Caring for a Three Legged Dog or Cat
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Hello, my 10.5 year old german shepherd (he is 60lbs) got an ACL tear & was scheduled for a TPLO surgery when they discovered xrays changed significantly. He is now recommending amputation, so I want to be proactive as possible. These are the results from the pathologist & xrays to see if anyone can help me figure out what it looks like. Thank you so much. The surgeon has said that my dog's case is tough & in the 10 years he has been working hasn't seen a case like this. I want to know if putting him through a biopsy is going to be painful and unnecessary when amputation could be next. Especially if the biopsy could come back as inconclusive.
History:
Chronic RFL - previous injury as a puppy, radiographs not available but right elbow significantly thickened with decreased ROMRHL lame - pre-TPLO radiographs today are concerning for an aggressive lesion within or around the joint (see radiologist report). Differentials include neoplasia, osteomyelitis with atypical DJD response or autoimmune disease less likely. Needle aspirate of the joint and bone showed a significant neutrophilic component which is atypical for DJD alone. While we are still unsure as to why Mac is lame, concern remains that this is more than just a cruciate tear. After discussing his case with our internal medicine specialist, next diagnostic steps discussed include;
Arthroscopic explore of the joint with synovial biopsy and culture waiting 4 to 6 weeks and assess bone changes via repeat radiographs. If cortical disruption on the distal femur worsens, further supporting an aggressive process then amputation could be considered.
Leg photo/xray:
https://ibb.co/X4qSXdv
More xrays:
Results
Unit Lowest Value Highest Value Qualifier
CYTOLOGY SOURCE Joint fluid. Right hind limb. Source as indicated on diagram.
CLINICAL HISTORY Chronic right hind limb lameness with severe muscle atrophy and pain localized to the stifle region. Concern for aggressive process associated with stifle neoplasia, osteomyelitis.Suspicious lytic lesion seen in distal femur radiographs with severe stifle effusion and muscle atrophy. Synovial fluid and periosteal aspirates obtained.
PATHOLOGIST REPORTMICROSCOPIC DESCRIPTION: The samples examined (10) from both leg lytic lesion and synovial fluid are cytologically similar and are of moderate cellularity and good quality. Smears contain a mixed population of inflammatory cells, moderate amount of blood in a thick proteinaceous pink background. Inflammatory cells include moderate numbers of neutrophils and foamy macrophages with occasional erythrophagocytosis and rare small lymphocytes. Microorganisms and atypical cells are not seen.
MICROSCOPIC INTERPRETATION: Most consistent with neutrophilic/macrophagic (chronic) inflammation (seen in all aspirates).
COMMENTS:The cause is not apparent for the inflammatory response. No etiologic agents could be identified, but the possibility of underlying infectious disease (bacterial, fungal) or neoplastic process cannot entirely be ruled out. Cytologic findings could also be consistent with a foreign body reaction. Cultures could be considered to assess for underlying infection. Histopathology of the LAD lesion may be needed for a more definitive diagnosis.
Report for US6 History:suspected lytic lesion in leg, met checkFindings: Three-view thoracic radiographs are available for review:The lungs are normal with no evidence of soft tissue nodules or masses. There is no mediastinal lymphadenopathy or pleural effusion. The cardiovascular structures are normal in size and contour. No tracheal or esophageal abnormalities are detected. The diaphragmand cranial abdomen are normal. On limited evaluation of the forelimbs, there is evidence of severe elbow osteoarthrosis. Incidentally, there is mild spondylosis deformans.
Conclusion:Normal thorax. There is no evidence of thoracic metastatic disease.
Findings: Two-view radiographs of the right pelvic limb are available for review: There is severe soft tissue swelling surrounding and within the right stifle joint. There is heterogeneous medullary lucency in the right distal femoral metaphysis as well as in the condyles. The lateral femoral and tibial condyles are flattened with a flared appearance.There is mild stifle osteoarthrosis. No obvious tibial or patellar subluxation is present. The patellar ligament is normal. The right tarsus is unremarkable.
Conclusion: Severe intra-capsular and extra capsular soft tissue swelling of the right stifle and irregular lucency in the right distal femur- Differential diagnoses include an aggressive bone lesion such as osseous or joint associated neoplasm, atypical degenerative change or less likely fungal osteomyelitis, depending on travel history.Possible underlying subchondral bone lesion such as OCD of the lateral tibial and/or femoral condyle with associated degenerative change vs. previous trauma or atypical age associated degeneration.
RECOMMENDATIONS: Consider performing three-view radiographs of the thorax to screen for metastatic disease. Pending these results, bone and/or synovial biopsies may be of benefit to screen for underlying neoplasia.
The samples examined (10) from both leg lytic lesion and synovial fluid are cytologically similar and are of moderate cellularity and good quality. Smears contain a mixed population of inflammatory cells, moderate amount of blood in a thick proteinaceous pink background. Inflammatory cells include moderate numbers of neutrophils and foamy macrophages with occasional erythrophagocytosis and rare small lymphocytes. Microorganisms and atypical cells are not seen.
Photos of the sample: I do have these in a link that could be enlarged.
https://ibb.co/k10bFGC
Continued Results:
Abdominal Ultrasound Performed by: MP
Liver: WNL
Gall Bladder: Distended but otherwise WNL
Stomach: The gastric wall appears markedly thickened in the proximal fundus. The remainder of the stomach appear WNL. Spleen: WNL
Pancreatic Region: NSF - pancreas could not be definitively identified.
