Della’s Mammary Tumor, Part One 

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.

Ruger’s HItchhikers

D. E. Larsen, DVM

The little shepherd pup was lying with his neck extended and head flat on the exam table, and he did not budge when I entered the room.

Kris was seated in a chair, but her two boys stood at the table with the pup.

“Which one of these guys are we looking at today? I asked.

Both boys stepped back from the table and pointed at the pup.

Kris, a short gal in her mid-thirties with well-kept blond hair, was a regular client, but I had not seen this pup before.

 “This is Ruger; he isn’t feeling very well today,” Kris said.”  We’ve had him for a little over a week. He was fine at first, but then he started slowing down. Peter wormed him, and he passed a mass of ugly worms. But he has just kept getting worse. Today he is just like this, and he won’t get up to do anything.”

“And boy, did he poop a gob of big ol’ worms!” Jason, the larger of the two boys, said.

I lifted Ruger’s head with my left hand under his jaw. He acted almost lifeless. I turned his lip up, and his oral membranes were white. Not a hint of pink in his mouth or tongue.

“What did you use to worm Ruger?” I asked.

“I’m not sure,” Kris said. “A bottle of liquid that Peter picked up somewhere. I think it was like piper something. It was a clear fluid, slightly yellow in color.”

“That sounds like it was piperazine,” I said. “That is a good dewormer for roundworms, which is what you saw. The problem with it is it does do anything for the other worms. But we need to get some blood out of Ruger and see why he is so weak.”

“Do you think this is serious, Doctor?” Kris asked.

“Looking at his white membranes, I think Ruger is probably critically anemic,” I said. “I would guess we will need to give him some blood first off, and then we need to figure out why he is in this situation.”

“Could all those worms do this to him?” Kris asked.

“Roundworms can cause some problems, but it is usually gut problems,” I said. “There are some worms, especially hookworms, that can do this to a puppy. But, I rarely see hookworms in an Oregon dog.”

“Ruger was born here, but his mother is from Alabama,” Kris said.

“We will collect some blood and look at a stool sample,” I said.

“We have been watching his stool and haven’t seen any more worms in it,” Kris said.

“We do a floatation, where we float the worm eggs to the top of the vial and then look at those under the microscope,” I said.

“And you said he was going to need some blood. Where does that come from?” Kris asked.

“Ruger is a little pup. We won’t need a lot of blood to make him feel better,” I said. “My dog is is big Chesapeake Bay retriever, and he volunteers to be a donor.”

“He volunteers?” Kris asked.

“Yes, it is sort of a reluctant volunteer situation,” I said. “He loves coming to the clinic, and most of the time, he sleeps in my office. But he knows that he is about to volunteer for something when we take him into one of these rooms. And he really applies the brakes.”

We collected a small tube of blood, and it was evident that it was very thin. It almost looked like the blood from a leukemic cat. And at the same time, we collected a small stool sample.

I made a smear of the stool on a microscope snd added a drop of floatation fluid. As Dixie was running a quick CBC on the blood sample, I stuck the slide on the microscope.

I was totally shocked at the view through the microscope. The slide was covered with hookworm eggs, hundreds, if not thousands, of eggs in the first low power field.

Dixie had just finished with the CBC and handed me the paper.

“I think it is good that Odie is here today,” Dixie said.

Ruger’s packed cell volume, the percentage of red blood cells to total blood volume, was ten percent. In the dog, this was one the edge of death. I had seen cats with a PCV of six percent. Most of those died, but some could be saved with an immediate blood transfusion. I am not sure I had seen a PCV this low in the dog.

I returned to the exam room, pondering how to present this information to Kris with the boys in the room.

“You look concerned,” Kris said.

“Yes, Ruger is in a very fragile situation right now,” I said. “His red blood cell volume is at ten percent, which is as low as I have seen it in a living dog. We will have to take him in the back and transfuse him with blood right now. In his condition, we will give him the blood that we have available. We will not do any cross-matching, but it shouldn’t be a problem with this first transfusion. Any undue stress and Ruger could be gone in a moment.”

“What caused this to happen?” Kris asked.

“He has a massive infestation of hookworms,” I said. “We just don’t see this in Oregon, but it happens regularly in the South. With Ruger, it reflects on his mother.”

“Can we take care of that?” Kris asked.

“Yes, we can treat the hookworms, but Ruger needs blood first,” I said. “If we get some blood into him, he will come alive in an amazing fashion.”

“If you want to reduce his stress, I think you should do the transfusion right here,” Kris said. “The boys can keep him calm.”

“Okay, if the boys are up to it,” I said. “Sometimes, owners transmit stress to the pet. All I have to do is convince Odie to volunteer, and then I will collect a couple of large syringes of blood from him. When I come in here, we will place a small winged IV set in Ruger’s front leg and inject the blood right out of the syringes. It will be a slow injection, but it will only take a couple of minutes. Ruger will make a dramatic recovery, probably before the injection is complete. So, you prepare the boys for their job, and I will go get the blood.”

