LBAH Informational Articles

Mast Cell Tumor

Up to 20% of dogs will get a malignant Mast Cell Tumor (MCT) in their lifetime, making it the most common tumor we encounter in dogs. Other names for MCT are mast cell sarcoma, histiocytic mastocytoma, and mastocytosis.

This disease has a cutaneous form (skin) and a systemic form (internal organs).  The cutaneous form is more prevalent, and is sometimes referred to as the “great pretender” because the skin growth appearance is so variable.  What might seem like just a minor swelling or inflamed area can be a highly malignant cancer. It might also be called the “great fooler” because most people underestimate the problem.

MCTs have the potential to be highly malignant and their treatment needs to be thorough and comprehensive in order to minimize the chance of spread and premature death of your pet. In almost every case the treatment of choice is surgery to remove the tumor. After surgery additional treatment might be indicated.

This page will give detailed information on MCT in the dog since that is the primary species that gets this disease. We occasionally see MCT in cats and ferrets. MCT are second most common tumor in cats. They behave somewhat differently in our feline friends. We will go over MCT in the cat at the end of this page.

Throughout this page are links to numerous other areas on the LBAH web site to give you additional information on that specific topic.

There are some mild surgery pictures in this page showing the open skin after a MCT has been removed. They are suitable for most viewers.

Physiology

Mast cells, also known as mastocytes, originate in the bone marrow and live for weeks to months. Once produced by the bone marrow they circulate through the body ending up in large numbers in the connective tissue of the body, lymph nodes, under the skin, and in internal organs.

Mast cells surround nerves and blood vessels, and are oftentimes found at the interface between the environment and the pet. This means they tend to be found in higher numbers under the skin and the lining of the respiratory system and digestive systems. They play a role in wound healing and defense against invading bacteria, and are a big part of the immune system. They have binding sites on them for the immunoglobulin called IgE. This immunoglobulin is a big part of the immune system when it comes to allergies. You can learn more about it by linking to our allergy page.

Mast cells have the potential to release several different compounds, the most important of which are called vasoactive amines. Vasoactive amines are nitrogen-containing compounds that act on blood vessels. The more important vasoactive amines are histamine, heparin, serotonin and prostaglandin. Histamine is the most important one in relation to MCT.

Histamine goes to the stomach lining and stimulates the secretion of gastric acid. Histamine also dilates blood vessels and increases permeability of the blood vessels, leading to swelling (edema). This mechanism is part of the normal inflammatory process.

Release of large amounts of histamine from a mast cell can result in ulceration or perforation of the GI tract (stomach and intestines) causing pain, hemorrhage, delayed wound healing, shock, and dark blood in the stool (melena). A significant number of dogs with MCT that are necropsied (autopsied) after death have ulcerations in the stomach.

This release of excess histamine is called the paraneoplastic syndrome. It is serious and needs to be addressed prior to and after treatment. This is why any skin growth needs to be handled gently in case it is a MCT and histamine gets released in an excessive amount.

When excess secretion of histamine occurs and only affects the skin it is sometimes known as Darier’s sign. You will notice raised and red areas of the skin when this happens.

In young animals the disease might spontaneously resolve. This is not something you should count on though. This cancer in dogs is unpredictable and can be extremely aggressive, so waiting to see if it resolves is not a good option. Every MCT should be treated as potentially malignant. MCTs can mimic other tumors, making it impossible to identify them simply by appearance.

 Tumor Behavior

As a general rule, benign MCT will be slow growing, well circumscribed (their margins are easy to feel), non-painful, not attached to the underlying tissue, and exhibit minimal inflammation. They might be irritated if your dog or cat is licking at them.

Malignant tumors tend to grow more rapidly, might be ulcerated or painful, have poor margins to determine where they begin and end, are fixed to the tissue below, and may have spread to nearby blood vessels and lymphatic tissue as evidenced by enlarged peripheral lymph nodes.

If the MCT spreads to the internal organs (called systemic mastocytosis) it usually goes to the liver, spleen, lymph nodes, or even back to the bone marrow.

In dogs most MCT are usually found on the trunk and perineum, sometimes on the limbs, and occasionally on the head or neck. MCT of the perineal and inguinal regions tend to behave more aggressively than their tumor grade would predict. Some dogs get multiple tumors.

Mast cell tumors that are large (more than 4 cm), on the face, muzzle, and oral cavity tend to have a poor prognosis.

Mast cell tumors located in the perineal region (anus, scrotum and vulva) may be may be more difficult to remove completely. They might need additional surgery or radiation and chemotherapy.

Dogs that have signs of gastrointestinal ulcers (vomiting, poor appetite, lethargy, or black stools) generally have a poor prognosis. Tumors that recur soon after surgery have a poor prognosis.

You cannot tell definitively whether any skin inflammation is a tumor or something else, and if it is a tumor, whether it is benign or malignant, just by looking at it or feeling it. Microscopic analysis by a veterinary pathologist is the only way to confirm this diagnosis. When we take a tiny sample of cells with a needle (called a fine needle aspirate- FNA) we call this cytology. When we take a large piece of tumor, or even the whole tumor, we call this histopathology.

Cause

There are several factors that contribute to this problem that include genetics, hormonal, environmental, and immune influences. There is suggestion that MCT are related to red or golden hair coats, allergies, or viruses. None of this has been proven at this time.

As is the case with many cancers it is a genetic mutation that is the originating factor. A tumor suppressant gene (called p53) can mutate and is suspected to cause MCT in 50% of the canine cases.

A gene named C-Kit can mutate, leading to excess production of a protein called Kit, which can cause excessive stimulation of mast cells.

Diagnosis

Diagnosis is made based on the Diagnostic Process we utilize in call cases. This includes:

  • Signalment- species, breed, reproductive status, and age.
  • History- observations of the problem you make at home, along with diet, environment, medication, and past medical history
  • Physical exam- Abnormal and normal findings on our exam
  • Diagnostic tests- used to rule in our rule out certain diseases
  • Response to treatment- Does your pet improve when we treat it

For more detailed information on the Diagnostic Process follow this link .

1. Signalment

MCT’s occur in both males and females, typically around 8 years of age or older, although they have been seen in dogs much younger.

This is one of the few diseases that might occur in mixed breed dogs as much as purebred dogs. Certain breeds have a higher incidence though:

  • Boxers
  • Pugs
  • Boston Terriers
  • Labrador Retrievers
  • Beagles
  • Schnauzers
  • Bulldogs
  • Bull terriers
  • Basset hounds
  • Weimaraner
  • Golden retrievers
  • German shorthaired pointers
  • Scottish terriers
  • Shar peis
  • Rhodesian ridgebacks

In cats it is the Siamese breed that has a higher incidence. There is no difference in occurrence rates between males and females.

 2. History

The most consistent symptom of pets with MCT is a growth somewhere on the skin when grooming or petting. Multiple growths are possible, but in most cases it is one skin growth that is found. It might be tiny and barely inflamed, or it might be large and firm. Some pets will be oblivious to the tumor, while others might lick or chew at it. Many MCT wax and wane, which can make pet owner’s think the growth is not important. This waxing and waning can go on for months.

Other symptoms depend on whether heparin or histamine is being released (the paraneoplastic syndrome). In this case a pet can be vomiting, have a bleeding disorder (coagulopathy), have stomach ulcers, blood in the stool (melena), poor appetite (anorexia) or no appetite, abdominal pain, or literally be in shock.  Some symptoms will look as if your pet is having an allergic reaction and require immediate veterinary care. In pets that have spread of MCT to other parts of the body there might also be weight loss.

The following pictures are all MCT’s. As you will see they can vary considerably, so just looking at a skin tumor will not give you a diagnosis. Basal cell tumors, histiocytomas, soft tissue sacromas, and lipomas can all look like mast cells at times.

 This is a close up of a 2.5 cm mast cell on a dog’s side

This large mast cell is on the back of a dog’s leg seen as it is being prepped for surgery

Above the vulva

A large MCT on a dog’s upper eyelid. To help you get your orientation this is the left eye and the dog is facing to the left.

For curiousity sake this is the same dog immediately after surgery

On the skin of the rear leg

Another close up of a MCT on the side

The white arrows are pointing at a MCT on a dog’s scrotum

The black arrow points to an almost imperceptible area that is slightly red and raised. This is a MCT

3. Physical Exam

A complete physical exam is performed on every pet brought to us for a skin growth. There are a multitude of reasons why check other body organs and not just the skin growth you noticed at home:

  • So we do not miss other skin growths that might also be present and that are small or hard to detect. These might be other MCT, lipomas, or squamous cell carcinomas, for example.
  • To ascertain any spread of tumor to lymph nodes. We check the following peripheral lymph nodes during our exam:

o   Submandibular

o   Pre-scapular

o   Axillary

o   Inguinal

o   Popliteal

For more information on where these lymph nodes are located and their role in the immune system follow this link. Our doctors will gladly show you how to palpate them for an in-home exam.

