond. There are too many factors. Any information you read online about survival will be at least 10 years old and not take into consideration new testing and treatments you could have. The team here will support you and take care of you the best they can and I know the treatment you will get will be as good as anywhere.
How long do I have to live?
Estimating how long you might live with advanced cancer is very challenging. Current estimates are using data from a large group of patients based on treatments and outcomes that are more than 10 years old. The data presented may not reflect current treatments or be applicable to your particular situation. Estimates of survival can give a general insight but are far from precise. If you like I can give you numbers about how long most people with this cancer will live and the chance of being alive at 5 and 10 years. (cancersurvivalrates.com)
Explain why a cancer recurrence is not suitable for surgery?
We discussed your case at the cancer specialists meeting on XXX.
I’m sorry, but I don’t think surgery something that will help you at this point.
Surgery for cancer is most effective when the cancer is localised. It can be used to decrease the overall amount of cancer in a person’s body and to improve symptoms in some cases.
- In your case the benefit of operating is outweighed by the risk of complications of surgery - In your case the cancer has recurred in multiple areas. Not all can be removed and there are likely to be more smaller areas that we cannot see.
The recommended treatment for your cancer at this point is to try and treat-
- all of the cancer sites with chemotherapy which will treat those too small to see as well
- The areas of cancer with radiotherapy and chemotherapy
It may be that some form of surgical management is useful in the future but I (and the other specialists at the cancer meeting don’t feel that surgery is the best option at this point. I will continue to try and support you though this into the future.
You have diagnosed a recurrence that is non curable. Initial explanation.
I’m sorry to say that your cancer has come back.
The biopsy and the scans indicate that the cancer has returned in XXXXXX
When a cancer returns in multiple locations it is not curable. It is treatable.
There are multiple options and types of treatment that you can have to shrink and control the growth of the cancer. We will be there to help you through this.
I have organised …..
Advise on how to tell your children about a cancer diagnosis:
You are an expert in your family and children and as you known, no two are the same.
You don’t need to talk to them today and it often will take a few times to figure out the right way to do it. Kids are observant and will pick up that something is going on.
There is an excellent short resource from the cancer council that I can send you. It talks about how kids respond at different ages to news about cancer and it’s treatment. There are other online resources that I’m happy to send you as well if you wish.
I think it would be a good idea to look at that resource and discuss it with your partner. I have also spoken to the psychologist and social worker and they are happy to speak to you and help you through this.
I suggest you try to talk to them about it sooner rather than later. It is OK to tell them that you don’t know the answers to their questions. As you move forward and start treatment they will know something is going on.
Can I send you this resource? Do you mind if I get the social worker to contact you about this?
Monologue on thh benefits of risk v benefits of surgery
Deciding to have surgery is based on the balance of the benefits of surgery vs the risks of not having it and the risks of surgery and recovery.
The benefits in your case are that you have a cancer that we can operate on and remove. With a XX chance of removing it
The risks are both short term, that is during and shortly after the operation as well as changes that can affect you for longer.
Overall most people recover well after surgery. The level of the risks depends on the type and duration of surgery as well any medical issues you have.
Risks during and just after the operation include infections which can be in the wound, chest, bladder, abdomen. Blood clots in the legs and chest, improper wound healing. After abdominal surgery your bowels may take time to work which can cause discomfort. You will also have some pain after the operation. It is also possible to have heart attacks and strokes after the operation. The risk of dying during the procedure if very very low.
Longer term risks can be that you have a change in function of something like your bladder or bowel. In more elderly, or less well patients there can be difficulty in getting back to your previous level meaning you might need more help with your day to day activities.
You have been part of a mistake made. Have an initial talk with the patient about it.
I would like to apologise and feel responsible for what has happened.
From what I know thus far ….. As more becomes known I will continue to updates you. I would rather not guess at why XX happened.
My main goal here is to make sure you get the best care possible.
Immediately I will organise
I have made sure this has been reported to hospital management and that the organisation will look at how this happened and investigate how any systems that have failed can be fixed to stop this from happening again.
I can understand if you would prefer to move your care to a different specialist or hospital. If you wish to do that I will organise that as soon as practicable. If you would like to complete a consumer / patient complaint form please let me or your nurse know and we can provide you with the details. I have also asked the social worker to speak to you about this. Is it OK if they come?
What factors would you take into consideration when deciding whether to use a protective ileostomy for an anterior / low anterior resection
Look up Mayo Criteria including 7cm, leak test, pelvic RT. Pt factors.
What would you take into consideration prior to reversing an ileostomy?
Patient and disease factors
- Patient factors
o What are the patients wishes regarding the stoma and what is their functional status
o What is their nutritional status like and is the stoma making that worse
o Has their been complications with the primary join, i.e. leak or infection - if concerned consider flexi - sig or CT with rectal contrast
o Are they passing wind or a small amount of faecal mucous.
o Can they tolerate an anaesthetic or do they need a period of prehabilitation prior to anaesthesia.
- Disease factors -
o Primary treatment should have been completed and the patient recovered post treatment - i.e. not neutropenia post CT
o Are there signs suggestive of recurrence. Consider tumour markers and PET CT prior to planning reversal
- I would recommend not reversing the stoma if:
o There were ongoing anastomotic issues
o There was known recurrent disease that may cause future bowel obstruction
o The risk of an anaesthetic complication is high.
Patient declines reversal.
Sepsis intial Mx
