Below is the copy and paste of an email I just received from the surgeon at University of MN.
Please help. Opinions needed and welcomed. I’m trying to cypher through this and all I’m seeing is no matter which cancer, it has spread at least to the lungs, highly aggressive, a palliative amputation, or am I reading this wrong?
I’ve never been so confused about medicine as I am now. I feel like it’s all filled in with unnecessary minutiae and I just need bottom line. Not to mention amputation of the “forelimb” is disconcerting since it’s his hindlimb.
I can’t, for the life of me understand why their isn’t a suggestion of having him PTS if it has spread instead of palliative driven amputation for therapeutic removal of the pain. He would be spending his last few months trying to recover from the amputation and suffering from the metastasized area. Which at least in the Hemangiosarcoma, death usually occurs from rupturing at the primary tumor sight that’s usually in the right heart, lungs, liver or spleen and associated with catastrophic hemorrhaging.
So we couldn’t do the things that he loved like swimming, running, UFC bouts with Calamity and Moonshine. By the time he heals enough to be active he’ll most likely be near death or dead.
What do I do first?
Sorry it’s so discombobulated, in both format and form. My head is gonna explode!
DOBERMAN PINSCHER RED AND TAN
Case # 6541412
DOB APR 20, 2012
Discharging DVM: Dr Chris Thomson Instructions By: Dr Chris Thomson
Attending DVM: Dr Chris Thomson Tech:
Thank you for your recent visit to the University of Minnesota, Veterinary Medical Center, below is a summary of the visit. Huckleberry was presented to the Surgery Service for evaluation of a pathologic fracture of the distal right tibia.
RELATED HISTORY: Huckleberry presented to the UMN VMC ER Service on 11/15/2018, for evaluation of lameness of the right hindlimb. Upon physical exam, Huckleberry has marked swelling around his right hock. ER Radiographs (x-rays) of Huckleberry's right hindlimb showed a comminuted oblique pathological fracture in the distal right tibia.
PREVIOUS DIAGNOSTICS, TREATMENT, MEDICATIONS
Codeine Sulfate 30mg tablets: Give 2 tablets by mouth every 8 hours for pain.
Deracoxib 100mg tablets: Give 1 and 1/4th tablet by mouth once daily for 4 days. Last dose given Sunday pm.
PHYSICAL EXAM FINDINGS:
Pulse: 90 Resp: 20 Mucous membranes: pink Capillary refill time:<2s Wt: 41.7 kg BCS 5/9
On physical exam, Huckleberry is bright, alert and responsive. His eyes, nose and ears are clear and free of debris. He appeared to be euhydrated. Peripheral lymph nodes palpated small, soft, symmetrical and freely moveable. Cardiac auscultation was unremarkable with no murmurs or arrhythmias appreciated. Femoral pulses were strong and synchronous. Normal bronchovesicular sounds were heard on lung auscultation, with no audible crackles or wheezes. Abdominal palpation was unremarkable with no masses, organomegaly, fluid waves, or pain appreciated. He was partial to non-weight bearing in the right hindlimb from distal tibia fracture with pain on direct palpation; custom fiberglass splint still in place.
Fine needle aspirate (FNA): A small needle was used to obtain cells from Huckleberry’s fracture site. The collected cells were reviewed under a microscope.
RESULTS: Based on the atypical cells present on the slides, there is concern for an aggressive ‘sarcoma’ tumor. However the slides were of low cellularity with only a handful of cell clusters providing a diagnosis. Additional stains were performed but unable to further differentiate the type of sarcoma. A surgical biopsy is needed for a confirmatory diagnosis.
Thoracic Radiographs: This is an x-ray of the chest that allows us to evaluate the heart, lungs, and other
Print Date: 11/26/18 Page 1
structures within the thoracic cavity.
RESULTS: Two pulmonary soft tissue nodules were noted; differentials include early metastatic disease or superimposition of normal structures such as end-on vessels
ASSESSMENT: Based on the findings of the right tibia limb radiographs, cytology, and thoracic radiographs, Huckleberry likely has a malignant type of tumor called a sarcoma. Possible differentials include hemangiosarcoma, histiocytic sarcoma, or osteosarcoma. Unfortunately, these types of cancer are highly aggressive and have a high rate of metastasis (i.e. spread to other organs). Confirmation of which type of tumor can be made with a surgical biopsy of the fracture site to further assess the cell morphology.
Due to the aggressive nature of these cancers, the primary recommended form of treatment is amputation of the limb. This treatment would be palliative (removal of the source of pain), aid in achieving a diagnosis (surgical biopsy), and would be considered local control of the tumor if there is no evidence of metastasis (spread) elsewhere in the body. For all three tumor options, adjunctive chemotherapy is highly recommended as these particular tumors are responsive to various forms of chemotherapy. Unfortunately, many dogs will have metastasis at the initial presentation, whether detectable or not. At this visit we screened for metastasis in the thoracic cavity with chest radiographs, which is the most common area of metastasis for these particular sarcomas. There were two small nodules in the lungs that are concerning for early spread of this cancer. However, it is possible that these could be normal structures such as end on vessels.
Prior to moving forward with forelimb amputation, additional staging could be considered. This includes an abdominal ultrasound (roughly $550, to assess for spread of cancer to the liver, spleen, or other abdominal organs, a common finding for hemangiosarcoma or histiocytic sarcoma), a bone scan ($900, to assess for possible additional bone metastasis, which can occur in up to 10% of osteosarcoma cases), or a combined thorax and abdominal CT scan ($1200, to further define any potential lung metastasis or spread to abdominal organs, beneficial for all three differentials). If interested, these tests should be performed prior to surgery; if evidence of metastasis is observed elsewhere in the body, it would highly effect Huckleberry’s prognosis but not necessarily his next treatment recommendation (forelimb amputation). If you would like to discuss the advantages and disadvantages of the various staging options, please let me know and we can discuss by phone.
At this time, Huckleberry is scheduled for a right forelimb amputation with Drs. Callie Blackford and Betty Kramek on December 5th. Drop off instructions are listed below.
Thank you for entrusting us with Huckleberry’s care. He was a pleasure to work with. If you have any questions or concerns regarding Huckleberry’s progress at home, please do not hesitate to call us at (612) 626-8387 or email the surgery service at [email protected]
Chris Thomson, DVM
Small Animal Surgery Resident [email protected]
Surgery Chief of Service:
Shiori Arai, DVM, PhD, DACVS-SA
Senior Veterinary Student
Even when broke, he’s still broke.
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