  • To look for other problems that might be present but not obvious. Common ancillary problems in pets that get MST include dental diseasearthritiskidney diseaseliver diseaseheart disease (a heart murmur might be detected), skin allergies and even obesity. It is important that we address these issues for a successful outcome when treating MST.
  • To make sure the pet is ready for any anesthesia in the future

Care must be taken not to palpate a suspected tumor too vigorously because if it is a MCT it can degranulate and release histamine.  At the least it might cause the skin growth to become more inflamed (Darier’s sign), and in the worst case it will cause your pet to go into an allergic reaction and shock if excess histamine is released from the MCT. This is a rare occurrence but something to keep in mind as you touch any specific growth on your pet’s skin.

4. Diagnostic Tests

Routine blood panel, urinalysis, and fecal exam are needed in every case prior to any treatment. These tests give us a detailed picture of your pets overall health status and look for other problems that are not obvious during the physical exam. Finding other problems in pets that present for just a skin growth is a situation we encounter more often than you might think. Heartworm and FeLV/FIV status needs to be know also.

The results of a normal blood panel on a dog that prior to mast cell tumor removal. Sometimes we will see anemia due to blood loss from an ulcer in the GI tract.  We might also see an increase in liver enzymes if the MCT has spread to the liver, and also an increased BUN (Blood Urea Nitrogen) if there is GI bleeding.

We take special pre-anesthetic precautions on older dogs undergoing mast cell surgery. One of those precautions is an EKG to make sure the heart is ready for anesthesia. This is the same dog as the blood panel above, and is a normal EKG.

A very important test to diagnose any skin tumor is called a final needle aspirate (FNA). In this test we take a tiny needle and syringe and obtain some cells from the mass. The test is easy to perform, feels like a pinprick, and does not require anesthesia. It is similar to giving a vaccine, but in this case we are not giving something, we are taking something.

The small number of cells obtained from an FNA are put on a microscope slide and sent to our pathologist. They know why we are sending the sample to them and they specifically look for any signs of a benign or malignant tumor. Due to the high incidence of MST they look for these cells specifically. Pathologists are experts at analyzing cells under a microscope and they will come to one of the following conclusions:

  • They will tell us what cells the aspirate is made of and recommend appropriate treatment.
  • They will give us an idea of what different cells might be involved but have no specific diagnosis
  • They will not be able to tell us anything because of too few cells in the sample or the cells are not identifiable.

This is what a pathologist is looking for under the microscope for a FNA. The arrow points to a clump of 3 mast cells that have been stained to stand out.

Here is a typical report from a FNA on a dog with MCT

Even though no guarantee can be given to the usefulness of the FNA, it is worthwhile in almost all cases because the potential to give us useful information is high, especially when you consider the ease of obtaining the sample.

Knowing whether we are dealing with a MCT ahead of surgery is important because these tumors need aggressive surgery to be certain we remove the complete tumor. If we know going into surgery that we have a MCT we will take at least 3 cm margins around the visible mass. We will also dissect down to a deeper fascial plane to make sure no tumor remains after surgery. This type of aggressive approach is usually not needed in other skin tumor surgeries.

A pre-surgical radiograph is indicated in many cases to look at the thorax and abdomen looking for any spread of the MCT from the skin to the internal organs (systemic mastocytosis).  In addition, a radiograph is indicated any time we anticipate anesthesia and surgery.

We might seen an enlarged sternal lymph node in the chest if the MCT has spread.  The white arrow points to the location where the sternal lymph node resides.

This crescent shaped organ under the black arrow is a big liver, called hepatomegaly, on a radiograph. A MCT is one of several causes to an enlarged liver.

This is a large spleen, called splenomegaly, on a radiograph.

If an abnormality is found on the physical exam, or any diagnostic test, an ultrasound might also be needed. If we see an enlarged liver or spleen prior to surgery we will perform an ultrasound. This is what a spleen looks like during ultrasound

Here is the report on the normal appearing dog spleen above. There is no sign the MCT has spread to the liver or spleen.

DESCRIPTION:

Cellular slides consist of a heterogenous lymphoid population and a few scattered aggregates of stromal connective tissue/splenic trabeculae against a hemodiluted background. Small mature lymphocytes predominate followed by a low number of intermediate lymphocytes and large lymphoblasts. A few metarubricytes, mature plasma cells, and macrophages noted. Nor organisms or atypical cells seen.

MICROSCOPIC FINDINGS:

Spleen consistent with normal or hyperplastic lymphoid tissue

This is an enlarged spleen with nodules that could be caused by a MCT, although there are other causes to this also

If a regional lymph node is enlarged or draining we will perform an aspirate to determine if the tumor has spread. We can also aspirate the bone marrow looking for mast cells.

Information from all these tests is used as part of the surgical plan. It is also used to determine prognosis after surgery once the final tissue sample has been analyzed. If it looks like there has been the spread of tumor to an internal organ then chemotherapy or radiation therapy might be indicated in addition to surgical removal of the mass.

Surgical Treatment (surgery pictures in this section)

The overwhelming majority of MCT are treated with surgery. Microscopic tumor cells that are not visible or palpable can occur, so we remove a margin of 3 cm from the edge of the visible or palpable tumor. We also dissect deep down into the tissue for another 3 cm. This is problematic on tumors of the face, neck, and extremities. In those cases radiation and chemotherapy might be more appropriate.

It is not unusual to perform more than one surgery, especially if the tissue report (histopathology) reveals that we did not remove all of the tumor. This is referred to in the report as the margins not being clean. We like to have 10 mm margins to feel comfortable that we removed all of the tumor. When in doubt a second surgery is indicated to remove any suspected tumor remnant.

We use the laser for all of our MCT surgeries because of the dramatic reduction in bleeding during surgery, along with substantial reduction in swelling and pain after surgery. In the picture our surgeon is gently holding the mast cell between his fingers as he dissects with the surgical laser.

The tumor has been completely removed (notice the lack of bleeding) and what you are seeing is the fat layer under the skin. Notice how large the incision is. This is because we took 3 cm margins on all sides of the tumor, and also because the skin is under tension and spreads wide open when we remove the tumor.

In most cases we need to go deeper than this fat layer and get right down to the muscle layer. At this point we feel comfortable that we have gone 3cm deep into the tissue and have removed all of the tumor that is not visible or palpable.

The piece of sking with the MCT in the center after removal

 

MCT surgical sites sometimes heal poorly due to the disruption the cancer cells cause in the area. This fact, added to such a large incision, has the potential to heal poorly due to the tension on the skin. It is imperative that your pet wears an e-collar and you follow our postoperative instructions.

During the surgery we might also perform an aspirate or biopsy a lymph node in the region of the skin mass to look for spread of the tumor.

Gentle tissue handling is important when obtaining a fine needle aspirate and during the actual surgical procedure. Mast cells can release histamine during these times, so in addition to gentle handling we might put your pet on prednisone, Benadryl, and Pepcid AC prior to, during, and after surgery to minimize the release of histamine and its serious effects on the stomach and intestines.

In the rare cases where surgery might not be feasible, or the tumor is not completely removed, treatment can include medical therapy, radiation therapy, and chemotherapy.

Tissue Analysis and Prognosis

Analyzing the removed tumor tissue after surgery, called histopathology, is crucial to confirm the diagnosis, determine if more surgery or treatment might be needed, and to make a long term plan. The pathologist will let us know if the entire tumor was removed, what grade the tumor is, and what is the mitotic index of the tumor. This is a typical report on a dog with MCT:

SOURCE– 5 cm skin biopsy of mass on left flank

DESCRIPTION

 Examined is a section of skin and subcutis. The section contains a moderately well-dilineated, loosely cellular, unencapsulated dermal and subcutaneous neoplasm. Neoplastic cells are generally round and characterized by round to oval nuclei with moderate variation in nuclear size and chromatin pattern, and moderate to abundant amount of pale amphophilic to deeply basophilic granular cytoplasm. These cells infiltrate between resident collagen fibers, and are accompanied by low numbers of mature eosinophils. The mitotic index is 1. There is multifocal collagenolysis and eosinophil degranulation throughout the mass.

MICROSCOPIC FINDINGS–  Grade 2 mast cell tumor, well-differentiated, mitotic index 1.

