Help/advice please; my little dog

Re: Help/advice please; my little dog

Anthony Dennison — Wed, 26 Mar 2014 14:27:46 GMT

Sorry to hear the news. I know how it feels - just last night I delayed going to bed for an hour because I thought my dog was having an increased resp effort in his sleep - turns out he was huffing and puffing because he'd curled up under a throw and got too hot!!

I had a client that has a dog with multiple lung masses on chest xrays, was referred and she was found to have diffuse histiocytic carcinoma. We went along the palliative care route due to the prognosis, and started on preds and bronchodilators. She was happy and playful up until the last 3 or 4 days of her life. We arranged a home visit for euthanasia, and she died the night before I was due to go.

The owners were very glad of that extra month they had with her; when she went she deteriorated quickly and didn't suffer too badly.

Good luck with everything

Re: Help/advice please; my little dog

Jscvet — Tue, 25 Mar 2014 13:29:12 GMT

[quote user="Hannah Wynne Richards"]

I'm really sorry. Spoil him rotten for as long as you have him.

Wynne

[/quote]

Thank you Wynne, I have been; hes been loving all the extra treats (that I was always so careful with so he didn't get fat : ( ). This has been one of the most difficult things I've had to do; decide whats best for him, in the most informed manner, whilst balancing out the fact, that I know my little dog best. That's him in my avatar, taken just earlier this year, he is an extremely special dog to me. I will continue to research everything to ensure I give him every chance at as long and good quality life as possible (with absolute and complete emphasis on the latter). Rest assured, it will always be what is right for him, that will be the path I chose. At least I can say that I'm trying my best, and everyone has been so helpful in aiding me to do that; you've all been wonderful :), thank you

Re: Help/advice please; my little dog

Hannah Wynne Richards — Tue, 25 Mar 2014 08:55:23 GMT

I'm really sorry. Spoil him rotten for as long as you have him.

Wynne

Re: Help/advice please; my little dog

Gerry Polton — Tue, 25 Mar 2014 08:13:19 GMT

For those of you following this thread, this is the large part of my response to Jayne's further e-mail:

Hi Jayne

Palliative care means symptomatic treatment and I guess in my head the term includes a change of focus from trying to resolve the problem to one of trying to accept the problem and to minimise the negative impact of the fact of the problem on the patient. So, if steroids have helped, I would consider using them again. I suspect the reason they helped is because they have an antitussive effect rather than because the tumour has a significant inflammatory component.

With a respiratory rate of 30, and a readiness to tire, I would definitely not be advising surgery, for all the reasons stated previously. This indicates a degree of compensation for the presence of the significant disease burden noted radiographically and I interpret this to mean that Toohey would continue to thrive, despite his cancer, for a few months yet if surgery was avoided. I sadly suspect that if surgery were performed Toohey would either be euthanised under GA or would recover but would take a number of weeks to truly get over the surgery, only for further problems to arise within or shortly after that time.

A CT would certainly help to clarify the extent of Toohey's problem. However, I think we know enough already and therefore I do not think it is a clever thing to do right now. If you were happy to commence chemotherapy then I think that is likely to be your best bet. I would be much happier stating that advice having seen Toohey but I realise that you would have to travel a long way for that.

My sympathies once again

Gerry

Re: Help/advice please; my little dog

Jscvet — Mon, 24 Mar 2014 20:10:10 GMT

[quote user="Gerry Polton"]

Hi Jayne

I am sorry that I have come to this one a little late. I was on annual leave for the last week. I hope that your appointment with the consultant turns out/turned out well.

To answer the general questions that have been asked: the radiographic appearance and cytology findings you report are sadly most consistent with a primary lung tumour.

Prognosis for these patients is very closely associated with clinical stage, which in plain English means that small non-metastatic tumours respond well to excision and larger or multifocal ones do not. I do not advise surgery for the cases with large or multifocal tumours. Large in this context can be defined as 'big enough that the tumour extends into the lobar bronchus or through the pleura'. CT categorically does provide excellent detail of the anatomic extent of the tumour so long as you know can obtain good CT images and how to interpret them in the context of this particular kind of tumour. If satisfactory CT capability is not available, I can see how thoracoscopy might be helpful.

For the patients with focal 'small' tumours, surgery should be expected to achieve at least twelve months of being disease-free, alert and happy. For the patients with large or multifocal tumours, surgery almost without exception leads to an earlier demise than would have been the case with palliative care alone. This is a message to all of you; many of these patients are made considerably worse by the do or die approach that has historically been taken to cases of similarly grave disease. Sadly, it is sometimes better to accept the inevitability of a terminal complaint and to ensure that best supportive care is provided than it is to attempt 'life-saving' surgery. There is a significant increase in post-op morbidity, for those that survive the peri-operative period.

