The Diagnosis

I call the diagnosis Logan’s death letter.  On November 22^nd I took him in for an ultrasound.  When we returned from the Specialty we started him on treatment for the tick disease, and he showed improvement.  He was playful again, eating well, but something was still nagging at me.  I knew something just wasn’t right.

Yet, the morning of the ultrasound, we took the dogs to the park and watched Logan run ahead to take the lead.  I said to Russ, “You know, I feel pretty confident we aren’t going to get terrible news today.  He’s looking so good.” 

And Russ responded, “Yeah, I’m not really expecting to hear anything negative either.” 

I responded back, “It scares me though, to say that, because I’m not prepared to hear anything different.”

The ultrasound took longer than I had hoped so I had to take the call at work.   How difficult it was to sit there and listen to the diagnosis that I was not prepared to hear.  Each line described our universal heritage, that one day we will all confront our own mortality.  For Logan, that end was predicted to occur in a month.

Dr. Gottschalk:

Logan presented for further evaluation of weight loss, intermittent vomiting, and diarrhea.  Clinical signs initiated October 4, 2016 and appeared to respond to empirical therapy (Cerenia, famotidine and metronidazole). He later exhibited hematuria.  He received doxycyline for approximately 2 months and Simplicef for 4 weeks.  Logan is currently receiving famotidine 10 mg orally every 24 hours, Ligaplex II every 12 hours, Dasequin 1 tablet every 24 hours, Thyrocomplex 1 capsule every 24 hours, Mitomax 1 capsule every 24 hours, Vitamin E 400 U every 24 hours and Vitamin B complex 50 U every 24 hours.

Physical examination demonstrated grade 4 out of 9 body condition score, pink mucous membranes, normal CRT, mild dental tartar, lenticular sclerosis OU, normal fundi, normal heart rate (116), normal pulse quality, normal respiration rate (40), and normal lung sounds. Abdominal palpation revealed a readily palpable spleen (smooth, nonpainful). Rectal examination was normal.  Integumentary examination demonstrated several subcutaneous lipomatous masses, the most notable being on the left medial forelimb.

Complete blood count revealed normal leukogram and hemogram.Coagulation panel (PT and PTT) were unremarkable.

Serum chemistries demonstrated mildly increased ALT (227 U/L), mildly increased GGT (19 U/L), normal ALP (64 U/L) and normal total bilirubin (0.2 mg/dl).  Phosphorous (2.2 mg/dl) and magnesium (1.3 mg/dl) were mildly (1.3 mEq/L).

Abdominal ultrasound demonstrated multiple masses of mixed echogenicity within the liver parenchyma.  The largest mass measured 3.67 cm X 4 cm and was located between the stomach and gall bladder. Multiple smaller masses 0.8 - 1.6 cm diameter were observed in the surrounding liver parenchyma.  A somewhat irregular cystic structure was noted in the left caudal liver lobe with a 0.5 cm mass of mixed echogenicity abrupting the cystic component.  No significant morphologic or echogenic abnormalities associated with the gall bladder, stomach, pancreas, spleen, intestine, kidneys, adrenal glands (slightly "plump"), or urinary bladder.  No free fluid was evident within the abdominal cavity.

Thoracic radiographs (3 view metastasis series) revealed normal cardiac silhouette and mild, diffuse bronchointerstitial pattern consistent with Logan's age.  There were numerous radiopaque nodules in the area of end-on vasculature in the ventral pulmonary fields.

Today's diagnostic findings are most consistent with diffuse liver neoplasia with possible pulmonary metastasis.  There are multiple masses within the liver parenchyma.  This is strongly suggestive of malignant neoplasia (cancer).   The numerous radiopacities  associated with end-on pulmonary vasculature are very suspicious as the diameter of the radiopacities is somewhat larger than normal end-on pulmonary vasculature.

Definitive diagnosis would likely require biopsy; however, ultrasound guided fine needle aspirates are sometimes effective in determining tissue type (sarcoma, carcinoma, round cell tumor) and malignancy.  Blood work was pending (coagulation panel at the time of discharge).

Prognosis is typically very poor to grave for liver neoplasia that is this extensive.  It provides an etiology for the body condition score and many of the clinical signs.

We are discharging Logan to the care of her family with the following recommendations:

1) Feed bland diet. This may consist of several commercially available foods (Hill's i/d, Purina EN, Royal Canin Gastrointestinal).  Bland homemade diets may utilize braised or boiled ground chicken, turkey, or lean ground beef mixed with pasta, bread, rice, or potatoes (1 part meat to 2 parts carbohydrate by volume).

2) Restrict exercise to short leash walks for elimination purposes.  Avoid forced exercise or rough play.

3) Give medications/supplements as currently administered.  Avoid use of NSAIDs.

Unfortunately, patients diagnosed with advanced or end-stage disease often suffer significantly and euthanasia becomes a consideration.   Although there are no rules for determining the need for euthanasia, guidelines for evaluating quality of life are sometimes helpful. 

Indicators of discomfort and suffering may include:

1) Prolonged inappetence or complete anorexia for 48 hours.

2) Prolonged decrease in water intake or complete avoidance of water for 24 hours.

3) Inability to sleep without interruption.

4) Incessant pacing or hesitation to lay down and rest.

5) Uncontrollable fever, vomiting, diarrhea or seizures.

6) Prolonged or progressive respiratory distress

7) Vocalization associated with pain

8) Inability to avoid soiling with urine or feces.

9) Stupor, coma or other debilitating neurological signs.

10) Respiratory distress or cyanosis.

We regret that we were unable to provide Logan and his family with a more promising prognosis.  Should his owners decide to pursue additional diagnostics or should he require assistance after-hours, we will gladly see you here at VRCC.  Please do not hesitate to contact us if there are any problems, questions, or concerns.

Respectfully,

Ed Fallin, DVM, MS

Diplomate ACVIM

Small Animal Internal Medicine

 

I’m a relatively private person, so perhaps it was the shock of it all that inspired me to write on Facebook, “Two words I never want to hear again…..liver cancer.”

I was overwhelmed by the 60+ comments of support and advice.  However, there was one in particular from Darlene Paul that got my attention, “Stephanie PM me.  I have been dealing with a liver mass in Tobi since last June…” So I reached out to Darlene and she told me about some alternative medicine methods she used on Tobi working with a woman named Patti Green.  Darlene implored me to come up to her place and see Patti.  I won’t go into the details of the successes that Patti has had treating cancer homeopathically, but I will say that the stories Darlene shared gave me the greatest gift.  Hope.