PROGNOSIS– Fair to guarded

COMMENTS-Local excision appears to be complete with margins of 1.3 and 1.0 cm on either side, and 0.4 cm deep. Within the sample submitted there is at least one fascial plane deep to the tumor.

Grade 1 MCT are what is called well-differentiated and are usually benign. Grade I MCT occur in 30% – 50% of dogs.  Up to 90% of dogs are cured by surgery alone.

Grade 2 MCT are intermediately-differentiated and might be benign or malignant. In other words, they are unpredictable. Grade II MCT occur in 25% – 55% of dogs. Mean survival time after surgery is 28 weeks. Radiation therapy following incomplete removal can cure over 80%. Chemotherapy is sometimes used in addition to radiation therapy.

Since these tumors can go either way more information is helpful to determine the next course of therapy if at all. This is where the mitotic index comes in to play.

Grade 3 MCT are poorly differentiated and usually malignant. Grade III MCT occur in 20% – 40% of dogs. Mean survival is 18 weeks with surgery. Post-operative chemotherapy and/or radiation therapy might prolong survival.

Mitotic index is another predictor of biological behavior of MCT. Mitotic Index is an indirect measure of cell division. It is measured as the number of mitotic figures per 10 high-powered fields (a high powered field is 400x) when using a microscope.

These grading systems are the best way to determine the individual behavior of the MCT we remove from your pet and its prognosis. Nature is complicated, and unfortunately, not all MCT fit into these orderly classifications, so thoroughness of treatment and vigilance for recurrence are important.

In addition, histopathology is an art and a science, so a pathologist that might assign a specific grade to a tissue sample might not be consistent with another pathologist. Because of this no guarantee can be given to any of these prognostic indicators.

Different studies give varying statistics on prognosis. According to the Veterinary Cancer Group in Tustin, CA the prognosis is as follows:

Grade 1 tumors have a 5-67% chance of recurrence at 12 months.

Grade 2 tumors have a 50% chance of recurrence at 10 months. 88% of dogs with Grade 2 tumors that are incompletely excised and undergo radiation are disease free at 5 years.

Grade 3 tumors have a 94% chance of recurrence at 12 months.

Dogs with a mitotic index of 5 or less had an average survival time after surgery of over 70 months. Those with a mitotic index of greater than 5 had a survival time of less than 2 months, no matter what grade of tumor it is.

Another study showed that 83 percent of dogs with a Grade I MCT, 44 percent of dogs with Grade II and 6 percent of dogs with Grade III were living 1500 days after surgery.

In another study, 100 percent of dogs with a Grade I MCT, 44 percent of dogs with Grade II and 7 percent of dogs with Grade III were living two years after surgery.

Radiation and chemotherapy may be used following surgery. Even if the MCT is not completely removed, 90 percent of dogs that received radiation following surgery for Grades I and II MCTs survived for at least three years.

Medical Treatment

Medical treatment is usually used when surgery is not feasible. Prednisone, a very common and effective corticosteroid (cortisone), can help in some cases when used judiciously and monitored for side effects.

Chemotherapeutic drugs are sometimes used in dogs, especially if the tumor has spread. Common drugs include:

  • Lomustine
  • Masitinib
  • Palladia
  • Vinblastine
  • Torcerinib

Palladia is a kinase inhibitor which blocks the excessive production of the kit protein. It is FDA approved to treat MCT in dogs and is getting lots of hype. It is not a panacea, and when it does work (around 40% of the time), the response is for around 3 months.

Use of chemotherapeutics should never be undertaken without consultation with a veterinary oncologist. These drugs are powerful and need to be monitored for potential side effects. They also cost more than the other medications we routinely use.

Additional Therapy

As is the case with every disease, proper nutrition, access to fresh water at all times, parasite control (both external parasites like fleas and internal parasites like roundworms), exercise, and lots of TLC cannot be overlooked. In our older pets particular attention needs to be paid to the debilitating effects of arthritis, dental disease, and chronic organ disease. Hill’s makes a Prescription Diet for cancer patients called n/d that nourishes the patient without nourishing the cancer cells.

Long Term Care

Even if we completely remove a MCT there is up to a 17% chance another one will appear during your dog’s lifetime. Vigilance and early detection is of importance. Run your hands over your dog’s body at least several times per week for any problems. If you find any mass or growth we need to do an immediate FNA (Fine Needle Aspirate) looking for mast cells. We will teach you how to palpate the more obvious external lymph nodes as an additional monitoring technique.

Any pet that has been previously diagnosed with a MCT should be examined every 3-6 months. This exam should also include a blood panel, urinalysis, fecal exam, radiograph, and abdominal ultrasound.

Feline Mast Cell Tumor

MCT are the second most common tumor in the cat. Even though the basics are the same, MCT’s in cats behave differently than dogs. Cats get a skin form (called cutaneous) and what is called a visceral form (internal). It is possible for a cat to get both forms. They tend to get systemic mastocytosis more commonly than dogs.

There is no correlation to FeLV or FIP in cats that develop MCT. Siamese cats might be genetically predisposed because of a greater occurrence in this breed.

In the cat the grading system used for dogs does not apply regarding prognosis. Some are benign and some are malignant, and spread of the tumor (metastasis) can occur.

Cutaneous Form

The skin form of the feline MCT occurs around the head, eyelids and neck. Lesions can look like almost any growth, although they tend to be solitary, hairless, and raised. Lesions could be multiple, although the presence of multiple lesions does not necessarily mean a poor prognosis. Cutaneous MCT in the feline is usually benign, and for the rare times it does spread, it will go to regional lymph nodes, liver, spleen, and bone marrow just like in the dog.

Visceral Form

The visceral from of MCT usually occurs in the spleen first, then less commonly in the liver or intestine. MCT is the 3rd most common intestinal tumor in the cat after lymphoma and adenocarcinoma.

Typical symptoms in a cat with visceral MCT are vomiting, poor appetite, lethargy, and weight loss. These are the same as the dog and relate back to histamine release in excess.

During a physical exam one of our doctors might palpate an enlarged liver or spleen, abdominal fluid (ascites) or even a mass.

Treatment

Treatment of choice in both forms is surgical removal. If the pathologist report says tumor margins are not clean we can perform the surgery again or do radiation therapy.

The spleen is a common organ for visceral MCT in the cat. This is a normal spleen during surgery.

Prognosis

Prognosis of mast cell tumors of the skin is usually excellent and surgery is generally curative.

Prognosis of mast cell tumors localized to the spleen is good and many live for an additional one to two years after the spleen is removed.

Prognosis is guarded if the mast cell tumor is located in the gastrointestinal tract.

A good prognostic indicator in the cat is appetite when first examined. Those eating well tend to live much longer.

We have a case study of a cat (her name is Ruby) that had intestinal mast cell tumor. The case study covers this cat’s diagnosis and treatment from beginning to end, with pictures of surgery. Here is the link.

Cancer Specialists

When we treat a case of MCT (or any malignant tumor) we routinely refer the case to the Veterinary Cancer Group. They are experts on cancer in animals and provide the latest treatment available. Any time we diagnose and treat a dog or cat with MCT (or any malignant tumor) we recommend you go to them for a second opinion. They will review all data and set up a long-term plan. They are also able to provide chemotherapy and radiation therapy.

This email was sent to us through the LBAH email system. It is typical of the feedback we receive from clients sent to the Veterinary Cancer Group.

Below is the result of your feedback form.  It was submitted

on Thursday, August 11, 2011 at 10:25:07

Name: Leslie

location: Anaheim, CA

Dear Long Beach Animal Hospital,

I just wanted to thank you for everything you’ve done for Bijou and me over the years.  There are no words to express my gratitude to you and your staff.  Bijou is still going through chemotherapy.  Realistically, I know that she doesn’t have very much time left, but she has more good days than bad and, thankfully, seems oblivious to the drama that surrounds her.

I’m also writing to let you know how happy we are that you led us to the Vet Cancer Group in Tustin.  We are seeing Dr. Jarrod Vancil.  He is an incredible vet–knowledgeable, candid, and compassionate with both dogs and their owners.  I feel so fortunate to have him as our oncologist during this difficult time.  At each visit, he provides chemotherapy for the dogs, but he also provides reassuring and much-needed “therapy” for me, the owner.  I just wanted to pass along this information.  The staff at the Vet Cancer Group is also amazing, much like the staff you have at LBAH.  Bijou does not exhibit the fears and anxiety that she did when we were going to the other cancer center.  The staff goes out of their way to make people and animals as comfortable as possible.