For those cases that are considered to be poor candidates for surgery, there are some that respond to the adminstration of the semi-synthetic vinca alkaloid, vinorelbine. This confers a relatively high risk of myelosuppression but the treatment protocol that would be used would incorporate a strategy for dealing with that. I would advise that if you wish to pursue this treatment, you start working with an oncologist and then plan to take on the treatment yourself, if you wish to, once the nature of the response to therapy has been established.

Finally, Jayne, I wish to forward my sympathies that you find yourself in this situation. Do feel free to contact me directly if you have any further questions: gpolton@ndsr.co.uk

Gerry

[/quote] Thank you Gerry, very much, I've sent you an email :)

Re: Help/advice please; my little dog

Gerry Polton — Mon, 24 Mar 2014 08:56:44 GMT

Hi Jayne

I am sorry that I have come to this one a little late. I was on annual leave for the last week. I hope that your appointment with the consultant turns out/turned out well.

To answer the general questions that have been asked: the radiographic appearance and cytology findings you report are sadly most consistent with a primary lung tumour.

Finally, Jayne, I wish to forward my sympathies that you find yourself in this situation. Do feel free to contact me directly if you have any further questions: gpolton@ndsr.co.uk

Gerry

Re: Help/advice please; my little dog

Andrew Kent — Sun, 23 Mar 2014 16:00:21 GMT

[quote user="Jscvet"][quote user="Andrew Kent"]The other thing you could consider (depends on centre you are going to) is that if CT looks good then to start with thoracoscopic assessment and then to proceed to thoracotomy if it looks like removal is possible. That way if something comes to light at the thoracotomy that means it won't be removable they can still wake up from GA after taking some biopsies as the recovery from that is minimal and hopefully avoid the possibility of euthanasia under GA in a dog that is still bright and happy.

Andy

[/quote] That sounds like a very good option, I've been looking into thoroscopic assisted thorocotomy but wasn't sure how utilised it was in veterinary medicine as yet or which centres offered it. Could I please PM you to discuss it a bit further? (Do I just use the start a conversation option?!) thank you :)

[/quote] No problem, I've sent you a PM so you should just be able to reply to that in 'my conversations.' Andy

Re: Help/advice please; my little dog

Jscvet — Sun, 23 Mar 2014 15:36:11 GMT

[quote user="Andrew Kent"]The other thing you could consider (depends on centre you are going to) is that if CT looks good then to start with thoracoscopic assessment and then to proceed to thoracotomy if it looks like removal is possible. That way if something comes to light at the thoracotomy that means it won't be removable they can still wake up from GA after taking some biopsies as the recovery from that is minimal and hopefully avoid the possibility of euthanasia under GA in a dog that is still bright and happy.

Andy

Re: Help/advice please; my little dog

Andrew Kent — Sun, 23 Mar 2014 14:53:24 GMT

The other thing you could consider (depends on centre you are going to) is that if CT looks good then to start with thoracoscopic assessment and then to proceed to thoracotomy if it looks like removal is possible. That way if something comes to light at the thoracotomy that means it won't be removable they can still wake up from GA after taking some biopsies as the recovery from that is minimal and hopefully avoid the possibility of euthanasia under GA in a dog that is still bright and happy.

Andy

Re: Help/advice please; my little dog

Andrew Kent — Sun, 23 Mar 2014 14:50:58 GMT

Ultrasound can certainly help to a point, it will allow some assessment of the extent and association with major vessels and will allow assessment of some lymph nodes (for example sternal lymph nodes) but not all. It won't give you nearly as much information as CT which allows assessment of all the thoracic lymph nodes, a more complete evaluation of extent and is the most sensitive way to look for metastatic disease. You could do the abdomen as well in case this is not a primary. Ultrasound might be slightly better at looking for foreign material?

I wouldn't consider surgery without CT as you wouldn't want to miss a met and go through surgery for minimal benefit.

you would have to ask a surgeon about how best to acces this but sometimes even big masses can be accessed intercostally depending on origin.