I stepped to my office door and slapped my leg for Odie to come, and he jumped up and was beside me in an instant. When I walked to the surgery room, Odie stopped at the door, and we had to pull him into the room by his collar. 

I had two sixty cc syringes, each with three ccs of heparin added, that I used to collect blood from Odie with a jugular puncture. It only took a moment to make the collection, and Odie was wagging his tail when I set him on the floor. He knew he would get a can of dog food for his service. He was bouncing around Dixie as she headed back to the kennel with a can of food.

Back in Ruger’s exam room, Ruger looked like he was fading away. I quickly placed a winged IV set into his left cephalic vein and started the injection of Odie’s blood.

Both boys were petting Ruger and didn’t seem bothered by the procedure.

“I think you guys will be amazed at how quickly Ruger is going to get well,” I said.

“I don’t know,” Jason said. “He looks worse now than when we came.”

As I finished the first syringe, Ruger picked his head and nuzzled Jason’s hand. By the time the second syringe was empty, Dixie had to hold Ruger down so we could get the IV set removed. When Dixie released her grip, Ruger was licking the faces of both giggling boys.

“That is sort of amazing,” Kris said. “I don’t think I have seen anything like it before.”

“Red blood cells are sort of important,” I said. “Now we have to get a dose of Nemex into this guy.

Nemex was a flavored liquid, and Ruger lapped it out of the end of a syringe.

“Is that all there is to it?” Kris said.

“That is all for today,” I said. “But Ruger is probably going to have problems for his entire life. He probably got a massive exposure of infective larva from his mother. Many of those will encyst in his tissues to become active later. They won’t drain his blood like this when his size is bigger, but he will need to be wormed regularly.”

“And I guess that means wormed with something other than piperazine,” Kris said with a smile on her face.

“Yes, you will have to get the stuff here or read the labels well if you get them elsewhere,” I said. “For now, I would like to see Ruger next week. Just to make sure he is doing okay. I will repeat the worming then, and I can fix you up with medication to worm him every week for the following month. Then we can play it by ear, but he will probably need medication a couple of times a year.”

***

The following week, Ruger was a different pup when he came in for a recheck. He bounced through the door on the end of a colorful leash with both of Kris’ boys trying to corral him.

When Ruger was shown into the exam room, Odie was in the lab area. In a somewhat unusual move for Odie, he was up and came over to rub noses with Ruger.

“This is Odie,” I said to the boys. “He is my dog, and he is the dog who gave the blood that we gave Ruger last week.”

“He almost acts like he knows that he saved Ruger’s life,” Kris said.

“Sort of, doesn’t he,” I said. “He is a smart dog,” 

Ruger was doing well on his recheck, and his blood numbers were back in the normal range. He did require medication for his hookworm problem every three to six months for the following six years that he got to see me. Kris and her family, and Ruger, moved away at that time.

Photo by Torsten Dettlaff on Pexels.

Cookie’s Litter, From the Archives

D. E. Larsen, DVM

“Dr. Larsen, This is Maude, from Brownsville,” Maude said into the phone. “Cookie, my best milk goat, is about ready to deliver. She is so large that she has been down for two days. Can I bring her up to your place so you can look at her?”

“That’s fine, Maude, you just need to know that we are not in the clinic yet,” I said. “We are still practicing out of our house on Ames Creek.”

“I think I can find it,” Maude said. “It doesn’t bother me, and Cookie is used to an old barn, so a garage won’t be a problem for her.”

When Maude arrived, and we got Cookie unloaded, her appearance was amazing. She had been down for two days because her abdomen was so massive, she could not support it standing. I was worried that she might even have a Hydrops Allantois, but I could easily palpate a couple of very active kids in the uterus. 

The only time I had seen Hydrops was while I was in school at Colorado State University, in a cow bred to a Bison bull. In that cow, you could not palpate any fetus. And on C-Section, the calf was dead. Hydrops is common in cows bred to Bison bulls. The Beefalo’s calves come from Bison cows bred to a Bovine bull. 

“We have some decisions to make, Maude,” I said. “If we wait for her to deliver, there is a good possibility that she will suffer significant musculoskeletal injury from being down for such a long time. If we do a C-section, we take a chance on the kids being early. That will mean that all of them may not survive.”

“You say, all of them,” Maude said. “How many do you think are in there?”

“I think a bunch,” I said. “I have seen 4 lambs in a ewe, and she was almost this big. There is about a 1 in 10,000 chance, and it might even be higher in the goat. There are at least 3 kids in there, I think there may be 4.”

“I think I am more worried about Cookie than I am about the kids,” Maude said. “It would be nice to get a bunch of kids out of her, but I want you to know that Cookie is the priority in this event.”

“So, I hear you say that you want to do a C-Section,” I said.

“Yes, that is what I want to do,” Maude said. “When can you do it?”

“Maude, I am just getting started here,” I said. “My days are not full, I can do it right now.”

“Good, can I stay and watch?” Maude asked.