Take care, Leslie and Bijou

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Femoral Head Ostectomy (FHO)

When the neck of the femur is fractured it needs surgical repair. There is a surgical procedure, that was developed many decades ago, that removes the non-functional head, and allows the body to form a false joint. This procedure is called a Femoral Head Ostectomy (FHO). Ostectomy means removal, so the head of the femur, where the ball joint is located, is completely removed.

We also use this procedure when there is a hip dislocation (called a subluxation) and the hip will not stay in the socket, even when we put it back in and put on a special bandage called an Ehmer sling. We also use this surgery for pets with hip dysplasia that will not be undergoing the more extensive hip replacement surgery called a Total Hip.

These are the radiographs of a young German Shepherd that was hit by a car. It was brought to us for a limping problem on the left rear leg. A thorough physical and orthopedic exam revealed some swelling at the left knee. This is a VD (venture-dorsal) view of the pelvis.

Do you see the problem?

The wing of the ileum and the acetabulum are fractured. You can also see that the neck of the femur has been fractured. Compare the problem area above in the red circle to the other side. 

This purple line like gives you a conceptual idea of where the neck of the femur will be cut during the FHO surgery. The exact angle during the procedure is different, and is customized for each bone.

This fracture is 3 week old, and there is swelling and scar tissue around the fracture that is not apparent on this radiograph. Also, this is a large breed dog with large muscles and tendons surrounding the fracture. In a difficult case like this, especially in a young dog that has a long life ahead, we have an orthopedic specialist come to our hospital to perform the surgery. He has special equipment, and over 45 years of experience, to make this a successful surgery with a pain free and active dog that is not limping for the rest of its left.

Before any surgery is performed, our surgeon Dr. Paul Cechner, consults with the owner to go over all of the options. This includes post operative care, which is an important part to make sure adequate healing occurs.

Long before surgery we perform a blood panel and a chest radiograph to make sure there are no other problems from the initial trauma that are not apparent on physical exam. This is important to know before surgery to minimize the risk of anesthesia, and to make sure all problems are corrected. Our patients do not talk to us, and they have high pain thresholds compared to us humanoids, so they don’t always show symptoms and we need to be thorough. We do not want any surprises on the day of surgery.

It is important to take a chest radiograph prior to surgery to make sure the heart and lungs look normal

Once the consultation was performed we put this dog on a pain and anti-inflammatory NSAID called Rimadyl until the day of surgery. Our patient was brought into the hospital the night before surgery and intravenous fluids were started and a pain patch was applied. On the day of surgery another examination was performed by one of our veterinarians to make sure everything is OK. At this point the surgery is a go and our surgeon prepares.

Our patient is anesthetized and the leg is shaved outside of our surgery room

While our patient’s leg is shaved our surgeon starts the scrubbing process with a surgical hand scrub to make sure this is an aseptic procedure

Our patient is brought into surgery, and before anything else is done, is hooked up to our anesthetic monitor and the IV fluid pump (at the top of this picture) is set for the correct amount of fluids to be given during the procedure. These fluids are critical to minimize anesthetic risk. 

Once our patient is stable and under the proper plane of anesthesia, our surgical assistant goes through the multi step process to scrub the leg. This is a crucial step to minimize the risk of infection after the surgery, so we are thorough and methodical in our approach to this part of the procedure. As you view the following pictures you will realize that preparation is a key part of this surgery.

The first step is to tape the leg up in this position

The first scrub of the leg occurs with the leg in this position

He continues scrubbing the leg after our surgeon does an initial draping

Once our surgeon is satisfied with the initial surgical scrub,s he does his own final scrub with a special antiseptic

It is called DuraPrep

It is applied directly over the area of the incision

After the DuraPrep our surgeon drapes the leg with it still hanging. In the background is our anesthetist monitoring anesthesia.

The top of the leg is wrapped in sterile aluminum foil and the tape is cut to bring the leg down

This is the position of the leg during the surgery

The foil is wrapped with a special sterile tape

The appearance of the foot before the final draping

Another drape without a hole is put over the surgical field

Our surgeon makes a custom opening in the drape specific for this surgery

He checks the exact location of where his incision will be before proceeding any further

The next step in the preparation involves and aseptic barrier called Ioban

It is adhered right to the skin where the incision will be

The surgical preparation is now complete and our surgeon is ready to make the skin incision to start the surgery

His sterile bone cutting tool is now opened up

He palpates the landmark for the skin incision 

Let the surgery begin!

Once through the skin the next layer encountered is the subcutaneous (under the skin) layer, sometimes abbreviated as SQ.

The surgical approach goes between several important muscles and tendons in order to gain access to the joint where the fracture is located. These include the biceps femoris muscle, the tensor fascia latae muscle, the superficial gluteal muscle, the deep gluteal muscle, and the vastus lateralis muscle. The muscles and tendons are not cut in order to gain this access to the joint. Careful dissection is performed in this area to preserve the normal anatomy, and not interfere with important nerves and blood vessels  This is one of the most difficult parts of the procedure, and where the experience of our surgeon comes into play.

After much careful dissection Dr. Cechner has the head of the femur exposed in the center of this photo. It is difficult to see because it is covered in scar tissue.  On the left is the special oscillating saw that will cut through the neck of the femur. The opening is small, so our surgical assistant on the right is using a retractor for better visualization

The oscillating saw gives a quick and precise cut with minimal bone trauma

The appearance of the head of the femur just before the cut is complete

A special rongeur is used to smooth off the bone incision

Now the long process of suturing everything back together begins

The postoperative radiograph

Our patient stayed overnight with pain injections administered that were in addition to the pain patch. He went home the next day with antibiotics and oral pain medications The skin sutures were removed in 14 days. After several weeks of confinement, and several weeks of moderate use, he is doing great! Our thanks to Dr. Paul Cechner for doing such a great job.

If you would like to learn much more about how we do surgery at the Long Beach Animal Hospital, including pre-anesthetic testing, anesthesia, and surgical concepts, please visit our Surgical Services web page.

 

 

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Retained Deciduous Teeth

It is not uncommon for us to encounter dogs with retained baby teeth. If they are still present at 6 months of age when your pet is spayed or neutered, we will remove them.

This dog is 8 months old and has a retained deciduous (D) tooth behind its erupting adult lower right canine (C) tooth. It is interfering with the eruption process of the normal canine tooth and will be removed

The instrument used to remove this tooth is called an elevator. The tooth is gently removed by rotating the elevator around the base of the tooth where it meets the gum line. This is to ensure complete removal of the tooth, including its root. Each tooth takes 5-10 minutes of gentle elevating to remove.

 

When the tooth is removed a small hole remains in the gum. The hole is usually so small that it heals rapidly and rarely requires suturing the gum. The healing time is the same whether the gum is sutured or not.

 

Here is the culprit after removal, notice how deep the root goes. The left 2/3 of this tooth (to the left of the arrow) is the root.

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Hip Dislocation

On occasion a dog or cat will dislocate its hip. This page shows the treatment of a poodle mix that fell while running, and is now completely lame on its rear leg.

Diagnosis

The diagnosis in this case is made with x-rays after an initial examination. The exam gave us clues that the pain was caused by a dislocation. When we gently extended the rear legs (depending on the type of dislocation) the dislocated leg appeared shorter than the normal leg.

This x-ray is of a dog with a dislocated hip. The ball of the left femur is completely out of the socket. Ligaments and the joint capsule have been torn for this to occur.

 

Medical Correction

Some pets with dislocated hips can be corrected without the need of surgery. Whether or not this occurs depends on the extent of the damage, especially to the ligaments, tendons, and joint capsule.

This pet was anesthetized and the head of the femur was gently placed back into the socket. It was securely taped so that the femur was held firmly in the socket. a special type of sling was applied to keep the head of the femur (the ball) pushed back into the socket. This method is not always successful, but it is worth trying to prevent surgery.

 

 

A radiograph is taken immediately after application of the splint to be certain the femoral head is still in the socket. One week later we repeated the x-ray to be certain it was still in place. This splint stayed on for 3 weeks, and this pet eventually healed completely.

 

Pain medication will be given to minimize discomfort. This dog will need to be confined and have minimal activity for several weeks.

Surgical Correction

In many cases we have to resort to surgery to correct the dislocation. When the hip is replaced in these dogs it does not stay in the socket.  We have pictures of the surgery

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Forearm Fracture in a Dog

It is not uncommon for a dog or cat to fracture its forearm. The two bones that are usually involved are the radius and ulna. Depending on the severity of the fracture, it is either splinted or surgery is performed to stabilize the bones with plates or pins. In small breed dogs, due to their bone anatomy and blood supply, and splint will not suffice, and a plate is needed surgically for proper healing.

