Your Pet's Best Friend

WIDE Surgical Borders

If you had a cancerous lump you'd probably want to have it cut off.  As long as we're cutting it off, I suppose we might as well get it all, shouldn't  we?  Makes sense to me... only... how do we know how much to cut off?

Everybody has rules to live by.  Some are sensible, like "Don't eat yellow snow" and some are questionable as to their utility, like "Never eat anything bigger than your head."   Today's rule is "If it's important enough to cut it off, it's important to find out what it is and whether you got it all."

If the lump is cancerous, then you want to cut a wide margin around it.  Sometimes it looks like the lump has nice, obvious, well circumscribed borders.  Sometimes it does.  Other times, microscopic examination of the surrounding tissues shows little cancer cells creeping away into what looked like normal tissue to your naked eye.  So, with a cancerous lump you need to go wide and deep.  With mast cell tumors, the oncologists recommend that you take a 3cm margin all the way around, including deep.  That means you cut an inch and a half BELOW the tumor, as well as all round it.  That's a 3-inch diameter hemisphere: think half a baseball.  It's a big crater of a wound that is hard to close up.

Of course, if the lump is NOT cancerous, you would really prefer that the surgeon not excavate some great crater around it.  That will be a bigger, more painful wound.  PLUS, if you don't happen to be as fat as the rest of America, that inch and a half deep might be a chunk of muscle.  Ouch!

So, what's a mother to do?  Sometimes you can just stick a needle in the lump, pull out some cells, identify them under the microscope and know how to proceed.  Many times that doesn't work, as the individual cells don't tell you as much as a sample that shows how they are arranged, as well.  Therefore, when we've got a lump that's fast growing, or bleeding, or just generally nasty-looking, we cut it off and take a small margin of apparently normal tissue around it.  Then the whole mess goes off to the pathologist.

The pathologist slices it up and examines the architecture and types of cells.  She also looks at all the borders of normal tissue for evidence of cancerous cells. If the tumor is not an aggressive type, one that usually doesn't spread much, and you have clean margins, you're done.  If it turns out to be benign and not cancerous, it's all good.  On the other hand, if you've got "dirty margins" (cancerous cells going out to the edge), it's back to the surgery table for wider excision, with the size of the hole governed by our experience with that type of cancer.   If it's a really aggressive type of cancer with a high potential for spreading, we may be going back for a bigger crater, even if we had clean borders.

Two surgeries where one would do sounds like a lot of wear and tear on the patient (not to mention your pocketbook).  It's one of those "durned if you do and durned if you don't" situations.  If it's malignant cancer, you need to go for the gusto.  If it turns out to be benign, you'll be so glad you didn't amputate the leg to get the benign tumor off the toes.

Speaking of amputating legs to remove the tumor on the toes, in a previous post on cancer, we mentioned that very situation.  That little poodle with mast cell tumor turned up clean on all her staging tests, so we went ahead with amputating her front leg.  Her pathology report came back today, showing no spread of tumor up the leg.  She is recuperating well from her surgery and we have high hopes of extending her life.  Only time will tell, but we've given her our best shot.

In Memoriam: Checkers

Old Yeller Alert

You may remember Checkers from my post on chemotherapy.  He was the poster boy and his success inspired a number of pet-owners to treat their buddy's cancer instead of just throwing in the towel.  Today, Checkers finally threw in the towel.

I first met Checkers in August of 1998.  He was a rambunctious Cocker Spaniel.  Even though he was nine years old, there was a lot of the puppy in him still.  He didn't look or act old.  In June of 1999, he developed some lumps under his neck.  Further examination revealed that most of his lymph nodes were swollen.  He didn't feel good, and he certainly wasn't acting like a happy puppy.  Cytology exam revealed lymphoma -- lymph node cancer.

At that time, the University of Missouri's College of Veterinary Medicine teaching hospital was undertaking a new study on the treatment of this disease and Checkers was eligible to participate.  He went to Mizzou for some evaluations and testing, but most of his chemotherapy was done here at Kennett Veterinary Clinic.  After his very first treatment, the cancers shrank dramatically and he never looked back.  He received treatments and repeat evaluations through May of 1999. He took some of his meds at home and received I.V. treatments at the clinic about every three weeks.

