Not a routine visit (Sue Marsh)

A woman attended the outpatient clinic the other week as an emergency appointment. She had been seen three weeks previously with no outstanding problems and her next cycle of chemotherapy had been arranged.

She originally presented in June 2002 with stage IIIa ovarian cancer. Following debulking surgery she began chemotherapy and over the intervening years she had received carboplatin, paclitaxel and liposomal doxorubicin. Recently her abdominal disease had progressed again and she was currently receiving further chemotherapy with few problems and stable disease.

When she arrived in clinic she was unusually quiet and quickly removed her upper garments to reveal what had been worrying her. I could see an angry looking cyst-like nodule just to the left of her right breast. On questioning, the patient revealed it had started like a spot but had grown quickly over the past two weeks. She thought it was a cyst. The nodule was solid, appeared filled with blood and measured 2cm in diameter. The nodule itself wasn’t uncomfortable, but she was experiencing some non-specific pain round her ribcage.

The clinic nurse and I had never seen anything like this before in ovarian cancer patients. I had seen infected cyst-like nodules or externally growing tumours in breast cancer patients. What was this? Was it an infected cyst? — didn’t look or feel like a cyst. Was it disease? — an unusual presentation for ovarian cancer. Racking my brain — what could I do to find out?

An urgent check of the patient’s blood results showed a rising tumour marker, suggesting further disease progression. A review of previous CT scans highlighted a soft mass in the anterior chest wall, first noted on CT scans in 2008. Could this have developed enough to grow externally?

I needed help. I believed this was disease progression but what if it were something else? I bleeped the consultant’s registrar. He appeared quickly and I updated him on what I had considered. After viewing the nodule he too believed her disease had progressed but wasn’t sure enough not to order a chest X-ray and prescribe antibiotics — just in case of infection.

We cancelled the next planned chemotherapy cycle, sought an urgent CT scan and arranged an urgent appointment with the consultant. The outcome: her cancer had relapsed in the chest area; the mass had grown dramatically and forced itself externally rather than internally.

Most clinic appointments are routine, spent discussing side effects of chemotherapy and planning the next cycle. But there are some occasions when my consultation can go no further without seeking medical input.

 

Sue Marsh is lead pharmacist for cancer services at University Hospitals Coventry and Warwickshire NHS Trust