Radiograph

This pup had a mild fracture of the radius and ulna (forearm). Since young animals heal rapidly, and because the fracture was relatively stable, a special type of padded plastic splint was used to stabilize it. It will stay on for 4-6 weeks.

Splint

After the pup is sedated an anchoring tape is applied to prevent the splint from sliding off.

A heavy layer of cotton is wrapped around the leg, and the plastic splint is placed along the bottom of the leg outside this cotton layer.

Several layers of gauze are tightly wrapped over the cotton and plastic splint, and the initial anchoring tape is adhered on top of this gauze. This prevents the splint from sliding down.

A final layer of tape is wrapped over the gauze. This helps keep it dry, adds to the stability, and identifies this as a girl dog!

We can trace the progress of healing on a different dog (his name is Kaiser-he is a large Doberman puppy) with a radius and ulna fracture, by taking x-rays at 3 week intervals. This first x-ray shows Kaiser’s fracture, which he obtained by running into a table.

Here is Kaiser after his splint was applied. He is hiding his face because we used pink tape instead of blue (hey, that’s all we had at the time).

Three weeks after the splint was applied a routine x-ray was taken to assess healing. Both the dark areas and white areas at the fracture site are normal stages in the healing process.

Six weeks after the fracture (and not a day too soon for his dad), the bone has not only healed, but it has remodeled making it smoother and anatomically more correct. This bone will continue to remodel for many months.

Surgery

Surgical correction of a radius or ulna fracture frequently involves plates.  In toy and small breed dogs a splint will not suffice. Plates are mandatory to prevent a malunion or nonunion, which could lead to amputation. It is a specialized surgery requiring special equipment and expertise, along with meticulous placement of the fractured pieces.

If you look at this view of Pebbles’ fracture it looks like a splint could be utilized for stability.

On this view of the same bones the severity of the fracture is obvious. Surgery is needed due to the amount of displacement at the fractured edges and the fact it is a small breed dog.

Here is a view of the bones after a plate has been applied surgically. As you can see from the fractured ends, the alignment is perfect.

Another x-ray gives you an indication of the size of the plate from the top. The amount of cotton padding around the splint can be visualized also.

During and immediately after surgery we will give pain medication.

A splint is put on for additional support, comfort, and to prevent Pebbles from chewing at the surgical site. Pebbles will need to wear this splint as additional support until the fracture heals. This will take up to several months.

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Ear Cleaning

One of the most important things you can do to keep your pet’s ears clean and healthy is to clean them periodically, especially if they have been prone to infection. This page will show you the proper technique using a medium sized dog as an example. The technique for a cat is similar, the only major difference is in restraint. No matter which species you are restraining, pick a room that is quiet and free of small children. Please let one of our nurses give you an actual demonstration of this technique to develop your confidence.

Before we institute any cleaning of problem ears it is important to make a diagnosis. Not every case of ear infection is caused by ear mites, as many people are prone to think. Ear infections are commonly caused by bacterial infections, hypothyroidism (low thyroid), and allergies. We have found a consistent cause of chronic ear problems and infections is due to a food allergy, which is why we recommend Hill’s z/d, the gold standard for this type of food.

Canine Restraint

Depending on its size, put your dog on a table so that it is approximately chest high. Gently hug your pet under its neck with one of your arms, and put the other hand on the back of its head if necessary. Be patient, yet persistent. If your dog is small you can use the cat restraint technique.

Hugging your pet with your left hand under its chin gives you control and flexibility as to how much restraint is needed.

Feline Restraint

Wrapping your cat with a towel is a good way to restrain it for ear cleaning. In essence you will be wrapping it like a burrito. For cats in general the less restraint the better- let the towel do the work.

Put a large towel on a table and put your cat towards the front end of this towel.

Bring each side of the towel over the cat and leave only the head and tail to stick out

Bring the back, unfolded section of the towel over the front just up to the back of your cat’s head.

Finish the “burrito” by wrapping the towel under each side of your cat. The only thing sticking out of the towel at this point is the head.

Hug your cat gently to you with one hand and you will have your other hand free. Besides cleaning ears this restraint technique enables you to administer oral or topical medication.


Cleaning

Never put anything in your pet’s ear canal without proper restraint. As a general rule you should clean the ears by letting the cleaning solution bring the infection and discharge to the outside of the canal to be wiped away. You should not put Q-tips into your pets ears unless we tell you to and you have been shown the proper technique, and your pet is adequately restrained. Q-tips can damage the sensitive tissue that lines the ear canal. Also, an ear drum can easily be ruptured by placing objects in the ear canal, especially if the ear has an infection.

This is a typical picture of what might be encountered in an ear that needs cleaning.

The first thing to do is use a gauze to wipe away discharge that is on the surface.

Gently pull up on the ear and partially fill the ear with the cleaning solution. By straightening out the ear you allow the cleaning solution to flow down the ear canal to where the infection and debris are located.

After the canal had been partially filled massage the base of the ear canal very gently. Most pets find this part soothing.

Let your pet shake its head if it wants to. Then use a gauze to soak up the fluid that comes out of the ear.


Instill several drops of the actual medication we prescribe after the cleaning solution is out of the ear and the ear is relatively free of discharge. Most pets do fine with daily cleaning and medicating, your doctor will let you know if it should be done more or less frequently than daily.

Now is the time to reward the cleaner and cleanee for a job well done! If you think that was tough, how would you like to restrain this pet and clean its ears? The hugging under the chin technique doesn’t always work on a 300 pound tiger!

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Canine X-Rays

A few of the many radiographs we take each month. Click on some of them and they will enlarge. You can see the detail available with our Digital Radiography.  Click on them and most will enlarge.

All of these metallic objects (see arrows) are stainless steel sutures in Spunky. He is a Schnauzer that has gone through 3 abdominal surgeries. Two have been to remove bladder stones, one was to remove something he ate (you wouldn’t want to know what it was) that got lodged in his stomach.

 
The round white thing on the far right is a bladder stone in a different dog (urolithiasis). It is a Digital Radiograph, so click on it to enlarge. Do you see anything else in this radiograph?

The diffuse white area in the center of this dog’s abdomen is an abdominal tumor. Ultrasound will help pinpoint the exact location and will also enable us to perform a relatively simple biopsy.

 

That very large and rounded object in the chest of this dog is the heart. This is called cardiomegaly, and is due to heart failure.

This is what it is supposed to look like

Radiographs-VDChest1

Radiographs-VDChest

Severe Hip Dysplasia

Radiographs-HipDysplasia

Screw holes that remain after a plate to fix a fractured tibia (shin bone) is removed

OLYMPUS DIGITAL CAMERA

After surgery to lengthen the ulna. Damage to the radius has caused a deformity in this growing dog, and lengthening the ulna helps straighten it out.

OLYMPUS DIGITAL CAMERA

Normal knee joint

OLYMPUS DIGITAL CAMERA

This dog had chronic diarrhea that was finally diagnosed when an x-ray was taken. Those are 3 pennies in the rectum at the far right of the x-ray.

 

This Irish Setter has a condition know as bloat (GDV- Gastric Dilatation Volvulus). The large dark and circular area in the middle of the x-ray is a twisted and distended stomach. This is a very serious condition that requires immediate care.

Here is GDV one on a different dog. You can see the greatly distended stomach along with all the gas (dark areas) in the intestines on the right of the radiograph.

This is what a fractured femur (the one on the left) looks like months after it has healed

How many puppies can you count in this pregnant dog ? Do you want to see how a C-Section is performed?

With our Digital X-Ray you can see more detail on a different dog

The arrow points to arthritis in the spine, known as spondylosis. This is a common problem in many dogs as they age. We have numerous medications at our disposal that will help alleviate this painful affliction.

In this Digital Radiograph the spondylosis is so severe that nerves to the urinary bladder are not working well. The large round object on the right is the urinary bladder filled with urine because this pet cannot urinate properly. This is a painful condition that can lead to secondary infection and severe kidney problems.

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Cancer

The scientific word for cancer is neoplasia, meaning new growth. In reality, it is an abnormal growth of cells that interferes with an organ’s ability to function, resulting in a degree of failure in that organ. Some of these abnormal cells break off from the organ and spread to other organs in the body. This process is called metastasis, and is the hallmark of malignant cancer.

Cancer it is not one disease, has many different causes, and can affect every organ. This makes it quite a challenge to diagnose and treat. Even though the cause is not known in many cases, we do know of major factors that predispose pets to getting cancer. You will learn about this on this page regarding squamous cell carcinoma (SCC) in white cats that are exposed to the sun.

