I had a downer of a week (which explains my lack of posts for the past two days).

Two weeks ago, a seven-year-old girl came into clinic to see me for a second opinion about a bump on her head. She wasn’t a patient of mine up until then, but her mother wasn’t satisfied with the answers that their primary pediatrician had been giving them, so she ended up with an appointment to see me in clinic. Unfortunately, I wasn’t scheduled to see patients that morning, so the girl ended up seeing another resident in the clinic. (To make things easier, I’ll call her “Jenny” — rest easy, though, that’s not her real name.)

The basic story was that Jenny had fallen off of her scooter last August, and that night, her mom had noticed a bump on the back of her head. She brought her into her pediatrician the next day, and after examining her, he felt that the bump was probably traumatic; he got skull X-rays, which were negative, and reassured Jenny’s mom that it was probably just swelling that would resolve over time. As standard practice, the doctor told her what she should look for if it was a fracture that had caused injury — dizziness, headaches, confusion, loss of normal sensation or movement, loss of consciousness, or anything that Jenny’s mom thought was out of the ordinary.

Over the next couple of months, the bump didn’t resolve at all, but her mom also didn’t notice any of the things that Jenny’s pediatrician had warned them about, so she didn’t worry all that much. Come last month or so, though, she began to think that it wasn’t normal for swelling from a scooter fall to last that long, so she booked the appointment to see me in clinic.

When I got to clinic that afternoon, the resident who saw Jenny filled me in on the visit. On his exam, he noted that the bump was at the back of her head, was around three or four centimeters in size, and was firm and nontender. She had no other symptoms to speak of — no neurological changes, no other bumps, no developmental changes, nothing. In this age group, the most common thing to suspect would be a dermoid cyst (a benign growth of tissue), so he had paged the dermatology resident on call and set Jenny up to see the dermatologists and get an ultrasound of the bump the next day.

Two days later, the derm resident called me to give me the details of his visit with Jenny. They had done the ultrasound, and saw a mass around six or seven centimeters in size with “cystic changes” at its core. (This just means that some of the tissue had formed walled-off areas filled with fluid; for various reasons, many masses do this when they reach a certain size.) This was consistent with the idea that the bump was caused by a dermoid cyst, but because ultrasound doesn’t do a great job penetrating very deeply (especially when there are cysts of fluid obstructing the beam), he had obtained a head CT scan.

His call to me was to tell me the reading on the head CT scan. It had shown pretty much the same thing as the ultrasound — a six or seven centimeter mass — but it also showed that the mass was inside the skull, compressing her brain. The radiologists had not been able to determine the type of mass, though (they weren’t able to tell what type of tissue it was, or where it originated), so they recommended that we get an MRI.

Now, the problem with getting an MRI is that it’s just not that easy to do at a big academic center. MRIs take a long time to do (much longer than a CT scan), and if the patient moves at all, it means that the study has to be restarted. This means that the scanners are constantly booked, and since priority is (obviously) given to patients who are currently in the hospital, getting an MRI for someone who isn’t in the hospital usually means waiting anywhere from a few weeks to a few months. I’m a persistent and ornery bastard, though, so instead of calling the scheduling desk, I called the attending radiologist directly; I managed to convince him that I needed to get this MRI sooner and he set it up for last Friday. I called Jenny’s mom and explained to her that we needed to further clarify what the bump was, and she said it wouldn’t be a problem to bring Jenny in Friday for the scan.

When I got into clinic at the start of this week, I went onto the hospital info system and checked the report on the MRI, but I wasn’t really prepared for what I read. The high resolution of the MRI allowed the neuroradiologists to clarify more about what was going on, and based on a few pretty specific findings, they predicted that the mass isn’t a dermoid cyst — instead, they read the scan as consistent with a meningioma or meningiosarcoma. Both are brain tumors, and both are very, very rare in the pediatric population; the difference between the two is that meningiomas are generally benign, and meningiosarcomas are universally aggressive and malignant. Either one of them would mean major brain surgery for Jenny, possibly followed by radiation.

I immediately paged the neurosurgeons and asked them what would be next, and they set up an appointment for Jenny to see them in their next clinic. I also called Jenny’s mom to ask her to come in, and we arranged for a visit this past Thursday… and then I realized that this would be the first time that I had told a mom that her child has cancer. That’s about when my stomach clenched up into a tight little ball, and my heart sunk into my legs. Nonetheless, I started to arrange all of the support that I’d need (my clinic attending and a social worker), making sure that at least one of them spoke fluent Spanish — Jenny’s mom is a native Spanish speaker, and I didn’t want there to be any chance of misinterpretation.

Alas, Thursday did roll around, and Jenny came in with her mom. And, since nothing that I dread ever gets easier, mom also brought in Jenny’s sister as a sick visit; I quickly examined and cleared her before asking their mother if we could go talk in private. The social worker and my attending joined us, and that’s when I had to break the news. I started by telling her that she had done the right thing by bringing Jenny in, and that we had the results from all the studies that Jenny had had done. I told her that Jenny had a mass in her head, and that from the MRI, it was likely that it was cancer — and at that point, mom lost it. The rest of the visit was alternating between consolation and answering questions, and it was probably the toughest hour of my life. At one point, the two girls came and opened the door to the room we were in, and I quickly got up to shepherd them away; as we were walking back to my exam room, Jenny asked me why her mom was crying, and I just plain didn’t answer.

The social worker spent another half-hour with Jenny’s mom, making sure that she had someone to take them home, that mom had someone to talk to (it turns out that she has a therapist), and that they had all their paperwork for their visit to the neurosurgeons. During that time, I went into my exam room and just played with the sisters, trying to block out that one of the two was about to begin one of the most trying and difficult things a person can ever go through. And once their mom was ready to go, Jenny reached up and gave me a big hug goodbye; it took absolutely everything that I had in me to not completely disassemble into a sobbing mass right there.