He had been in clinical remission (meaning, he looked and felt good) within weeks of starting treatment.  At ten  years of age, after a year of chemotherapy, he still looked good and we stopped the chemo.  When he was twelve, he was back at the University for evaluation.  His folks asked the specialists there how much longer they might hope for. "What's the bench-mark?"  The doctors just pointed down at Checkers.  "He's the benchmark."  The benchmark after two years of survival, he went on to beat the odds for another five years.  When Checkers was sixteen, six years after his initial diagnosis, he walked in a cancer walkathon with human cancer survivors. 

Not many dogs live to be seventeen, even if they haven't had cancer like Checkers.  In his seventeenth year he began to have more of the problems we associate with aging, but was still feisty, and a joy to his owners.   He had a lot of trouble with arthritis and had to take some pain medication.  Ear infections are the bane of Cocker Spaniels and he had more trouble with them.  We began to see him fairly frequently with his geriatric problems.  He turned seventeen in May and still had a pretty good quality of life, amazingly enough.

This summer, he began to be a little more cantankerous, and he developed some neurological problems that made him stumble a lot.  Then, in early October, we found a new mass in his abdomen.  There were a lot of days when we didn't really feel he was comfortable.  Finally, the day came when he just couldn't get up.

As we prepared to let that rambunctious puppy leave his worn-out body, his daddy said, "If I could make him a puppy again, I'd sell everything I have and start over."  As veterinarians, we think we know how attached people are to their pets.  Sometimes, we don't know the half of it.   

My staff and I and Checkers' family all knew this day would come.  That didn't make it any easier.  The one thing we didn't have to deal with was the "what if" that comes when you haven't given things your best shot.  One doesn't often have the privilege to experience such a total committment from the pet-owner that is also met with such great success.

He was something, all right.  Now I expect that he's picking up a new puppy body and getting ready to go again.  You can't keep a good man down, and he was a good one.

When You KNOW Something's Wrong

Old Yeller Alert 

It's funny (funny strange, not funny ha-ha) to see the different extremes in how we react to some abnormality in our pet's behavior or condition.  Some folks will be in a for a comprehensive exam if Fluffy so much as passes gas in front of company.  Others don't see a problem until there is blood on the floor.  The situation that struck me today is different from both of those extremes, but fraught with subtle ramifications. 

When you have had a pet for a long time, they become a big part of your life, part of your family.  We know that a pet is not going to live as long as we do, but we put that out of our minds until the day when we have to face it.  There are some things that we attribute to "just getting old" as the animal becomes a little less active, a little less playful, sleeps a little more and so forth.  When other signs of disease creep in, we may choose to accept it as "just getting old".  That's often incorrect, but it's an easy trap to fall into.  Then there are folks who see something wrong and just refuse to admit that it is wrong.  I once had a patient who had been terribly overweight for years.  Frequent attempts at reducing diets had never produced results.  When his weight began to rapidly approach normal, they just decided that the diet had finally "decided to work".  Bad decision.

Today was a similar and sad case.  These extremely nice folks from Michigan had traveled to our area to visit relatives and brought their cat along.  When they arrived at our hospital today, they told us that Tiger had been having difficulty breathing ever since they left home two days ago.  "He was fine Friday night before we left."  Well, that's a drag -- you leave for a vacation and the pet gets sick while you're out of town.  Very unhandy.  I can relate, as my son developed an earache the first night out of town on a family vacation.  We spent the next morning looking for a doctor.

On examination, Tiger was not only breathing really hard, he was also pretty dehydrated.  "Well, he hasn't been eating or drinking much since we left."  He was also really thin.  "He weighs nine pounds.  What does he usually weigh?"  "Twelve pounds."  "Have you noticed him losing weight?" Yeah, we have, I guess.  "How long would you say he's been losing weight?"  "The last six months." So, he's eleven years old, losing weight for six months, has lost 25% of his body weight.  How do you ignore that?  You ignore it because you don't want to think about losing your buddy.  Hey, he's still eating and playing.  Maybe he's just getting older.

When I listened to Tiger's chest, I didn't hear much air moving, despite the dramatic movement of his chest wall.  X-rays showed his lungs compressed into about one fourth their usual space in the chest.  The rest of the chest was full of something besides lungs.  It could have been fluid, tumor, some of both.  I'll never know for sure because his owners could not undertake heroic measures in the face of a poor prognosis, and I couldn't offer them much reassurance under the circumstances.  So we sent Tiger off to find a new body somewhere else where he can be a kitten and run and play again.

Could Tiger have had another nine lives if his strange weight loss had been addressed months ago?  Hard to say.  If his people had been able to confront losing him, would they have saved him? Hard to say.  I can say this, though: when you know something is wrong, the only way out is the way through.  You can't fix it if you won't face it.