A major predisposing factor is dogs, cats and rabbits that are not neutered and spayed when they are young.  Their chances of getting breast, testicular, and prostate cancer increase significantly when they are not altered at an early age. The following pages have detailed information on this:

Dog Spay

Dog Neuter

Cat Spay

Cat Neuter

Rabbit Neuter

Rabbit Spay

We tend to see cancer more commonly in our geriatric patients.

This page has links to some of the more common cancer’s we see in animals. Click on any photo to enlarge it.


Dogs and Cats

Intestine

Kidney

Liver

Lymph node

Mammary (breast)

Mast cell

Spleen (hemangiosarcoma)

Squamous cell carcinoma (SCC)

Ferrets

Adrenal disease

Insulinoma

Liver

Rodents

Mammary (breast)

Ovarian

Reptiles

Tegu oral tumor

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Kidney (Renal) Cancer

Its not that often that we see a primary kidney cancer in a young pet. Unfortunately, it does occur. This page will show you how we diagnosed and treated it on a one year old Basenji.

This page emphasizes how fast things change, and a pet that is perfectly healthy on a physical exam and blood panel, can change for the worse.

Click on any photo to enlarge it. Graphic photo of a kidney with cancer on this page.

Normal Physical Exam

As part of our routine pre-operative spay exam a blood panel is run. It came back normal. Note the circle over BUN and Creatinine. They are tests of the kidneys, and they are normal.

Kidney-Tumor12 copy

Surgery and healing progresses as expected for a young dog. Over the next several months there was no indication of a problem.

Abnormal Physical Exam

History

Three months later this young dog was presented with signs of decreased appetite and not feeling herself.

Physical Exam

  • Body Temp- 101.6 degrees F
  • Mucous membranes- pink
  • Respiratory rate- 40 breaths per minute
  • Heart rate- 150 beats per minute
  • Haircoat- normal
  • Musculoskeletal system (bones and muscles)- normal
  • Mout- normal
  • Eyes- normal
  • Abdomen- normal
  • Lymph nodes- normal
  • Ears- normal
  • Heart- normal
  • Urogenital- normal
  • Weight- 22#, no change from 3 months prior

Interpretation- Even though this exam is essentially normal, a lack of appetite in a young dog is of concern. Also, no weight gain over the last 3 months is cause for concern in a young animal, and confirms the owners observation of lack of appetite.

Diagnostic Tests

  • Blood Panel

    It is obvious there is a serious problem with the kidney tests compared to 3 months prior. In addition, other tests are elevated, all leaning towards a serious kidney problem.

    Kidney-Tumor6

  • Ultrasound

    This is the abdominal ultrasound report. Read it carefully to see how detailed it is and note the abnormalities.

    The abnormalities are marked in the pictures to follow.

    Kidney-Tumor1

    Left kidney

    Kidney-Tumor2

    Right kidney

    Kidney-Tumor3

    Liver

    Kidney-Tumor4
    Kidney-Tumor5

    Small intestine

    Kidney-Tumor13

  • Cytology

    A fine need aspirate (FNA) was obtained during the ultrasound. This is a non-invasive way to obtain a sample as compared to a highly invasive (and more expensive) exploratory surgery. The skill of our ultrasound doctors gives us confidence in the accuracy of the FNA, although there is on guarantee it will give us an accurate cause to the enlarged kidneys.

    The sample is sent to a pathologist for microscopic analysis. It came back a malignant cancer called lymphosarcoma (LSA), also known as lymphoma.

    Kidney-Tumor9

  • Necropsy

Necropsy photo of a cat with kidney cancer. This is how lymphoma looks in a cat, not the dog above. The cancer is at the arrow, from the 7 PM to 2 AM position on the left.

cancerouskidney

Treatment

This is a serious problem that needs to be treated by a veterinary oncologist.

We send all of our cancer cases to the Veterinary Cancer Group

Kidney-Tumor14

This is the treatment protocol initiated 4 months ago

Kidney-Tumor11

Four months later this dog is doing well, with the kidney tests dramatically improved:

BUN- 35

Creatinine- 1.8

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Hemangiosarcoma

Spleen Disease (Hemangiosarcoma, Hematoma)

It is not uncommon for us to encounter problems with the spleen. Sometimes it just enlarges without any major problems, sometimes it twists on itself, sometimes it causes internal bleeding, and oftentimes it becomes cancerous. This page will emphasize cancer of the spleen, called hemangiosarcoma.

In breeds that have a high incidence of splenic tumor we recommend yearly exams starting at 5 years of age,  with radiographs and ultrasounds to catch this problem early before complications and spread, since the prognosis is poor in most cancerous spleens because they have already spread by the time of diagnosis.

Unfortunately, some pets, especially large breed dogs, will not show any symptoms until the spleen is huge. This occurred with a Labrador Retriever that was presented to us with the owner telling us “he just wasn’t doing right”.  He was eating good, was not vomiting, had no diarrhea, and was not coughing. This owner was astute and brought him in for an exam just in case.

A thorough exam and blood panel revealed no problems, so a radiograph was taken. This radiograph revealed a large abdominal mass. This could have been coming from the liver, spleen, intestines, kidneys, pancreas, or mesenteric lymph nodes. An ultrasound revealed it was from the spleen. The next day we removed an 8 pound rupturing spleen! You can see pictures of the surgery to remove this large mass in the surgery section later in this page.

Graphic surgical photos are on this page

Nomenclature

We will use some medical terms regarding the spleen:

  • Extra medullary hematopoeisis – The making of red blood cells outside of the bone marrow
  • Reticuloendothelial system – in regards to the spleen, it is the system that recycles red blood cells
  • Anemia – a low amount of red blood cells or hemoglobin
  • Thrombocytopenia – a decrease in thrombocytes, which are an important part of the clotting factors when there is bleeding.
  • Hemoabdomen – free blood in the abdomen
  • Splenomegaly – enlargement of the spleen as a result of any cause
  • Splenectomy – removal of the spleen
  • Hypersplenism- an enlarged spleen that is normal and not causing any problem

Spleen Anatomy

The spleen is an elongated and relatively flat organ that resides in the abdomen of mammals along the outer edge of the stomach. It has a tremendous blood supply that is closely attached to the blood supply supporting the stomach. It is the largest filter of blood in the body.

It has an outer capsule composed of smooth muscle and elastic fibers. The internal part of the spleen (called the parenchyma) has white pulp and red pulp. The white pulp is lymphatic tissue and the red pulp is part of the venous blood system. In between these pulps is elastic tissue that can fill up as needed.

A normal spleen in a cat

A normal spleen in a  small dog

A normal spleen in a medium sized dog

A swollen spleen in a medium sized dog

The blood supply to the spleen is closely adjoined to the stomach. You can see the dark vertical blood vessels in this photo as they enter fat between the stomach and a very enlarged and dark spleen in a semi-circle at the far right.

Physiology

The spleen has many functions. The four primary ones are:

  • Storage of cells
  • Production of red blood cells
  • Filtration of the bloodstream
  • Production of cells for the immune system

Iron that has been recycled from old red blood cells is stored in the spleen where it awaits transport to the bone marrow.

Fortunately, the body can get by without a spleen in most cases, so if there is a serious problem, and all other factors are equal, we will remove it. We tend to remove only spleens that are cancerous, rupturing, or have a torsion.

Diseases

Splenomegaly

Splenomegaly is a generalized term that simply means enlargement of the spleen. In some species, like ferrets, an enlarged spleen can be normal, and is called hypersplenism. A spleen can be enlarged diffusely or it might  have nodules in certain areas.

There are many causes for an enlarged spleen. The most common and important are listed in more detail below. Some of the more uncommon ones are due to infectious agents (erlichiosis, babesia, hemobartonella), FIP, medications, and immune mediated diseases.

This spleen has splenomegaly in addition to numerous nodules

Splenic Torsion

In this problem the spleen twists on itself, compromising the blood supply. When the spleen twists the blood keeps on pumping into it by the arterial system, but this same blood is not able to leave through the venous system, and the spleen becomes grossly engorged.

It can occur on its own, after excessive exercise, or due to trauma. It can occur in conjunction with Gastric Dilatation Volvulus (GDV), also known as bloat. We tend to see this torsion, along with GDV, in large and deep chested breeds.

