A crash course in cancer surgery (Emmie’s story)

Emmie, a 9 year old Golden Retriever, had a small mass on her left thigh.

For weeks, it waxed and waned.

A needle test (a Fine Needle Aspirate or FNA) suggested a mast cell tumor, a very common skin tumor.

Eventually, it almost disappeared. Instead of brushing it off, her amazing owner reached out to me and asked me to remove it regardless.

This is how tiny the mass was at the time of surgery: less than 1 cm, or less than half an inch. It was basically flat. It would have been impossible to see or feel under a Golden retriever’s hair!

How many pet owners do you think would have requested surgery to remove it?

Well, Emmie’s owner sure did!

Because of the behavior of a mast cell tumor, and without knowing how aggressive it was (ie without knowing it’s “grade”), the surgery had to be aggressive.

With a special pen, a 3 cm in diameter circle (a bit over 1 inch) was drawn around the mass.

However, we cannot remove a circular area of the skin (the scar would be tight and ugly). We can however remove an oval area. So the shape was changed to this:

Then the mass was removed along those purple lines (OK, OK, for the purists, this is a fusiform shape, not oval).

One week later, the biopsy came back. A mast cell tumor was confirmed – a grade 2, which is considered “intermediate.”

(Grade 1 is low grade or least aggressive, grade 2 is intermediate grade, and grade 3 is high grade or most aggressive)

The good news however is that being aggressive to remove the mass (and not wishy-washy) allowed us to “get it all.” Here is a picture of the incision:

Now, Emmie has fully recovered and can enjoy her walks again.

Her owner simply commented: Emmie “looks great!! I’m very happy with my decision!”

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

Dr. Phil Zeltzman

Dr. Phil Zeltzman is a traveling veterinary surgeon in Pennsylvania & New Jersey. An award-winning author, he loves to share his adventures in practice along with information about vet medicine and surgery that can really help your pets. Dr. Zeltzman specializes in orthopedic, neurologic, cancer, and soft tissue surgeries for dogs, cats, and small exotics. By working with local family vets, he offers the best surgical care, safest anesthesia, and utmost pain management to all his patients. Sign up to get an email when he updates his blog, and follow him on Facebook, too!

At what age should you spay or neuter your cat?

The American Veterinary Medical Association (AVMA) recently published their guidelines on the age to spay or neuter cats. The official title of the document is “Veterinary Task Force on Feline Sterilization Recommendations for Age of Spay and Neuter Surgery.”

This is a highly controversial and debated topic (even more so in dogs). There are many opinions out there.

Most people have an opinion on the subject, often based on dogma or personal beliefs more than science.

The AVMA put together a group of various veterinarians (from corporations, private practice, vet schools and associations).

They also included non-veterinarians: Steve Dale (behaviorist and journalist), a lady from the Philanthropy for Animal Advocates and the Chair of the Cat Fanciers’ Association.

So I think it’s fair to say that there were many cat lovers and cat advocates on the team. So what are their conclusions? I quote (I only added a few definitions between parentheses):

“Current recommendations for the age to sterilize (spay/neuter) cats are arbitrary and inconsistent.

Adoption of evidence-based guidelines is expected to limit confusion among cat owners, reduce the risk of unwanted litters, and maximize health and welfare benefits. (…)

The following key findings and proposals emerged from a review of the currently available scientific literature and group discussion:

1. Recommendations for the optimal age to sterilize cats may differ from the age to sterilize dogs.

2. Current scientific evidence documents benefits of spaying kittens before the first estrous cycle, including the following:

. Decreased risk for mammary carcinoma (aka breast cancer).

. Elimination of reproductive emergencies such as pyometra (aka an infected uterus) and dystocia (aka difficulty giving birth).

. Avoidance of unintended pregnancies that may occur as early as 4 months of age.

. Potential decrease in behavioral problems linked with cat relinquishment.

3. Current evidence does not support an increased risk for cats of complications or long-term adverse health effects with pediatric (6-14 weeks) or juvenile sterilization (>16 weeks).

4. More controlled prospective research specifically examining different ages in sterilization in cats is needed.

As new information becomes available, the recommended age for sterilization of cats should be revisited.

5. There is potential to increase the number of sterilized cats and reduce the unplanned/unwanted litters of kittens if veterinarians routinely schedule this surgery for client-owned cats at the end of the kitten vaccination series.

Given the known benefits of sterilization and the lack of evidence for harm related to age at which the procedure is performed, the Veterinary Taskforce on Feline Sterilization calls for veterinary practitioners and professional associations to recommend sterilization of cats by 5 months of age.

This provides veterinary practitioners with a consistent message that may increase veterinary visits and spay/neuter compliance while reducing the risk of pet relinquishment and unwanted offspring.”

Bottom line: spay or neuter your kittens by 5 months of age.

Simple!