“You are more than welcome to watch,” I said. “In fact, you might be put to work if we have 4 kids in there. I see you have a couple of bales of straw in the back of your pickup. Is there a chance we could use one of those to bed her down. She would be more comfortable than on the bare concrete.”

“That is what I brought them for,” Maude said. “Let me pull them out of the truck.”

We used one of the straw bales to bed Cookie down in the back of the garage while we set up for surgery. Sandy sets some chairs out for Maude and her driver.

“Once we get set up, things will go pretty fast,” I explained to Maude. “I will roll her up on her back, and we will clip and prep an area in front of her udder. I will make an incision, then we will start pulling kids out as fast as I can. If there are 4 of them, everybody will have a kid to take care as I close up things for Cookie.”

“I have never seen anything like this before,” Maude said. “I guess I will be okay. At least if there are kids to care for, I will have something to do.”

Paula had everything ready, so we rolled Cooked up on her back. Again, I was amazed at the size of her belly. It spread out in both directions. 

“I don’t think she could roll off her back if she tried,” I said to Paula. “You better tell Sandy to get every spare towel she can find. We are going to spell all sorts of fluid out of this uterus.”

With the abdomen clipped and prepped, I made the incision on the ventral midline in front of the udder. My kids watched from the kitchen doorway, and Maude sort of stretched her neck to see better.

“I thought there would be more blood,” Maude said.

“As long as I can avoid these large milk veins coming from the udder, there should be very little blood,” I said.

I extended the incision through the linea alba, pulled the omentum forward, so it was out of the way. Then I reached in to grab the head of the first kid I encountered. I drew this head through the abdomen incision and incised the uterus carefully. 

The kid’s head popped out of the incision and shook. I think she was ready to be out of there. Grabbing her neck, I pulled her the rest of the way through the incision. There was a rush of fluid that came with her. I handed her back to Maude. Maude was waiting with a towel.

“This kid is the same size as a single,” Maude said.

“No wonder she is as big as a house,” I said as I reached in and grabbed the second kid by the head also.

This kid came out fighting also. And like her sister, she was the size of a single.

“Two girls so far,” I said. “In a couple of years, you’re going to have so much milk you won’t know what to do with it.”

I reached in and grabbed a couple of hind legs in the far uterine horn. I tugged, and they did not move a lot. I felt close, I had one leg from two different kids. Correcting my error, I pulled the third girl out by her hind legs.

“Maude, there is another one in there,” I said. “And this one is another girl.”

Sandy stepped up, with the help of our girls, to take this kid. Maude had the first kid standing already. Everybody was busy now, and there were smiles all around. Nothing like baby goats to make people happy.

I reached in and pulled out the last kid, another girl. 

“This probably sets some sort of a record. Quadruplets, and all females,” I said as I handed the last kid to Paula.

I started pulling as much of the fetal membranes out through the incision as I could. There is no way to take them all out with damaging the uterus. But I would pull out a bunch and cut them off with scissors. We had all the towels and straw soaked with uterine fluids. 

“This is probably going to take as long to clean up this mess as it took for the surgery,” I said, more to myself than to anybody else.

I closed the single incision in the uterus. It was about a six-inch incision, sort of amazing that you could drag 4 kids through that incision. After returning the uterus to a normal position, I closed the Linea Alba with a sliding mattress suture using #2 Dexon. The external incision was closed in a conventional two-layer manner.

“Cookie, you are going have a flabby belly for a time,” I said as we rolled her off her back and made her comfortable on a clean spot in the straw. She wanted the kids, so Maude started handing them over to her one at a time. It didn’t seem to bother her at all to have all 4 of them to care for. 

“What do you think we should do with her now, Doc,” Maude asked.

“I think we should milk her out and get some colostrum into the kids,” I said. “It is early enough that leaving the kids with her for the day will probably be the best. I will give her some IV Glucose and Calcium just to give her a little more energy. I am guessing that she isn’t going to be up until morning. I would like like to keep her until then. I don’t know if I can handle the 4 kids running around the house.”

“I will go home for the day,” Maude said. “I have a lot of chores waiting. I will get back here around 5:00 this afternoon if that is okay. I will take the kids home. That is not a big thing. I have plenty of colostrum in the freezer, and I don’t leave the kids with my milkers anyway.”

“That will work fine,” I said. “Then, we will just see what morning gives us with Cookie.”

Cookie was up and looking for both food and a milker when I checked her early the next morning. Luckily, Maude pulled into the driveway about when I was heading into the house to give her a call.

“I guessed that Cookie would be up and ready to be milked,” Maude said. “I figured you would appreciate getting her out of here early.

“I think she will be ready for the milking stand by the time you get home with her,” I said. “She should be good to go. I see she passed her membranes last night. Just keep an eye on her, and I will drop by to just glance at that incision in a couple of days. I generally leave those sutures in place for about 3 weeks, just to be safe.”

Cookie healed with no problems, and the kids became a great addition to Maude’s milking string.

Photo by Brenda Timmermans from Pexels.