Andy

Re: Help/advice please; my little dog

Jscvet — Sun, 23 Mar 2014 13:11:02 GMT

Thank you Andy, with regards to the ct, it was suggested to me that ultimately it may not be as helpful in determining the extent of invasiveness etc, and that to be able to visualise it was probably the only way to get an answer as to the possibility of excision. The huge issue I have with that (even without the surgical aspect), is that, if it is found not to be resectable then pts on the table would be kindest. That thought, especially when I have him sitting here with me pretty much the same as he always is, is almost impossible to comprehend. Because any time with him (as long as it's good quality of course) is precious to me and I would always chose that. I was concerned with the possibility of tumour seeding also with fna, I will ask all these questions tomorrow. With regards to thoroctomy, I'm assuming it would need to be midline due to the size of the mass on rg? It just sounds such a big thing on a small dog. The other thing in my mind, is a couple of weeks ago, when his cough/retch seemed to be occurring daily (though v low frequency), I thought it may just be a cycle so gave him just 5mg pred (he's 7.4kg) Sid for a couple of days- it resulted in total and complete resolution, which amazes me now given it surely must be mainly the pressure of this thing on his airway. There must be a lot of inflamm associated with it I guess. In your opinion, will the repeated ultrasound be useful to see the extent of this things involvement? Do you visualise enlarged lns if they are present? We only scanned the right side of his lung, mainly to take the fna samples. So it will be more detailed tomorrow.

Re: Help/advice please; my little dog

Andrew Kent — Sun, 23 Mar 2014 12:37:13 GMT

[quote user="Jscvet"]I tried to edit my last post but am not sure it worked- really just to say I know I sound like I'm clutching at straws (which I am!), I know the most likely realistic scenario, I just can't seem to stop myself doing it just yet.

[/quote]

it's not a bad thing to keep better scenarios in your mind as well! it's easy to jump to bad conclusions about these things and the truth is that all that does it make you worry more. You can't do any more than you are already doing and so keeping some hope is not a bad thing.

I'm sure the specialist centre will get you and him sorted out. The one thing I would say is that repeated sampling of these masses is often not very helpful and comes with its own set of risks (seeding tumour, haemorrhage, pneumothorax etc). Whatever it is, inflammatory or neoplastic, it needs to come out if possible. Therefore if this is surgically resectable (which is best determined from CT and at thoracotomy) then I wouldn't push for trying to get lots of samples first. Dogs recover very quickly from thoracotomy (especially intercostal). I would only go for thoracoscopy if I don't think it's surgically resectable. And most neoplastic processes cannot be diagnosed with any great certainty on FNA. Just my thoughts based on how we normally approach these cases, but I'm sure other centres approach them differently, so there is not necessarily a right answer.

all the best for tomorrow.

Andy

Re: Help/advice please; my little dog

Jscvet — Sun, 23 Mar 2014 12:22:28 GMT

I tried to edit my last post but am not sure it worked- really just to say I know I sound like I'm clutching at straws (which I am!), I know the most likely realistic scenario, I just can't seem to stop myself doing it just yet.

Re: Help/advice please; my little dog

Jscvet — Sun, 23 Mar 2014 12:16:56 GMT

[quote user="Sarah McGurk"]

Best of luck tomorrow. I hope everything goes well.

[/quote] Thank you :)

Re: Help/advice please; my little dog

Jscvet — Sun, 23 Mar 2014 12:16:14 GMT

Thank you Suzanne, Joyce and Wynne, your thoughts are appreciated. I have my appointment tomorrow with the specialist at 12.30- tomorrow will be a through ultrasound, plus further fnas depending on the diagnostic value of our first set (which are being analysed tomorrow at the same place as a matter of urgency). Then I will need to consider things carefully. I have of course been researching it, new thoughts, treatment options etc, but until I know the exact cell type and have a better idea of what the actual mass is, that's slightly more tricky. I know fnas can be misleading, but all I can do is hope they give us an answer. If not, I have been considering things and have been thinking if a biopsy via thoroscopy may be a better choice rather than straight to massive surgery? I still keep thinking, what if this is some horrible inflammatory reaction surrounding a piece of fb? Just don't want to make the wrong decision- either to put him through something he doesn't understand, with little reward for him, or to give up on him thinking it's something completely untreatable, when it's not. He is the important one here that I need to consider, but I think we've all had those cases who amazed everyone and beat the odds. Plus when something is as rare as primary lung cancer is, and the fact he's a cross breed terrier who is 9 (and I was convinced those guys just go on forever :))- you think, there's limited data really to explore and so surely, we can't predict so accurately in these cases?? I will keep you updated, any further info/experiences much appreciated.

Re: Help/advice please; my little dog

Sarah McGurk — Sun, 23 Mar 2014 12:06:39 GMT

Best of luck tomorrow. I hope everything goes well.

