question 1

Try to use the first 3-5 minutes to map out the essay before you start, hopefully this way you won’t be crossing out and drawing arrows all over the finished piece.

Whilst reading the question, think about what the examiners are wanting to see in your answer, e.g.:

- They ask for a letter so give them a letter

- Your practical experience/knowledge of preparing a patient for chemotherapy

- Ability to communicate clearly with other healthcare professionals

- Knowledge of the principles for 1st line treatment of Mantle cell lymphoma

- Bonus: Ability to name and discuss relevant clinical trials

 

Example answer plan:

 

Dear GP,

 

Management Plan:

1. 24-hour urine collection for creatinine clearance

2. ECG

3. Bloods inc. FBC, U&E, LFT, Bone, LDH, Hep B, Hep C & HIV

4. Patient information leaflets on Mantle Cell Lymphoma and R-DHAP given to patient

5. Clinic in one week to consent for chemotherapy and book treatment start date

 

Diagnosis:

Stage 4 Mantle Cell Lymphoma

Performance Status 1

 

Medications started today:

Allopurinol 300mg OD

 

Results:

Today’s blood results awaited

 

Body of letter

- Re-cap patient’s history

- Diagnosis given to patient – mantle cell lymphoma, patient’s presentation typical of the disease, indolent or aggressive course, treatable but not curable, median survival 4-5 years in all comers

- Treatment options – he is a fit patient with stage IV disease and so the goal is chemotherapy followed by autograft, then rituximab maintenance. Treatment is cytarabine-based and a current common regimen is R-Maxi-CHOP/Cytarabine (NORDIC protocol). Bonus: LyMa trial 2017 recently published showing R-DHAP also an effective option. LyMa also demonstrated the benefit of R-maintenance post autograft.

- Risks – neutropenic sepsis (Bonus: mention 24 hr emergency contact card), cytopenias, GI, infusion reactions, renal impairment, iritis, cardiac impairment, tumour lysis syndrome, steroid side effects, hair loss, impaired fertility, treatment-related mortality (The MacMillan website is a great place to look for regimen specific side effects).

- Describe the management plan given above and the rationale for it.


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question 2

Example answer plan:


Diagnosis

  • CLL (Binet Stage C).

  • CLL Score at least 4 (surface Ig not given)

Further work-up:

  • Consider the need to rule out high grade transformation - is there a site of particular bulk that should be biopsied to ensure still CLL.

  • TP53 loss / mutation must be looked for (FISH/Molecular) as will direct treatment choices

  • Patient is anaemic, look for haemolysis - film, reticulocyte count, bilirubin, haptolgobins, DAT

Treatment:

  • Offer trial

  • Off trial, assuming no TP53 disruption - chemoimmunotherapy.

  • Give your preference and rationale (e.g. FCR based on CLL10 trial)

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Supportive Care:

  • Irradiated blood products for life - purine anologues, bendamustine

  • consider prophylactic LMWH - is there venous compression 2o to the pelvic disease

  • Annual ‘flu and pneumococcal vaccination

  • Patient Support Group,

Relapse:

  • Re-Stage +/- Re-biopsy

  • Avoid chemoimmunotherapy as remission only 2 years

  • Consider ibrutinib or R-idelasilib, based on availability and tailored to patient characteristics.

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