scott@vtx-cpd.com
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Replying to Rachel R. 12/09/2024 - 14:00
Hey Rachel.
Thanks for your brilliant questions.
I have some thoughts, but I will let Steph wade in first!
I hope you are enjoying the course!
Scott 🙂
Replying to Sarah W. 13/09/2024 - 12:43
Hey Sarah!
I hope you are well. Great question. I will make sure Rodolfo sees this one and we will get back to you soon!
Scott 🙂
Replying to Kerida Shook 04/09/2024 - 20:57
Hi Keri,
Thank you again for your insights! I completely agree that these cases with haemoperitoneum and splenic masses are difficult to manage, especially when immediate access to advanced diagnostics like MRI or CT isn’t feasible in actively bleeding dogs. Stabilization is always the priority, and more advanced imaging often becomes secondary due to the urgency of the situation.
Regarding tranexamic acid, while it’s being explored in veterinary trauma settings, there’s no substantial evidence showing it could slow bleeding effectively enough in a case of a ruptured splenic mass. It’s generally more beneficial in perioperative care than in acute hemorrhage.
You’re absolutely right about the poor survival statistics for hemangiosarcoma (HSA) post-splenectomy. Traditionally, we follow the “double two-thirds rule,” which indicates that approximately two-thirds of dogs with splenic masses will have a malignant tumor, and two-thirds of those malignancies will be HSA, meaning around 43% of all splenic masses are diagnosed as HSA. However, these numbers evolve when you factor in haemoperitoneum. Studies show that around 21.7%–37.5% of dogs with haemoperitoneum have benign masses, and that number increases to 63.1%–70.5% without haemoperitoneum.
The recent systematic review published in J Am Vet Med Assoc (2022) by Schick and Grimes sheds more light on this. They evaluated 1,150 dogs with nontraumatic haemoperitoneum due to ruptured splenic masses and found that 73% had malignant splenic lesions, with a higher 87.3% of those malignancies diagnosed as HSA. This study highlights that more dogs than previously thought are diagnosed with malignant splenic masses and specifically HSA, suggesting that the “double two-thirds rule” may underestimate the likelihood of HSA in cases of haemoperitoneum. While these findings add valuable context in emergency settings, it’s essential to remember that a portion of these dogs still have benign conditions or non-HSA malignancies that might have a better prognosis.
In addition, the 2020 study published in Vet Comp Oncol by Owen Davies and Angela Taylor added another dimension by identifying genotype-based breed groupings and the presence of haemoperitoneum as significant predictors for malignancy and HSA. This study, which included 288 dogs, found that German Shepherds were the most commonly affected breed, and that genotype-based breed grouping was a superior predictor compared to traditional phenotype groupings. This could help refine our approach to breed-specific risk and guide decision-making.
Diagnostics, such as thoracic and abdominal imaging, are critical for assessing metastases, but definitive diagnosis only comes from histopathology post-splenectomy. Stabilizing the patient with fluids, oxygen, and transfusions is essential if bleeding is ongoing, and if the dog responds, surgery might be a valid option. Importantly, 95% of dogs with haemoperitoneum survive to discharge after splenectomy.
Finally, a study noted that clients who chose surgery were more satisfied with their decision compared to those who opted for palliation or euthanasia, with higher post-operative quality of life for the dogs. While we must remain realistic about HSA’s prognosis, surgery might still be worth considering, especially for those rare benign masses or motivated clients looking to extend their pet’s life.
Best,
Scott
Replying to Karin V. 09/09/2024 - 19:56
Hi Karin,
Thanks for the great question! Lomotil has definitely been one of the more effective options I’ve found, though its availability can sometimes be an issue. Codeine is certainly an acceptable antitussive and one I use routinely as well, particularly in the UK, where Lomotil can be harder to source. If one doesn’t seem to work well, I often suggest trying the other since both are good alternatives.
Regarding the lesson notes, could you confirm if you’re able to access the lesson itself? I hope you’re enjoying the course so far. Let me know if you have any other questions, and I’ll look into the issue with the lesson notes for you.
Best,
Scott
Replying to Liz Bode 07/09/2024 - 14:25
Hi Liz,
That’s hilarious — I was thinking of exactly the same case! That dog was such a classic example of a collapsing trachea; you could literally hear it from the other side of the car park. Like you, I was absolutely amazed at how well it responded to medical management. It really highlighted the importance of optimizing meds before jumping to something more invasive.
In that case, I believe we managed it really successfully with a combination of prednisolone, doxycycline, and an antitussive — I think we used Lomotil — and the improvement was incredible. It just goes to show that, while stenting can be a great option, sometimes medical management can work wonders even in cases that seem pretty severe at the start.
Best,
Scott
Replying to Ariane N. 01/09/2024 - 08:09
Thank you for this!
I was interested to your comments regarding owners preferences and smell!
Do you mean the smell of the cleaners/treatments?
Scott 🙂
Replying to Ariane N. 01/09/2024 - 07:55
Really helpful!