The SECOND hardest thing...

It was just a little lump between Fluffy's toes.  I mean, it was tiny, but in three weeks it had grown and was about 3/8 of an inch.  Her owner wasn't too worried, but she wanted it "looked at".  I tried to aspirate it (suck some cells out through a small needle) for a cytology exam(looking at the cells under the microscope), but couldn't get much out of it.  So, we set her up to remove the lump surgically.  Not to worry, it's just a tiny little lump.

Unfortunately, when we cut into the skin, the lump didn't have a nice distinct border.  It just sort of went everywhere in and around the toes and tendons.  I had to remove it piece-meal.  There was no way to be sure that I really had it all;  I just kept snipping away things that didn't look like dog until I got everything that I could.  Well, hey, it could just be an inflammatory reaction -- maybe there was a little splinter or something in there.  We sent the crumbs of lump to the pathologist for evaluation.

Bad news: the lump is Mast Cell Tumor , Grade II.  If I could have removed it all with clean margins, I'd be feeling pretty good, since I've had such good luck with chemotherapy on these in the past.  Unfortunately, I couldn't remove it all and I know there is still tumor left in the foot.  I talked to the oncologist (the cancer specialist) and all of our options stink.

Fluffy's best choice for long-term survival is radiation therapy.  If you can take your dog to the University of Missouri (six hours away) and leave her for weeks, and spend about $2,000.00, the outlook is rosy.  Her owners can't do that.

If she doesn't have any spread of tumor to other parts of her body (metastasis) , we can get all of this tumor by the simple expedient of amputating her leg.  Good thing it wasn't on her nose.  Unfortunately, to do our best job of finding evidence of spread, or lack of spread ("Staging" the cancer), we need to spend about $400 in testing (and it will be about double that if she goes to the nearest specialist).

If it has spread already, then our third best choice is chemotherapy, eight treatments over twelve weeks.  It usually doesn't make them feel bad, but with tumor already spreading, the odds are we'll only get about eighteen more months for our patient.  The total cost would be between five and six hundred dollars for this little gal.  That's pretty cheap for chemo, but it's some significant money.

It's really hard to have to tell someone that they've got a bad disease and their treatment options are all expensive and may not work.  You can hold their hand and answer their questions, but you really don't have the answers they want.  I like solving problems and giving people good news, and this time that's going to be hard to do.

Chemotherapy isn't so bad.

Thinking about Macey's battle with cancer (see yesterday's post) reminded me that a lot of people have some real misconceptions about chemotherapy.  The commonly held belief is that the treatment is worse than the disease.  I often encounter pet-owners with the preconceived idea that chemotherapy makes you really sick, rarely works, and just generally makes you miserable until you die.  This is a long way from the truth, fortunately.

Chances are that you know someone who has undergone chemotherapy for cancer and who suffered extremely unpleasant side-effects, such as hair loss, vomiting, fatigue, and so forth.  This is certainly a problem.  However, the situation in pets is somewhat different than in people.

The very cool thing in treating pets with cancer is that we rarely use high-dose chemotherapy.  High doses are routine in treating people with cancer because we are trying to kill all the cancer cells and add twenty years to the person's life.  In treating pets, it has been well documented that the patient's results will be just as good with low doses of drug.  For instance, a dog with lymphoma is just as likely to go into remission (appear cancer free), and stay that way just as long when treated with low doses as with high doses.  At the low doses, the unpleasant side-effects are much less likely to occur. 

The poster boy for low-dose chemo is Checkers.  Checkers is a Cocker Spaniel who developed lymphoma when he was ten years old. His lymph nodes were hugely swollen, he was painful and very sick.  The College of Veterinary Medicine helped us to do his initial evaluation and the planning of his treatment program.  We gave him chemotherapy treatments over the course of one year.  After his first treatment, his tumors shrank noticeably.  He never felt bad for a day once his lymph nodes  returned to a normal size.  We have monitored his health and he has also made several trips back to the University of Missouri for follow-up evaluations.  He has remained free of cancer for six more years.  At seventeen, he does have some other health problems now, but no cancer.

The point of the story is that Checkers is the record-holder for lymphoma survival, being years ahead of whomever is in second place.  He took the low-dose chemotherapy, and it never made him feel bad.

Certainly we don't get such great results with every cancer patient.  Some do not respond to treatment at all.  The good thing is that the treatment probably won't make them feel bad.  The treatment is better than the disease.