D. E. Larsen, DVM
Della was a middle-aged white poodle. She could hardly contain herself and was wiggling all over the exam table when I entered the room.
Wilma displayed no such excitement. She was a nurse and usually knowledgeable about Della’s health care.
“What is going on with Della today?” I asked as I struggled to keep Della from licking my face.
“I must admit that I took Della to another veterinarian in Albany yesterday,” Wilma said. “I am here because I disagreed with his assessment of Della’s problem. She has a small mammary tumor that just appeared, and he said most of these are nothing to worry about and we should just watch it. I don’t think I want to watch it.”
I generally do a complete exam first and then end with a closer exam of the problem at hand, but with Wilma’s immediate concern with the mammary tumor, I quickly turned Della over onto her back and palpated her breasts.
There was a single, solid tumor in her right inguinal breast. It was firm and round, with an irregular surface. It was a centimeter in diameter, a little smaller than a marble.
“How long has this been here?” I asked.
“I first noticed it last month,” Wilma said. “I think it has grown since I first noticed it.”
“Could it have been longer, and you didn’t notice it?” I asked.
“I lost my last poodle to mammary cancer,” Wilma said. “I check Della’s breasts every month. If it had been tiny, I guess I could have missed it.”
“In the Albany veterinarian’s defense, many older female dogs have small mammary tumors that are benign,” I said. “These tumors will be present for years and cause little or no problem. They are often scattered in multiple breasts and may have been noted by the client for months or years before we see them. It is common to monitor those for growth or to do simple lumpectomies. I think this tumor is different. It is single, apparently rapidly growing, and it is new.”
“I think we should do a biopsy,” Wilma said with some finality in her voice.
“I’m not going to put Della through chemo,” Wilma said. “But, what do you mean when you say you like to do surgery yesterday.”
“I see,” I said. “This is veterinary medicine, and we have limited treatment options for cancer, even when the expense is not an issue. Surgery is often the only weapon we have to fight cancer. The philosophy that I was taught was to cut early, cut wide and cut deep. In human medicine, they schedule some testing, then schedule a biopsy. If the biopsy says cancer, then they schedule surgery. Or sometimes, they do chemotherapy before the surgery. It is often six weeks or more before they get around to treating the tumor. In the life of an aggressive tumor, six weeks is massive. I like to do surgery yesterday.”
“If we do a biopsy tomorrow, by the time we send it to the lab, they process it, then the pathologist reads the slides. We have lost a week by the time I get the report. I suggest we remove this entire breast with a radical resection that includes the muscle fascia under the tumor and the inguinal lymph node. That way, we save a week time-wise. Remember, cut early. If it comes back benign, Della has only lost a breast that she will not use anyway. If the report returns malignant, we are ahead of the game by a week.”
“That sounds good. Do you want her here in the morning?” Wilma asked.
“Yes, bring her in on an empty stomach,” I said. “We will work her into our schedule, one way or the other. She should be ready to go home in the afternoon.”
“And when will we get a report from the lab?” Wilma asked.
“I wouldn’t hold your breath,” I said. “If I can build a fire under them, we might hear something by the first of next week, but I bet it will be later in the week. We should have it by Friday at the latest.”
Wilma dropped Della off for surgery in the morning. We were able to reschedule some of the routine surgeries so I wouldn’t be under any time pressure with Della’s surgery.
The surgery was not complicated. I made an incision around the inguinal breast and extended it posteriorly to include the lymph node. I incised through all the soft tissue down to and including the deep fascia of the abdominal muscles. This allowed me to remove the entire breast and all the tissue deep to it in one intact tissue block. A simple two-layer closure proved satisfactory and did not put undue stress on the tissues.
I was tempted to cut into the tumor, but I restrained myself, so the pathologist could have a solid block of tissue to examine.
Della recovered with no problem and was ready to go home when Wilma came in at four in the afternoon.
“Things went really well, and we were early enough that I was able to get the tissues on the way to the lab with the afternoon courier,” I said.
“How did it look to you?” Wilma asked.
“I was really tempted to open it up and look, but the pathologist will be able to give the best information with an intact block of tissue,” I said. “So, we will have to wait and see the results.”
“I know I said I wasn’t going to put Della through any chemotherapy, but are there other treatment options available?” Wilma asked.
“You are probably going make me hit the books a little,” I said. “We can talk more when we get the lab results, but we might be able to use some immune stimulators. Those are new things in this fight against cancer, but the good thing is they don’t make the patient sick from the medication.”
The good news was the lab results came in the form of a phone call from the pathologist early Tuesday morning. The bad news was that there was no good news. The tumor was a mammary adenocarcinoma and appeared to be very aggressive. There were tumor cells scattered in the tissue surrounding the primary tumor mass. But my wide margins were very adequate to provide clean surgical margins. The real bad news was there were tumor cells in the lymph nodes.
“Dave, with a tumor that is this aggressive, with tumor cells in the regional lymph nodes, this tumor has already metastasized,” Doctor Albright said. “You are dealing with a dog with two feet in the grave.”
“This owner has already said she is not going to do chemo,” I said. “Do you have any thoughts on using levamisole as an immune stimulant?”
“I don’t know,” Doctor Albright said. “You can read the reports as well as I can read them. The information appears promising at buying some time, but in an individual case, how do you quantify that. The good thing about it is it gives the owner the feeling that they are doing something.”
I had Judy call Wilma and schedule an appointment to review the lab results and discuss using some treatments. That signaled that the lab report was not favorable, and Wilma was anxious when I stepped into the exam room.
“The news is not good,” I said.
“I assumed that,” Wilma said. “How bad are things?”
“The surgical margins were clean, but the tumor appeared very aggressive, and there were tumor cells in the lymph node,” I said. “That means this tumor has already metastasized or moved to other parts of the body. Most of the time, that means the lungs.”
“Can an x-ray tell us that it is in the lungs?” Wilma asked.
“Probably not at this time,” I said. “The tumors need to be about nine millimeters before they can be seen on x-rays. At this point, that information is sort of academic. We are not going to do chemo, so we go until Della starts having respiratory issues before an x-ray.”
“What about the immune treatments?” Wilma asked.
“The reports show a favorable extension of survival times with levamisole,” I said. “That is what we are talking about now. We are talking about buying time and quality of life. We are not talking about curing her cancer.
Levamisole is used routinely in large animal medicine as a dewormer. It is safe, inexpensive, and readily available. And it has few, if any, side effects. There could be some injection pain, but Della’s dose will be small, so that shouldn’t be an issue.”
“When can we start those injections?” Wilma asked.
“We can start now,” I said. “I will give Della an injection today and then set her up for injections every two weeks.”
“Is that an injection I could give at home?” Wilma asked.
“You probably could, but I mentioned that levamisole is a cattle drug,” I said. “It comes in five hundred cc bottles, and Della’s dose is less than one cc. It would probably be better to use it out of my bottle here.”
Stay tuned for the next edition with Della’s immune therapy, some additional surgery, and the eventual outcome in the story that follows on Friday in Della’s Mammary Tumor, Part Two.
Photo by Luis Alberto Cardenas Otaya on Pexels.