Re: Help/advice please; my little dog

Hannah Wynne Richards — Sun, 23 Mar 2014 11:07:13 GMT

All I can add is my sympathy and best wishes to you both.

Wynne

Re: Help/advice please; my little dog

Joyce Whitehead — Sun, 23 Mar 2014 10:08:31 GMT

Good luck Jayne, no advice from here except take care of yourself. It is very tough when these things happen to our own dogs, but fingers crossed for the little chap.

Re: Help/advice please; my little dog

Suzanne Kelly — Sat, 22 Mar 2014 23:46:31 GMT

+1 for CT, hope it turns out well for the little guy. It's really horrible when something happens to your own pet, being at the other side of the consult table is no fun at all. Let us know how he gets on.

Suzanne

Re: Help/advice please; my little dog

Jscvet — Sat, 22 Mar 2014 23:45:57 GMT

Thank you, all of you for your empathy and comments. I am likely to be seeing a consultant on Monday and I will keep you updated. It looks as though it will be Monday before I have the cytology results as clin path wasn't available this weekend, but they will be rushed through as urgent. I guide clients through such situations, help them with decision making (as far as I am able) etc most days, but when it comes to my little dog, I am struggling I must admit. There is the possibility that if an ex. thoracotomy is necessary to truly assess the degree/invasiveness of the mass, that I will be faced with letting him go whilst under. The decisions involved over the next few days will be so tough, I've had just since yesterday to get my head round the fact he's so unwell ( though his outward appearance doesn't reflect this, certainly not to the level I would've expected)- the possibility that I may actually be losing him so soon, when just a few days ago we were out walking, pretty much oblivious, seems surreal. Thank you all once again, I may very well request your collective advice very soon. Jayne

Re: Help/advice please; my little dog

james herriot lied — Sat, 22 Mar 2014 19:06:32 GMT

Sorry - re-read the OP and saw that I'd missed the bit about ultrasound.

Re: Help/advice please; my little dog

james herriot lied — Sat, 22 Mar 2014 19:04:56 GMT

Ouch. Hang in there, and keep doing what you're doing. We're all of us waiting for some good news from you

I don't tend to post much on here these days, but just wanted to empathise and share that I, too, know what it's like to casually examine my own dog and suddenly realise that that 'minor' ailment is anything but.

Re: Help/advice please; my little dog

Jscvet — Sat, 22 Mar 2014 17:23:30 GMT

It's good to know that I'm not the only one Mark! Although I took his bloods, placed his iv catheter and held him till he was induced, I handed him over then to my very capable colleagues (who then, poor things, had the horrible job of showing me the X-rays). Although I get very attached to my patients, you need sometimes that little bit of distance to allow you to be objective- I totally lack that with my own pets. On the basis of the radiographs- has anyone ever seen a mass lesion like this associated with a foreign body?? I believe they usually prefer the caudal lobe, and I know it's highly unlikely, but I just keep a little bit of hope that maybe Toohey will turn out to be one of those cases, where everything seemed dismal but something turned up that surprised everyone.

Re: Help/advice please; my little dog

Mark Hedberg — Sat, 22 Mar 2014 16:38:34 GMT

[quote user="Jscvet"]Thank you Andy, it's good to have the support of colleagues on here at this time because I've been a little bit in pieces since yesterday and at least this makes me feel like I'm doing something. My plan is to get the little guy referred next week and I was hoping they would suggest ct scan as a good next step. I do wonder if the report on the fnas may be inconclusive as part of one of the aspirates was quite caseous looking material. I will certainly post the fna and bal results on here when I receive them, which hopefully won't be long.

[/quote]

Total and massive sympathy for your situation. Whether a referral or simply a colleague, I've always made it a personal policy to never treat my own pets, precisely because I'm an absolute hopeless old softie/nutter about my own pets and I haven't a chance in hell of making an objective decision. Yes, when i'm a client, i'm 'that guy' - a thousand questions and wanting to know everything. My apologies in advance to any future vet who may see my pets...it's nothing personal!

Re: Help/advice please; my little dog

Jscvet — Sat, 22 Mar 2014 16:22:46 GMT

Thank you Andy, it's good to have the support of colleagues on here at this time because I've been a little bit in pieces since yesterday and at least this makes me feel like I'm doing something. My plan is to get the little guy referred next week and I was hoping they would suggest ct scan as a good next step. I do wonder if the report on the fnas may be inconclusive as part of one of the aspirates was quite caseous looking material. I will certainly post the fna and bal results on here when I receive them, which hopefully won't be long.