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Be More DogWhat does it mean to Be More Dog?

Find out in Be More Dog: Learning to Live in the Now by Tripawds founders Rene and Jim. Learn life lessons learned from their Chief Fun Officer Jerry G. Dawg! Get the book and find fun gifts in the Be More Dog Bookstore.

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Second Opinion? Rare form of cancer?
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Member Since:
13 November 2021
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13 November 2021 - 10:21 pm
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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:

https://ibb.co/MGjbYzM

https://ibb.co/1b416CD

https://ibb.co/VMVTBSd

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

On The Road


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14 November 2021 - 11:51 am
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Hi and welcome! Your future posts won't need to wait for approval so please post away.

I'm so sorry you and your pup are in this tough situation. You are in good company, as we just had a member from the UK, Bert, join with similar circumstances in that he has arthritis.

Based on what I'm seeing, it sounds like there's a lot going on and a lot of uncertainty with your pup. I'll be the first to say that I'm not a vet and I'm not qualified to give an interpretation of a pathology report like this. So what we like to do around here is to try to keep things as simple as possible. What I'm thinking it comes down to is this:

Is the leg beyond saving, no matter the diagnosis? Because if it is not going to heal with any kind of treatment other than amputation, then it's a matter of do you amputate, or not, and treat his pain with palliative methods (pain meds), until the meds no longer work. It seems so simple but I know it's a really tough call. 

When it comes to inconclusive pathology reports, you're not alone. This happens more than you'd think. What I recommend to folks is to 1) make sure an oncologist reviews the findings. And if it's leaning toward amputation as the only option (or palliative care), then have an orthopedic specialist to review your case and confirm if your dog is or is not a good candidate for becoming a Tripawd.

I hope this helps you and Mac. At 60 pounds, he's a pretty lean Shepherd, which is a huge advantage when it comes to life on three.

Tripawds Founders Jim and Rene
tripawds.com | tripawds.org | bemoredog.net | triday.pet

Member Since:
13 November 2021
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14 November 2021 - 12:36 pm
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Hi Jerry, thank you so much for your response, it was helpful! The surgeon did say that he highly doubts that it's going to be something other than amputation needed, but perhaps a biopsy could be helpful. Mac's primary vet looked over the report and he seems to think that the next step should be a biopsy because why amputate if it turns out it's not cancer. The surgeon has made it clear that any route we take is up to us, but this is the hardest thing to decide. I am afraid that if I don't do the biopsy, there will always be a what-if.

These past 2 weeks have been sort of a blur. Now that I'm reflecting back on this, it seems that overall, the surgeon has stated that whatever it is, the leg might be beyond saving but it's always nice to have a justification and a conclusive answer. But I think of course, he can't say with certainty. My main hesitancy about amputation is that from the beginning has been that before the TPLO surgery, three doctors looked at the xrays and nothing looked out of the ordinary and was consistent w a torn ligament.

I am still unsure as to what to do. His biopsy is scheduled for this Thursday, but I have the whole week off of work for Thanksgiving and I'm wondering if I should talk to the surgeon about going through with the amputation instead. Is the biopsy after the amputation going to give us more results as to what to do next?

Thank you, thank you & thank you for your help.

On The Road


Member Since:
24 September 2009
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15 November 2021 - 9:14 am
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Hmm. I re-read your post and what stands out to me is this:

 I am afraid that if I don't do the biopsy, there will always be a what-if.

Honestly I think that if this is your gut feeling, then you need to run with it. Yes, a bone biopsy does have an added risk of fracture, and of course it's another procedure that Mack will need to recover from. But if amputation is still recommended, at least you will feel better about the decision to do it. 

, it seems that overall, the surgeon has stated that whatever it is, the leg might be beyond saving but it's always nice to have a justification and a conclusive answer. 

What I would ask then, if you haven't already, is based on the condition of the bone, what conditions might be something that could be treated and bring his bone back to a healthy state? How likely is Mack to have one of those conditions? Is it even remotely possible that he could have a fungal or bacterial infection, based on his history?

 Is the biopsy after the amputation going to give us more results as to what to do next?

It might. Definitely worth talking to the surgeon about.

I wish I could be of more help. We have had some members here over the years who didn't get a conclusive diagnosis before amputation, but they proceeded anyways because of the amount of pain and bone destruction that occurred. It sounds like Mack isn't quite there yet and you may have some time on your side to ask more questions. I'd give the surgeon a call. You might also want to see if the folks at Colorado State's Argus Institute can help (their specialty is helping pet parents make tough medical decisions).

Let us know how this week goes. We are thinking of you guys!

Tripawds Founders Jim and Rene
tripawds.com | tripawds.org | bemoredog.net | triday.pet

Member Since:
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15 November 2021 - 5:49 pm
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Jerry, you have been so amazing and have so much information. He is going to be having a full amputation. If I wanted to look into a leg prosthetic, where should I start? 

On The Road


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15 November 2021 - 9:31 pm
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You are sweet, thank you for the kind words. Sounds like you made the decision. I hope you feel a little more relieved with that behind you?

I'm glad you asked about prosthetics . This is something that needs to be discussed with the surgeon asap, it has to be taken into consideration with the location of the cancer and how much leg can be left. The more residual limb, the better the chance for him to successfully use a prosthetic.