Thank you!
Scott 🙂
Replying to Ariane N. 01/09/2024 - 07:48
Thank you so much for the comprehensive reply!
These do seem to be very frustrating cases!
Scott 🙂
Replying to Maria W. 15/08/2024 - 19:46
We carried out FNA’s of the masses and analysis of the pleural fluid:
Cytology Report:
Specimen Received: 11 slides.
Site or Source: Chest mass-8 slides, axillary lymph node-2 slides.Microscopic Description:
Chest mass and axillary lymph node:
The slides appear cytologically similar. They are of high cellularity with many erythrocytes and many nucleated cells seen in a slightly basophilic background containing moderate numbers of lymphoglandular bodies and small amounts of nuclear streaming material.
The nucleated cells consist of intermediate-sized to slightly large lymphocytes with scant, deeply basophilic cytoplasm and a round nucleus with dispersed nuclear chromatin pattern. Rare mitotic figures are noted. Rare small lymphocytes and non-degenerate segmented neutrophils are seen. No infectious agents are observed.
Microscopic Interpretation:
Chest mass and axillary lymph node:
Consistent with lymphoma.
Comment: Both sites reveal an expansion of intermediate-sized to slightly large lymphocytes consistent with lymphoma. Immunophenotyping by flow cytometry may be considered for further characterization and potential prognostication and treatment options.
Specimen Received: Four mL of fluid in red top tube.
Site or Source: Pleural effusion.Analysis:
Appearance: Cloudy
Color: Orange
WBC count: 2.77 x10^9/L
RBC count: 0.02 x10^12/L
Total Protein: 18 g/L
S.G: 1.018
Microscopic Description:
Direct smears and cytospin preparations evaluated show modest cellularity with moderate numbers of erythrocytes and nucleated cells, predominantly macrophages with fewer small lymphocytes, occasional intermediate-sized lymphocytes, large lymphocytes, eosinophils, and non-degenerate segmented neutrophils. Occasional well-differentiated mast cells and few pyknotic nucleated cells noted. No infectious agents or neoplastic cells observed.
Microscopic Interpretation:
Consistent with modified transudate.
Comment: The effusion is most likely caused by the chest mass (lymphoma) causing increased hydrostatic pressure and/or lymphatic obstruction.
Replying to Maria W. 15/08/2024 - 19:46
Hey Maria!
I have popped the CT report below to give you some more detail regarding the imaging:
CT Report for Lucky
Diagnostic Interpretation:
Neck/Spine C1 – T2:
The right mandibular and medial retropharyngeal lymph nodes are moderately enlarged compared to the left.
In the oropharynx, there is a lobulated soft tissue structure that homogenously contrast enhances (precontrast: 49.9 HU, postcontrast: 104.2 HU). This structure is confluent with the ventral margins of the soft palate and occupies almost the entire ventrodorsal height and mediolateral width of the oropharynx at the level of the hyoid apparatus. The remainder of the included head is unremarkable.
The superficial cervical and middle and caudal deep cervical lymph nodes are mildly enlarged.
No abnormalities are noted in the thyroid gland.
Thorax:
Centered in the cranial mediastinum is a large rounded lobulated soft tissue mass that mildly heterogeneously contrast enhances (precontrast: 39.4 HU, postcontrast: 82.6 HU). The mass measures approximately 15.6 cm craniocaudally, 10.7 cm dorsoventrally, and 7.4 cm mediolaterally, occupying almost the entire dorsoventral height and mediolateral width of the cranial thorax.
The mass extends cranially to the thoracic inlet and caudally to the left ventral aspect of the heart, displacing the heart dorsocaudally and towards the right.
The mass causes dorsal elevation of the trachea, cranial thoracic esophagus, and brachiocephalic trunk and its branches. The cranial vena cava is dorsally elevated and narrowed.
The visualized tracheobronchial and cranial mediastinal lymph nodes are moderately enlarged. The sternal lymph nodes are not distinguished from the mass.
There is a large volume of bilateral pleural effusion with accompanying retraction and rounding of the lung lobes. Throughout the lungs, there are patchy ground-glass to soft tissue attenuations, more pronounced ventrally, most consistent with atelectasis.
There is marked enlargement and rounding of the left proper axillary lymph node.
Mild subcutaneous fat stranding and fluid attenuation are seen along the ventral thoracic body wall and axilla.
Included Cranial Abdomen:
There is moderate enlargement and rounding of the hepatic, splenic, gastric, and celiac lymph nodes.
The liver is mildly to moderately enlarged with smooth margins and homogenous contrast enhancement. There is possible asymmetrical thickening of the gastric pylorus with questionable reduction in wall enhancement. Within the included mid aspect of the spleen, there is a small isoattenuating and hypercontrasting nodule.
The remainder of the included abdomen is unremarkable.