If the torsion is chronic, there might be no symptoms at all, or there might be:

    • poor appetite (anorexia)
    • weight loss
    • discolored urine
    • vomiting- might be intermittent
    • weakness
    • weight loss.
    • collapse
    • death

Examination of a pet with splenic torsion might reveal:

    • pale mucous membranes (gums)
    • rapid heart rate (tachycardia)
    • painful abdomen
    • a large mass in the abdomen upon palpation
    • fever
    • dehydration
    • jaundice (icterus)

A blood panel might reveal:

    • anemia
    • low platelets (thrombocytopenia)
    • elevated white blood cells (leukocytosis),
    • elevated liver enzyme tests,
    • hemoglobin in the urine (hemoglobinuria)

This disease is diagnosed by imaging tests when the above symptoms are present. A radiograph might reveal a mass in the abdomen with the spleen abnormally located. Ultrasound can confirm the problem and give us an idea of its severity.

A splenic torsion is considered an emergency, so the treatment of choice is surgical removal after a pet has been stabilized by treating for shock. On the deep chested breeds we might even tack the stomach to the abdomen to help prevent potential GDV in the future.

Splenic Cancer

Some splenic masses that are cancerous are classified as benign, meaning they do not generally spread (metastasize), and only take up extra space within the abdomen. Even though they do not spread, sometimes this extra space they take up can interfere with other organs.

Some benign cancerous masses include lipoma (fatty tumors), hemagioma (associated with vasculature), and plasmacytosis (infiltration of plasma cells throughout the splenic nodule or tissue in general). Unfortunately, when a spleen has cancer it commonly is the malignant version and not this benign version.

The most common malignant tumor in the spleen is the hemangiosarcoma (HSA). It is also called malignant hemangioendothelioma). The cause is not known. It can spread to many different organs, making it highly malignant:

    • heart
    • lungs
    • muscle
    • skin
    • bones
    • abdomen
    • diaphragm
    • brain
    • kidney

HSA can also cause complications, such as disruption of the coagulation cascade which causes a mixture of abnormal clot formation as well as inability to control internal bleeding (known as disseminated intravascular coagulation, DIC).

Symptoms of HSA vary, and range from mild to severe. In extreme cases sudden blood loss can lead to sudden death.

These large nodules on this spleen are a malignant cancer called hemangiosarcoma

Another common type of malignant splenic cancer is lymphosarcoma, a type of cancer that can have a primary tumor in any other organ (i.e. lung, gastrointestinal tract, liver). Lymphosarcoma is one of the more common tumor types observed in the spleen of cats. Sometimes the tumor within the spleen is not even the primary tumor, but rather a single nodule or multiple nodules due to metastasis from a distant primary tumor.

Hematoma

Hematomas are one of the most common causes of an enlarged spleen in dogs, representing over 50% of splenomegaly cases. This type of splenic mass is basically an accumulation of pooled blood within the splenic tissue; many stop growing and are then resorbed after a period of time, but others grow exponentially and eventually rupture. A ruptured hematoma originating from the spleen is an emergency, and often the pet experiences an acute collapsing episode followed by a significant loss of blood into the abdomen (hemoabdomen). You can see the surgery of a dog with an 8 pound hematoma later in this page

Other causes

Congestions of the spleen can occur from iatrogenic causes, which are those associated with administration of certain drugs (i.e. anesthetic agents or tranquilizers). Congestion can also occur due to increased blood pressure within the vasculature of the liver (known as portal hypertension), which can occur secondary to congestive heat failure among others.  The spleen can over-react to particular conditions, resulting in a disease process known as hyperplastic, or reactive, splenomegaly. A spleen can become reactive when there is excessive stimulation of the immune system from conditions such as immune-mediated disease, bacterial infections, tick-borne diseases, and many more.

This spleen has a laceration

Diagnosis

Signalment

Dogs, cats, and ferrets can get splenic diseases, although it is much more of a problem in dogs. Splenomegaly itself can occur in most any age due to the numerous causes of the condition. For instance, if the cause of splenic enlargement is infectious, then the pet may be quite young. However, if the enlargement is cancerous, the pet tends to be middle aged (average 10 years in dogs). Due to the wide range of causes, there is no known gender predilection (males tend to be affected equally as often as females). Certain disease processes tend to be over-represented by specific breeds:

Splenic torsion tends to occur in large breed, deep-chested dogs:

Splenic tumors like HSA tend to occur in several breeds. It can be some common in some breeds that we  recommend physical exams, blood work, abdominal radiographs, and especially abdominal ultrasounds, yearly in these dogs as they reach 5 years of age:

    • German Shepherds
    • Golden Retrievers
    • Portugese Water Dogs
    • Boxers
    • English setters
    • English pointers
    • Great Danes
    • Skye Terriers
    • Bernese Mountain Dogs

History

In many cases, a patient with splenic disease has very little or no specific clinical signs. Observations made by owners at home might include non-specific indicators of illness:

    • lethargy
    • inappetence
    • weight loss
    • diarrhea
    • vomiting
    • collapse
    • discolored urine
    • abdominal distention

Physical Exam

Upon palpation of the abdomen, significant abnormalities of the spleen can usually be detected, especially when a large mass is present within the cranial aspect of the abdomen (toward the chest). However, a mass or enlarged organ in the cranial abdomen cannot always be differentiated from a mass or enlargement of the liver. In some cases, decreased pallor (pale gums) can be a sign of anemia or shock, which in combination with an abdominal mass can indicate a ruptured splenic mass or torsion. We confirm this with an ultrasound before surgery.

If the gums are pale, certain diseases of the spleen may lead to free blood in the abdomen, which can sometimes but not always be detected by palpation of a fluid wave. Other generalized signs might include weakness, fever, dehydration, poor pulses, increased heart rate (tachycardia), increased bleeding at site of blood draw (due to coagulopathy), and/or increased size of peripheral lymph nodes.

Diagnostic Tests

Some diagnostic tests which provide significant information include radiographs, blood work, ultrasonography, evaluation of the cells (cytology) through a fine-needle aspirate sample, and surgical exploration.

Radiography

The arrow points to what a spleen looks like on a radiograph. It is enlarged, although a lobe of the liver can easily overlap the spleen and make the spleen look enlarged. So in this case, technically its called hepatosplenomegaly.

Here is a dog with an enlarged spleen. Can you see it?

Splenectomy -SpleenRadSplenectomy -SpleenRadSplenectomy-LateralRad

The red circle delineates the enlarged spleen.

L.I. – Large Intestine

Pr- Prostate

Splenectomy -SpleenRadSplenectomy-SpleenRadCircle

Blood Panel

Blood work (clinical chemistry and complete blood counts) is a crucial component for detection of compromised organ function. Splenic involvement might reveal anemia (decreased red blood cells), thrombocytopenia (decreased platelets for clotting), leukopenia (decreased white blood cells) and reticulocytosis (increased immature red blood cells to indicate that the body is trying to compensate for the loss of mature red blood cells).

This is a blood panel that might be seen with splenic disease, although many other diseases can also cause this type of blood panel. The primary problem in this blood panel is anemia.

Fluid Analysis

If abdominal fluid is present we can remove it and analyze it. This is called abdominocentesis. There is no guarantee this will make a diagnosis since many cancers, including HSA, might not be found in this fluid.

Ultrasonography

Ultrasonography has revolutionized diagnosis in animals, and prevented many unnecessary exploratory surgeries (called celiotomies or laparotomies), while at the same time alerted us to the fact that we need to do immediate surgery. Keep in mind, our patients do not talk to us, and  an enlarging tumor in the abdomen in one of us humanoids would be uncomfortable, and cause us to seek medical care long before we see a dog or cat with a tumor growing in the abdomen.

Ultrasonography of the abdomen is an important modality for diagnosis of splenic disease because of its sensitivity to changes of organ size, shape, location, and even texture. An ultrasonographic examination in combination with radiographs provides a comprehensive understanding of which organs are involved and often helps to narrow the possibilities down to a select few differentials.

We use ultrasound to confirm our suspicions of a splenic tumor based on the breed, history, exam findings, and blood panels and radiographs. Ultrasound confirms the diagnosis, lets us know if the spleen is already rupturing, tells us the size of the spleen, and if there are any other internal organ problems. A critical component of the ultrasonographic exam in HSA is echocardiography (evaluation of the heart). A key site of metastasis associated with hemangiosarcoma is the right atrium. HSA that has spread to the right atrium of the heart is a serious sign, and the prognosis is not good. This is important information if we are thinking of surgical removal of the spleen.

The lines demarcate the margins of this spleen

Do you see the spleen in this picture without the demarcation?

