The Tumor Dilemma

WARNING: this post contains graphic content

This post is a bit different from my other subjects, but I feel it necessary to document the process we recently went through with our dog of choosing whether or not to pursue surgery for a large tumor. My hope is to provide information to others in the same position to help them make an educated decision about surgical options.

Patient: Vlad, a 13+ year old Siberian Husky/Greyhound mix, neutered male.  Owner is a retired veterinary technician.  Vlad was trained and used as a sled dog and companion animal.  Former residence in WI, IL, OR, and WA.  History of Lyme Disease, porcupine encounter, gunshot wounds, hit by car, dermal cysts, lipomas, adinomas, lick granuloma, anal gland infections, arthritis, partial hearing loss, and dental extractions for dead teeth likely from kick to face from a farm animal he chased.  Known beet pulp allergy.  Current diet is Orijen Senior.  Supplement of 1000 mg Glucosamine/chondroitin daily.  Owner has performed routine labs annually and uses flea/heartworm preventative monthly.

Vlad began to develop a growth on the inguinal aspect of the right stifle (inner right knee) around September 2015.  Due to its easily mobile nature, the owner assumed it to be another lipoma (benign fatty tumor) as Vlad had developed many by this time.  The mass slowly but continually grew and the owner brought it to the vet's attention at a routine annual visit in March 2016.  The mass was about baseball size at this time.  A fine-needle aspirate revealed the mass was in fact a spindle-cell type tumor.  A description of spindle-cell tumors is here.  With the location and size of the mass, curative surgery could only be achieved via amputation of the affected limb, and Vlad had started to lose fecal continency and conscious propriaception (awareness of feet) in both hind limbs from ankylosing spondylitis in the spine and was determined to not be a viable candidate for amputation.  Due to their propensity for ulceration, proliferation, and recurrence post-op, the vet and owner mutually agreed to refrain from other surgical intervention until additional issues occurred.  Routine labwork performed at this appointment revealed elevated BUN/creatinine levels and bacteria present in urine.  Enrofloxacin was prescribed and labs repeated post-treatment showed values within normal limits.

The mass showing scratch marks from nails of other foot

The mass continued to grow slowly to softball size until September 2016, when it began to affect Vlad's gait due to the tension applied to the skin around the joint as well as the mass hitting the opposing limb.  Vlad routinely "ran" in his sleep and this caused his nails to scratch the mass. Cephalexin was started prophylactically.   Irritation from the scratches led to Vlad chewing open the mass, leading to immediate need for surgery or euthanasia as ongoing open wound management would significantly impair both the patient and owner's quality of life.

Patient self-mutilated mass resulting in moderate blood loss

Blood loss on porch from mutilation

As the owner and the rDVM are friends outside their professional relationship, the owner was able to contact the DVM for advice.  The owner flushed the wound with sterile saline, placed a wet-to-dry bandage, and devised a sling from an old bra to support the mass overnight.  An elizabethan and donut collar were placed to prevent further mutilation, and the patient was tranquilized with acepromazine and given tramadol for pain.

Bra sling and wrap

Bra sling to support mass

Confined to crate and tranquilized

The owner met with the DVM the following day at an emergency clinic for evaluation.  A new wrap was placed and radiographs were taken to check for metastasis and submitted to a radiologist for evaluation.  The owner opted to continue wound management for a few days to allow evaluation of their options.

Multiple restrictive devices were necessary to prevent access to the wounds.

The radiology report showed no evidence of metastasis but did reveal a previously broken 10th rib (healed), significant arthritis and narrowing of the spine, and "focal indentation consistent with degenerative change or local infarct" of the left kidney.  Surgical estimate with a surgeon was around $2800.  With this information the owner weighed the pros and cons of surgery.

Pros: slow-growing tumor that would not likely recur before another complication of age arose, no evidence of organ malfunction on labwork or metastasis on radiographs

Cons: cost, surgery would be non-curative/palliative only and tumor is highly likely to recur, unknown recovery time, questionable owner ability to restrict activity post-op, unknown recovery time, owner unable to carry pet to go outside, questionable post-op longevity, questionable continued mobility and continence due to progressive spondylosis.

The owner decided on euthanasia due to the long list of cons and the general attitude of the patient.  On the day of the appointment the owner did not give acepromazine and brought Vlad to the dog park at Point Defiance for a last play session.  While there, it became apparent that Vlad had greater energy and mobility than the owner thought (she didn't evaluate this after the mutilation incident without tranquilizers) and decided to proceed with a surgical consult.

Enjoying the "last day" on the couch

The following morning Vlad presented to the surgeon who was able to describe the surgical and recovery plan in further detail and the owner determined she was able to manage the patient post-op.  Surgery was performed the same day and as the owner had experience with anesthetized and recovering animals the patient was sent home that night rather than remaining in hospital overnight.