R Kidney: NSF
L Kidney: NSF
R Adrenal: Not visualized
L Adrenal: NSF
Intestines: NSF
Urinary Bladder: There is a small polyploid structure (~0.5cm) attached to the dorsal bladder wall. The remainder of the bladder wall appears normal.
Abdominal Nodes: NSF
Prostate: There is a slightly irregular hypoechoic structure in the region of the prostate though it could not be well visualized due to the intrapelvic position. It may also be consistent with a medial iliac LN.
Uterus/Ovaries: NA Other/Comments: NA
Summary:
Gastritis is likely secondary to high dose NSAID administration. Gastric neoplasia is also possible. Possible prostatomegally vs lymphadenopathy No other significant findings or evidence primary vs metastatic neoplasia
Hi Mac & Family. I'll let our Fairy Vet Mother share her thoughts on your situation, since I'm not qualified to give an interpretation. But you can check out my response to your first post, here.
Tripawds Founders Jim and Rene
tripawds.com | tripawds.org | bemoredog.net | triday.pet
Thank you. Just wanted to flag that the first xray photo is the best quality photo and the clearest.
The distal femur is an area where we do see osteosarcoma but the radiographs do not have the obvious appearance of OSA although you could be catching it early. Synovial cell cancer is also possible and I am glad that they did an ultrasound of the spleen since hemangiosarcoma is very common in Shepherds and can metastasize to bone.
Either way if he is very lame then amputation with subsequent biopsy is probably the best option. Your vet can try to perform a biopsy first but this can be quite painful and there is a risk of fracture or sometimes the exact lesion is hard to locate and you could get a false negative if the site is missed. If the dog is not very lame you can repeat radiographs in 2-4 weeks to look for changes.
Pam
Thank you so much for your response. I think it's clear that the amputation will be happening. Even though this website has made it clear that dogs do okay on 3 legs, my heart is still breaking.
Dr. Pam you are a rock star, thank you for the great feedback.
@mackies, of course this isn't easy for you. We've got your back if amputation is the way things go. Keep us posted.
Tripawds Founders Jim and Rene
tripawds.com | tripawds.org | bemoredog.net | triday.pet
We use a test offered by VDI. They offer a canine cancer panel. They test two things, Thymadine Kinase 1 (TK1) and C-Reactive Protein (CRP). Both are indicators of rapid malignant cell growth. It's a very reliable test.
https://vdilab......screening/
Brian
Thanks for sharing Brian. This is a new one we hadn't heard about.
Tripawds Founders Jim and Rene
tripawds.com | tripawds.org | bemoredog.net | triday.pet
Mac's leg biopsy is back & it's not cancer. My heart is heavy because it seems like if it's a fungal infection, it may have been treated without the amputation.
I'm glad you posted here. Hopefully Dr. Pam will have some veterinary insight for you.
See my response to your other post.
Tripawds Founders Jim and Rene
tripawds.com | tripawds.org | bemoredog.net | triday.pet
Which type of fungal infection? He may need itraconazole or a different drug to treat systemically. When I lived in Wisconsin we saw a lot of Blastomycosis but other parts of the country have different types. There is a blood test to identify the organism.
Pam
So the fungal and bacterial infection were ruled out. As it stands now, there is no answer as to why his joint/bone responded this way. We may never know. Would it be helpful if I posted the biopsy record?
MICROSCOPIC DESCRIPTION:
Limb, right hind: Multifocally, within the stifle joint are moderate amounts of proteinaceous debris,
hemorrhage, hypertrophied macrophages, and fewer neutrophils. Widespread, the stifle joint capsule is
markedly increased in thickness characterized by marked synovial hyperplasia with formation of elongate
and branching papillary projections in a multilayered lining synovium. The subsynovial stroma is markedly
expanded by fibrovascular proliferation accompanied by marked inflammation dominated by plasma cells
alongside fewer lymphocytes, macrophages, uncommon scattered neutrophils, and Mott cells. Along the
articulating surfaces of both the femur and the tibia, there is multifocal, moderate articular cartilage
erosion to ulceration with loss of subchondral bone. In these areas, there is fibrovascular stromal
proliferation, occasionally overlying eroded articular cartilage, and accompanied by moderate to marked
inflammation similar to that described in the subsynovial stroma. An overtly neoplastic process is not
observed.
MICROSCOPIC INTERPRETATION:
Limb, right hind: Marked, chronic, plasmacytic, neutrophilic, and histiocytic proliferative stifle
arthritis and femoral and tibial osteomyelitis with articular cartilage ulceration, osteolysis, and
pannus formation
Margins: Completely excised
COMMENTS:
This is a preliminary report.
Mac's right hindlimb is characterized by marked chronic inflammation centered on the stifle joint marked
thickening of the joint capsule and accompanied by articular cartilage ulceration and osteolysis with
osteomyelitis in both the femur and tibia. An overtly neoplastic process is not observed. A primary cause
for this robust inflammatory response is not identified histologically. Primary differentials include but
are not limited to chronic infection, immune mediated disease, potential foreign body reaction, or
possibly remarkable biomechanical instability. Special stains are pending to more rigorously evaluate for
an underlying bacterial or fungal infectious agent. Correlation of histologic findings with radiographic
findings and overall clinical suspicions is recommended. If these results do not fit with your clinical
suspicions, please feel free to reach out for further case discussion.
12/6
Special staining was performed with PAS and Gram to attempt to aid in visualization of potential fungal
and bacterial organisms.
No infectious agents are observed. Though no agents are identified, it is important to note that special
stains have limited sensitivity in identifying organisms in tissue sections. Therefore, a negative result
does not completely rule out an infectious etiology. No additional findings are observed to add to the
initial interpretation.
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