Our link has information about prosthetics . Read up on it when you can but for now you want to talk to the surgeon asap. This is to find out if he is a candidate. Not all dogs are, especially those with cancer.

You want to make sure that your surgeon is experienced with prosthetics and orthotics, because the way the incision is done will determine how successfully the wound heals so that you can put the device on his leg.

I hope this helps. Keep us posted!

Tripawds Founders Jim and Rene
tripawds.com | tripawds.org | bemoredog.net | triday.pet

Member Since:
13 November 2021
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17 November 2021 - 9:14 am
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Hi Jerry, I definitely don't feel any relief. He is laying next to me right now & is running in his sleep with both of his back legs. It is so heartbreaking. This is the hardest thing i have had to decide.

There is still a part of me that thinks i should do the biopsy because what if the lesion ISN'T anything but inflammation? But the surgeon seems so confident that whatever it is, there is not a lot of healthy bone left.

On The Road


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17 November 2021 - 8:08 pm
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How did today go? I've been away and hope that you feel a little more confident one way or the other. If the biopsy is going to give you peace of mind, then do what you need to do. We get it. The risk of a fracture sounds pretty high though, based on what the surgeon is describing, so it would mean being really, really careful with him after the procedure.

I know it's hard to decide, this isn't what anyone expects when we take on the role of pet parent. Just know that even if you do the amputation, he will still run and have fun and be himself. Life goes on for dogs, it's the greatest lesson we learn in this journey.

Tripawds Founders Jim and Rene
tripawds.com | tripawds.org | bemoredog.net | triday.pet

Virginia




Member Since:
22 February 2013
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17 November 2021 - 8:37 pm
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Been following  your posts but really couldn't  add much.to support you. Not any easy decision  on so many levels and, at the same time, maybe not all that ha4d depending  on jow you seek about the feedbackmof the professionals.   Jerry was able to share her knowledge  and wisdom so well to help support you.

After reading  your posts, it seems that your "inner voice" , or your "gut", are telling   you to do the biopsy.    The biopsy could remove all doubt for you, HOWEVER,  sometimes it can be inconclusive.  Anyway, you will have done everything possible to find out the answers and I think that would be important  to you to give you the peace of mind you need right now,  I cert6 understand  your hesitation  in not doing because  of the scenario  where the three Surgeons missed the real problem in the beginning.

So the biopsy  is scheduled for tomorrow, Thursday?  Keep us posted.  We are here to support youn any way we can and in any path you take,

Hugs

Sally and Alumni Happy Hannah and Merry Myrtle and Frankie too!

Happy Hannah had a glorious additional bonus time of over one yr & two months after amp for osteo! She made me laugh everyday! Joined April's Angels after send off meal of steak, ice cream, M&Ms & deer poop!

Member Since:
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20 November 2021 - 3:50 pm
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A quick update: He had his surgery on Thursday & came home today because his red blood count was low & they wanted to make sure it stabilized before they let him go home. The fact that it went from 36 (Aug 31st) to 28 (yesterday) is usually indicative of cancer. He is super weak still, which scares me so much but the fact that it dropped that much in 2 months is reassurance that we did the right thing.

Now we wait for the results. Thank you for your encouragement & response!

Virginia




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20 November 2021 - 8:25 pm
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WELCOME HOME!!!    Remember  amputation  is MAJOR surgery so he's not gonna be feeling like running  a marathon any time soon!

Rest. rest, rest and more rest.  While he may appear "weak", it may also be the effect of the hospital  meds as they get out of his system.  Additionally,  the current meds he's on may get him on the lethargic side for now.

How is he otherwise?  Drinking  and peeing are important.   He may not feel much like eating right now and may not poop for a few days.

And yes, the blood count  can be yet another indication  that this definitely  was the right  decision. 

Try and get some rest yourself now.  

Hugs

Sally and Alumni Happy Hannah and Merry Myrtle and Frankie too!

Happy Hannah had a glorious additional bonus time of over one yr & two months after amp for osteo! She made me laugh everyday! Joined April's Angels after send off meal of steak, ice cream, M&Ms & deer poop!

On The Road


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20 November 2021 - 9:38 pm
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Aww I'm glad he's home! Hope you are having a snuggle fest on the couch. How is he?

Yeah you moved quickly and that's what counts.

Tripawds Founders Jim and Rene
tripawds.com | tripawds.org | bemoredog.net | triday.pet

Member Since:
13 May 2022
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14 May 2022 - 8:41 pm
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Did you ever get an answer? Some of this seems similar to my dog and he's 50% GSD. they seem to be the breed who are known for some of the more obscure illnesses. 

The Rainbow Bridge


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15 May 2022 - 3:13 pm
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I'm so glad you asked this question. We always hope that when we don't hear back from someone, that no news is good news. 

SO the last we heard from @mackies is he was getting PRP injections.  To backtrack a little, they posted here in Ask a Vetand Dr. Pam shared her thoughts about the case and pathology report.

Keep us posted on your own pup in a new topic OK? And if it's any comfort, we see allllll kinds of breeds come down with rare cancers and conditions. Then again, our own GSD Wyatt Ray went 12 years without any cancer. Seems like a roll of the dice no matter what.

We're here to help any way we can OK?

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