Recovery at home

Induction of anesthesia was performed using Propofol due to the patient's advanced age and history of adverse reaction to Telazol and Ket/Val to a lesser extent.  A Fentanyl CRI was used for surgical pain management.  The mass was well encapsulated (separated from other tissues) but more vascular than previously thought, and a Jackson-Pratt drain was placed to collect any fluid accumulation.  Available skin for closure was limited which made certain areas tight upon closure.  The incision was closed with staples superficially and dissolvable suture subdermally.  A pressure wrap was placed to help fluid to the drain rather than accumulating distally (at the toes).  The patient was true to his breed and vocal during recovery as well as anxious without the owner's presence.  At the time of discharge the patient was barely able to walk and a Buprenorphine injection was administered for overnight analgesia.  The overnight recovery was restless despite adequate pain control and administration of acepromazine.  The patient urinated on bedding but the owner had anticipated this and placed appropriate collection materials.  Cephalexin was continued, tramadol and Truprofen used for pain management.  Patient was uninterested in food post-op.

Bland diet of cottage cheese, lean ground beef, and rice

The following morning the patient ate a small amount of bland diet but was generally disinterested in food (Vlad has an easily upset stomach).  Famotidine was given to help settle stomach.  Acepromazine was used to keep patient immobile and bathroom breaks required carrying Vlad up and down the back stairs.  Transport from the bed to outdoors was accomplished via "magic carpet rides" on a large blanket as the owner was unable to carry Vlad very far.  Support was provided with a sling from a beach towel while standing.  In general the patient slept, but if the owner was not within sight he became anxious and tried to wander to locate her.  Fluid accumulation in the drain in the first 24 hours was about 60 mls.

2 days post-op

The wrap was replaced every 24 hours for several days.  Daily correspondence with the surgeon on drain production determined it would be left in place until 24 hour production was less than 25 mls.  5 days post-op the owner brought Vlad to be evaluated for drain removal and infection of the incision as well as a "razor burn" area at the anterior aspect of the hock from surgical prep.  Flocculent material was discovered in the drain fluid, swelling/edema at the distal aspect of the incision and redness/irritation of the incision warranted a change in antibiotics to Clavamox.  The drain was removed and the DVM ordered hot compresses to the edemous area 4-5 times daily.  Compresses were performed with a microwave bean-filled pouch.  Famotidine was traded for Omeprazole to help upset stomach.

10 days post-op

Three days after drain removal the staples were removed as an area of the incision appeared to be pulling apart/tearing from the staples.  The area mid-incision where there was the least amount of skin to close formed a medium scab and the surgeon was concerned about possible tumor involvement preventing healing.  However the day after removing the staples this site and the razor burn site began to drain pus.

Area of concern for surgeon

Pus began to drain along this scab

Draining tract at razor burn site

The new antibiotics began to combat the infection but the scab on the razor burn began to crack each time Vlad walked.  With the rDVM's advice both scabs were soaked off, the freshly opened areas were cleared of pus, antibiotic ointment applied, and a collagen-type wrap was placed over the razor burn site to maintain wound moisture and encourage healing.  The wrap was replaced daily.

11 days post-op, first real time out of the cone with direct supervision.

The day after the wound debridement Vlad was feeling a bit better, enough to dig up a previously-buried bone while the owner worked in the yard with him under direct supervision.

2 weeks post-op

2 weeks post-op

3 weeks post-op

3 weeks post-op

The incision continues to heal with the area of concern gradually closing.  However the skin in the area remains tight and needs to stretch/regrow before Vlad can comfortably walk again.  It is now 3.5 weeks post-op and the razor burn remains the most vexing aspect - difficult to heal due to the location being in constant motion.  I've continued to apply wraps with balm but recently switched from Bag Balm to Farnam Tri-care without wrapping which has helped healing immensely in 2 days.  My largest concerns at this point are his sensitivity on that leg which I believe I've determined to be from the extremely tight skin, and a swelling posterior to the incision that feels like part of the mass between the tendon and musculature; however that was also the area that became very edemous so I'm wondering if it's a hematoma.  He is playing, fighting with Potter, being belligerent, and finally back to sleeping in his crate since he's no longer wearing the cone.  Only medication at this point is the Truprofen for ongoing arthritis.

What's left of the razor burn 10/6

My takeaway message for those facing the same difficult decision is: evaluate all angles.  What are the pre-existing conditions?  Are you confident you can handle post-operative care including activity restriction?  Have you spoken directly with the surgeon after they examine your pet?  Do you have the patience to deal with possible complications of surgery like the infection?  Can you handle wound management?  Have you evaluated your pet's quality of life and will to live?  Do you understand that this surgery is not curative and the mass will regrow?  Do you have a veterinarian that is willing to answer your questions as they arise?  And are you financially able to handle the cost of surgery?

When I made my initial decision to euthanize, I did not have all these answers.  Now I'm glad I sought them and proceeded with surgery.  However your situation is unique and my decision cannot be applied universally; but I hope that the description of the process and the list of issues I needed to address help you make that decision.

If you need me, I'll be working a seasonal part-time job to pay this off.