Moderate non-bridging spondylosis is seen in the cervical, thoracic, and lumbar spine. Mineralization and protrusion of multiple thoracic intervertebral discs are noted, with no overt spinal cord compression. In the vertebral body of T8, there is a rounded hypoattenuating region, most consistent with a Schmorl’s node. The remainder of the included musculoskeletal structures are unremarkable.
Conclusions:
Large cranial mediastinal mass.
Multiple variably enlarged lymph nodes (head, neck, thoracic, and abdominal).
Bilateral marked pleural effusion.
No evidence of nodular pulmonary metastasis.
Ventral thoracic and axillary subcutaneous fat stranding and fluid attenuation.
Possible oropharyngeal mass.
Hepatomegaly.
Hyperenhancing splenic nodule – benign, less likely malignant.
Questionable gastric pylorus wall thickening.
Additional Comments:
The large cranial mediastinal mass and generalized lymphadenopathy are concerning for lymphoma. Other cranial mediastinal neoplasms (e.g., thymic epithelial neoplasia, ectopic thyroid carcinoma) with lymph node metastasis and/or lymph node hyperplasia are also possible. Cranial mediastinal granuloma cannot be entirely excluded.Ultrasound-guided sampling of the cranial mediastinal mass and affected lymph nodes (largest left axillary) is suggested for further characterization.
The bilateral pleural effusion can be due to neoplastic effusion, chyle, or less likely pus or hemorrhage. This can cause the reported panting and coughing. The rounded lung margins may suggest a chronic effusion. There is no evidence of nodular pulmonary metastasis, but this may be obscured by the suspected atelectasis.
Given the narrowed cranial vena cava, the subcutaneous fluid is suspected to be due to cranial vena cava syndrome (edema). A neoplastic effusion, cellulitis, or hemorrhage cannot be excluded. There is a possible oropharyngeal mass; however, this region is not entirely included in the field-of-view, and correlation with oral examination is suggested.
The questionable gastric wall thickening may be due to folding as this region is not completely included. Neoplastic infiltration or pyloric hypertrophy is possible. The hepatomegaly is nonspecific and can be due to a vacuolar hepatopathy, hepatitis, lymphoid hyperplasia, or less likely diffuse neoplasia. Clinical significance can be correlated with clinical history, and abdominal imaging can be performed if clinically indicated.
Replying to Kerida Shook 25/08/2024 - 17:14
Hi there,
Thanks for sharing your experience! I agree that while using certain techniques or avoiding particular procedures might make dentals a bit more challenging, it’s always worth prioritizing the safety and long-term well-being of the patient. The potential for post-GA blindness, while rare, is certainly something to consider, especially in our feline patients. It’s great that you’ve not encountered any cases, but as you mentioned, the effects might not always be immediately noticeable.
Scott 🙂
Replying to Kerida Shook 25/08/2024 - 17:42
Hello Kerida!
I hope you are safe and well. I agree with your recommendations! Here are the recommendations I made to the owners initially:
“Fluffy’s investigations are most consistent with inflammation of the lower airway.
Medication Adjustment: We recommend continuing the prednisolone at 0.5mg/kg once daily (2.5mg total dose once daily). Despite previous concerns over steroid use, these are the best medications to deal with airway inflammation. We recommend using this at this dose for a further 2 weeks.
Antibiotic Course: Due to the presence of some areas of consolidation, we recommend a course of antibiotics. We suggest using doxycycline at 10mg/kg/day orally. This medication can be dispensed by your referring veterinary surgeon.
Dietary Management: Given the suspicion that vomiting/regurgitation is related to eating too fast, consider feeding Fluffy smaller, more frequent meals or using a slow feeder bowl to prevent rapid eating. If vomiting/regurgitation is persistent, this may also need to be investigated as it could be contributing towards the coughing/gagging if any food material is being aspirated.
Further Diagnostic Testing: Consider further diagnostic tests such as bronchoscopy, CT scan, and bronchoalveolar lavage (BAL) to confirm the diagnosis of lower airway inflammation and determine the best treatment approach.
Environmental Management: Ensure Fluffy is not exposed to environmental irritants such as smoke, dust, or strong odors, which can exacerbate lower airway inflammation.
Follow-Up: Make an appointment for a telephone catch-up with me in 2 weeks to discuss Fluffy’s progress and adjust her treatment plan accordingly.”
We did indeed have discussion about using inhaled therapy in the longer term.
Scott 🙂
Replying to Ariane N. 27/08/2024 - 07:06
Thank you so much for the reply!
Really helpful!
Scott 🙂
Replying to Liz Bode 01/09/2024 - 20:38
Hey Liz!
Fancy seeing you here!
Scott 🙂
Replying to Anna H. 01/09/2024 - 20:39
Hi Anna,
Welcome to the course! It sounds like you have a wealth of experience, and it’s great to hear you’re embracing the challenges of GP practice. I’m sure the course will be a great way to refresh your knowledge and boost your confidence after returning from maternity leave. Looking forward to learning alongside you and sharing experiences!
Let me know if you have any questions.
Scott 🙂
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