A typical ultrasound report on a dog with a cancerous spleen

This ultrasound of the heart (echocardiogram) shows spread of the tumor to the right atrium, which is a poor prognosis

RV- Right ventricle

RA- Right atrium

Cytology

Aspiration of the cells in an organ for cytological exam by a pathologist is an important part of most abdominal ultrasounds. It helps prevent an exploratory surgery, and can lead to a diagnosis in many cases. Cytologic evaluation of splenic problems is not always indicated and can sometimes be contraindicated depending on certain disease processes. Certain cancers of the spleen as well as hematomas may result in significant blood loss if stuck with a needle due their fragile nature. Even though the ultrasound guides the biopsy location, if the disease process only involves a small portion of the splenic tissue, or is sporadically located throughout, then a small needle-sized sample may not obtain the affected tissue at all.

ECG (Electrocardiogram)

This tests the electrical activity of the heart. I some HSA’s there will be an arrhythmia

Definitive Diagnosis

Histopathology is the analysis of the spleen after it is removed. This gives us our final diagnosis.

Histopathology

Treatment

Surgery is a common treatment for splenic disease. This is called a splenectomy. If there is trauma or a problem in only a small part of the spleen, we might do a partial splenectomy since we always want to preserve as much function of the spleen as possible. This partial splenectomy is not common.

We do the surgery to remove the tumor, and if malignant add chemotherapy to help prevent spread after we do the surgery. Prior to surgery we do an ultrasound of the heart as already mentioned, and also take chest radiographs to check for spread of a tumor. We also perform a clotting panel since blood loss is common in this surgery and we do not want post operative bleeding.

Unfortunately, survival time for dogs and cats with surgery alonge HSA is only 1-3 months, with most dogs dying due to spread of the HSA to other organs, causing these organs to malfunction. This emphasizes the need for an early diagnosis in the breeds prone to this cancer.

Dogs that have surgery to remove the spleen, and that are also treated with chemotherapy, might survive up to 9 months. This depends on whether the tumor has spread, and again emphasizes the need for an early diagnosis. Dogs and cats have less side effects than people on chemotherapy, and their quality of life is high if this therapy is instituted immediately after surgery.

Dogs that are diagnosed at a young age, have had the HSA rupture prior to surgery, have evidence of spread to other organs when the splenectomy is performed, or have a more aggressive grade of tumor, do not tend to live 9 months after surgery.

The primary chemotherapy drug for HSA is Adriamycin (doxorubicin). It will slow the disease process, but it will not cure your pet of this disease. The doctors at the Veterinary Cancer Group in Tustin institute this therapy.

If a pet is anemic, or we anticipate significant blood loss during surgery, we will give a blood transfusion prior to surgery or during the procedure. Post operatively if a pet is not doing well we will give a blood transfusion also.

After doing a cross match to ensure compatibility we obtain whole blood for the transfusion

Splenectomy

A splenectomy is performed to treat and sometimes cure this problem. It is sometimes done as an emergency procedure if the spleen has ruptured and there is significant internal bleeding.

Pre-anesthetic preparation is important in every surgery we perform, no matter how routine, because surgery is not an area to cut corners.  Once a pet is anesthetized, prepared for surgery, and had its monitoring equipment hooked up and reading accurately, the surgery can begin.

This is a sterile abdominal surgery, and our surgeons scrubs with a special antiseptic soap prior to gowning and gloving

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While our patient is being anesthetized our surgeon is already in our surgical suite setting up instruments. Our surgeon is ready to start before our patient is at a proper plane of anesthesia. Once the anesthetist gives the green light the surgery starts immediately. We want our surgeon waiting for his patient, not the other way around.  All of this is to minimize anesthetic time.

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We keep a close tab on important physiologic parameters for all of our surgeries. Monitors like this give us an early warning of an impending problem.

This machine monitors:

Temperature

Heart Rate

Heart rhythm

Oxygen saturation

Carbon dioxide level

Respiratory rate

Surgery-Monitor

In addition to our monitoring equipment our anesthetist stays “hands on” in monitoring important physiologic parameters. Our anesthetist is using a special stethoscope (esophageal), that is passed down the esophagus and lays right over the heart. This gives us a clear sound of the heart and how it is beating.

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To minimize anesthetic time we routinely have 2 doctors working as a team performing the splenectomy.  They work together as a well orchestrated team.Our patient is under anesthesia and our surgeons are completing the draping process while our anesthetist is adjusting the surgical lights.

By working together early in the surgery we minimize anesthetic time.

For a pet that might already be anemic it is important to minimize blood loss during surgery. Special care is taken on entering the abdomen to minimize loss. There is minimal bleeding at this point as our surgeon gently dissects the sub Q (subcutaneous) tissue just under the skin.

As the surgery progresses we sometimes encounter significant bleeding from blood vessels in the sub Q fat and from muscles that are cut. All of them are clamped or cauterized before proceeding further. For a pet that might already be anemic this added blood loss is important to control, and it is stopped immediately.

When all bleeders are under control (called hemostasis) we enter the abdomen. We make our incision at a specific spot in the abdominal muscles called the linea alba. It is at this spot that there are minimal blood vessels. The linea also has strong tendinous attachments to the muscle, so when we sew it back together these tendons attachments have more holding ability than the abdominal muscles alone. This will prevent a hernia.

Our first view of the spleen once we have entered the abdomen. It is the round and reddish structure at the top of the abdominal opening and just to the left of our surgeon’s finger.

A spleen that is not healthy is friable and can easily rupture when handled. Our surgeon has to gently coax it out to prevent  this from happening.

Once it is finally exteriorized the problem is obvious. At this point we do not know if it is cancerous or not. We do know it is in the process of rupturing and glad we are getting it out now.

Now that we have it ready for removal we have to ligate its blood supply. As you remember from your surgical anatomy above the blood vessels to the spleen are closely related stomach. It is important to ligate the blood supply very close to the spleen so as not to compromise the blood supply to the stomach, leading to serious consequences.

This blood supply can be surrounded by fat. We have to isolate segments before we ligate.

In the center of this picture you can see one blood vessel that is already ligated. On the right our surgeon is in the process of ligating another blood vessel.

We have completed 3 ligations at this point, with many more to go.

Our surgeons work simultaneously, each starting at a different end of the spleen, so they can complete this tedious part of the surgery sooner. Its all about secure ligation of these blood vessels and minimal anesthetic time.

As part of the natural healing process there is a tissue in the abdomen called omentum. It is like a net, and surrounds an organ that might be diseased. For example, a ruptured intestine that is leaking intestinal fluid (extremely irritating to the abdomen and will cause a peritonitis), will have this net surround the intestine to wall off the leak.

In the case of this rupturing spleen the omentum covered the spleen to help prevent further blood loss. These are clots on the omentum from that. At this point in time during the surgery we cannot determine for sure if these are clots or spread of tumor. The report from the pathologist will tell us for sure. It turns out that this time they are clots.

When the spleen is completely removed we complete our exploratory surgery by checking the other internal organs, especially the liver. Once this check is complete we suture the muscle layer (the linea alba) closed. Again, we work as a team, with each surgeon (they are both lefties) suturing the linea until they meet in the center.

Once we have finished suturing our patient, who is already on a pain patch (Duragesic or Fentanyl patch- which is removed in 3 days), is given an additional pain injection and carefully monitored post-operatively. As part of the monitoring we perform a simple blood panel to make sure there was no problem with blood loss during surgery. If the blood loss is significant we will give a blood transfusion with the blood we have already set aside specifically for this patient.

Post operatively we take radiographs of the chest and perform and ultrasound every 2 months for cases of HSA looking for distant and local metastasis.

Occasionally we come across a spleen that is so large it is hard to believe it can get this big. The following spleen was over 8 pounds, removed for a 65 pound labrador named Jake.  Dr. P and Dr. R had to do this one together. Removing it was like delivering a baby!

The size was obvious as soon as we entered the abdomen. At this point in time we were not sure if it was a boy or a girl! Dr. P is coaxing it out of the abdomen at the beginning of the surgery, being very careful not to rupture it.

We had to be very gentle  because it was quite delicate(friable) and already rupturing

Ligating the blood vessels to the spleen was more difficult than usual because of the size, scar tissue, and omental tissue that covered the rupturing spleen

It turns out that this was a hematoma and the dog did fine for several more years. Lucky this spleen did not rupture before the surgery.  Most likely, with a hematoma this large, death would have ensued rapidly.

Ancillary Treatment

After surgery we will consult with the oncologists at the Veterinary Cancer Group for further treatment

Post Surgical Treatment

Prognosis

A successful outcome from surgery depends on what disease process is present and how long it has been present.

Splenic Hematoma – good

Splenic Torsion – good

Hemangiosarcoma – guarded to poor.

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