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MRCOG PART 2 SBAs and EMQs

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notes326
EMQ1462
SBA2091
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EMQ on CIN & Colposcopy

EMQ on CIN & Colposcopy Posted by Selayang T.
Dear Paul, I've gone through few EMQs on CIN (screening, colposcopy & treatment) and noticed that answers are based on the old NHSCSP Guideline as opposed to the recent guideline in 2013 which is incorporating the HR-HPV testing as part of 'test of cure'. I do understand that some of the questions do not have the latest treatment option listed. I find that this is confusing. May I suggest that these be tailored to the latest guideline? Thanks
Posted by PAUL A.

Thanks - we have revised the questions and notes but it is possible that some questions have been missed. If you find a question you think is not right please copy and paste in forum. In the meantime we will go through them again.

Posted by Selayang T.

Dear Paul,

Here are few questions I came across which I think is not managed according to recent guideline:

Options for Questions 9-9

A

Repeat smear within 6 weeks

B

Repeat smear in 6 months

C

Repeat smear in 12 months

D

Repeat smear in 3 years

E

Repeat smear in 5 years

F

Repeat smear at colposcopy within 6 weeks

G

Repeat smear at colposcopy in 6 months

H

Repeat smear at colposcopy in 12 months

I

Refer for colposcopy

J

Punch biopsy of cervix

K

Reassure and discharge

L

Treat with AgNO3 cautery

 

 

Instructions:For each of the scenarios described below, choose the single most appropriate management from the above list of options. Each option may be used once, more than once, or not at all.

Explanation

Question 9

A 43 year old woman has a cervical smear showing borderline nuclear changes in endocervical cells

 J
 

Explanation

Borderline nuclear change

  • Repeat tests are recommended for the first occurrence of borderline changes. A second repeat may be requested for borderline changes, but after three such samples colposcopy is expected. The interval recommended for repeat tests (usually six months) takes into account the time needed for resolution of such changes.
  • Borderline changes will occasionally be seen in endocervical cells, or there may be a suspicion of high grade disease. In such cases the cytopathologist should refer the woman immediately to colposcopy rather than waiting for repeat tests.
  • There should be no more than three borderline samples over any 10 year period without a recommendation for colposcopy.
  • Following mild dyskaryosis or borderline nuclear change, a woman should be returned to routine recall only after a minimum of three negative tests each at least six months apart or colposcopic assessment indicating no abnormality.
  • Before recall is ceased for reasons of age, at least three negative follow up tests should be reported after borderline nuclear change.

 

Options for Questions 11-11

A

Cervical smear within 6 months

B

Cervical smear within 12 months

C

Refer for colposcopy

D

Colposcopy and smear within 12 months

E

Cervical punch biopsy

F

Diathermy loop excision

G

Laser cone biopsy

H

Routine 3 yearly recall

I

Routine 5 yearly recall

J

No further cervical smears

K

Hysterectomy

   
 

 

Instructions:For each of the scenarios described below, choose the single most appropriate management from the above list of options. Each option may be used once, more than once, or not at all.

Explanation

Question 11

A 40 year old woman has been referred for colposcopy because of low grade dyskaryosis. Colopscopy is normal and a repeat cervical smear 6 months later is low grade dyskaryosis.

 D
 


For question 9, recent NHSCSP guideline says that we have to do HR-HPV test for borderline smear to decide the next step of management. I also noticed that the explanation for answer is not in keeping with recent guideline.

 

For question 11, recent guideline says we have to perform 'test of cure' 12 months after the colposcopy which comprises cytology and HR-HPV if needed based on cytology result. So, essentially for this question wouldnt the next step be doing HR-HPV testing?

 

Thanks

Posted by PAUL A.

Thanks - we left these questions in for several reasons.

The question says select the most appropriate option. It does not say you should select the option that is in line with the most recent guidelines. The option recommended in the guidelines is not always available to you or the woman might decline the option. So clinical practice is not just about knowing the best option as in the guidelines but also knowing the second / third best option. So some of these questions were left on-line for that reason.

 

In the second question, you are presented with a scenario. The test has been done and you are presented with an abnormal result. You have to deal with it. In real life, if you are presented with BP = 130/80 and PCR = 20 and the SHO did LFTs and the ALT = 90, you cannot say the ALT should not have been done and walk away. You will be given a number of options and you have to use your clinical judgement to select the best one.

Posted by Selayang T.

Dear Paul,

 

Thank you for clarification and greatly appreciated. I often got confused in answering EMQs as like you said the recommended investigation/treatment is not always part of the answers. I will keep that in mind for up-coming exam.