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

Dr. Phil Zeltzman

Dr. Phil Zeltzman is a traveling veterinary surgeon in Pennsylvania & New Jersey. An award-winning author, he loves to share his adventures in practice along with information about vet medicine and surgery that can really help your pets. Dr. Zeltzman specializes in orthopedic, neurologic, cancer, and soft tissue surgeries for dogs, cats, and small exotics. By working with local family vets, he offers the best surgical care, safest anesthesia, and utmost pain management to all his patients. Sign up to get an email when he updates his blog, and follow him on Facebook, too!

How do you know if your vet is any good?

This is probably the riskiest post I’ve written in a while.

I’m sorry, there are no cute kittens today. We bravely tackle a critical topic that should matter to every serious pet lover.
OK, but let’s first look at cute kittens anyway…

My hope today is to help you understand an important but mysterious concept: standard of care.
Standard of care is a legal expression, not a medical one.
There are different ways to define standard of care, and they’re rather nebulous and subjective.
. It is the degree of care, or the level of treatment, a reasonably competent and skilled vet should provide, taking into account the current medical knowledge.
. It is the customary practices an “average,” prudent vet would typically offer in similar circumstances.
. It’s the right thing to do to take care of a patient a client trusted us to treat – in an ethical manner.
Problem is, nobody knows what standards of care are. There is no book, no article, no definition of what vets should do in a particular situation.
Standards of care are constantly evolving as medicine improves, new discoveries are made and new drugs are invented. They depend on the treating veterinarian, the practice, the town, the region, the State and the country.
There are guidelines, suggested by various veterinary organizations, but they’re only guidelines.
There are basically 3 levels of standards of care.

1. The gold standard
This is the care typically provided at a vet school, a specialty hospital or a very progressive family practice.
It’s the best and safest way to perform a procedure or arrive at a diagnosis.
The purpose is to reduce risks and complications as much as possible. The end goal is to increase the chances of success as much as possible.
2. Reasonable standard of care
This is what the “average and prudent” vet would agree is reasonable to do for a particular treatment or procedure.
As you can imagine, this is extremely subjective. What might seem reasonable to one vet may seem unreasonable to another. There is no black and white, it’s all shades of gray…
3. Sub-standard care
This level of care is not reasonable or acceptable. It could be called negligence or malpractice.
It could harm the patient – and often does.
And no matter how cheap it is, it is cheating the client.
Sadly, this is what is sometimes portrayed on popular shows on TV… and many pet owners don’t even know it.
OK, if you’re still reading, you deserve to look at more cute kittens.

To better explain those levels, let’s take 5 everyday examples you may be familiar with:
. When we diagnose cancer in a pet, we typically take chest X-rays to check for spreading (metastasis) of the cancer to the lungs. Unfortunately, we can miss tiny masses in the lungs what X-rays simply cannot show. A CAT scan may cost much more, but it’s far better to see those tiny masses. Meanwhile, at some practices, the mass would be removed without even taking chest X-rays.
Which approach would you want for your pet?
. You can sometimes see a mass in the spleen on a simple X-ray. An ultrasound should not only confirm that the mass is truly in the spleen, but it can confirm that all of the other organs in the belly are OK, and that there is no spreading (metastasis) to the liver.
Next up: who does the ultrasound? A family vet who does ultrasound every once in a while, or a specialist who does it 20 times per day?
Which test – and which ultrasonographer – would you want for your pet?
. Some practices will remove a tooth without X-rays and without anesthesia monitoring.
Meanwhile, other practices in the very same town will remove a tooth with a dedicated veterinary nurse monitoring the patient under anesthesia. In addition, they will take X-rays of the jaw before and after removing a tooth.
What level of care would you want for your pet?
. Having a tooth removed is not exactly fun. Some practices don’t prescribe pain medications at all – before, during or after the procedure.
Some practices will dispense a mild pain killer beforehand (e.g. butorphanol) and a mild pain medication to go home (tramadol).
Yet other practices will provide a strong morphine-like drug and an anti-inflammatory before the surgery, will numb the area (local anesthesia, just like at your dentist) before the extraction, and will send home two pain killers (e.g. gabapentin and an anti-inflammatory).
Which one would you want if your pet needed a tooth removed?
. Some practices would not run any bloodwork before doing a procedure under anesthesia.
Some would do basic bloodwork (e.g. a mini-chemistry, which looks at liver and kidney function).
Yet other practices will do full bloodwork (i.e. a full chemistry, a CBC – which looks at red and white blood cells), as well as a urinalysis to check kidney function.
Which one would you want for your pet before anesthesia?

Veterinary medicine is like any other decision in life:
. You can have lunch at McDonald’s or Olive Garden or a fancy steakhouse. You’ll be fed either way.
. You can fix your own sink, or have a plumber fix it, or have a master plumber replace and upgrade it. You’ll have a sink either way.
. You can go to work on a bicycle, in a Ford Fiesta or in a BWM. You’ll get to work either way.

But there is a huge difference here: we’re not talking about lunch, a sink or a car. We’re talking about a living creature, who might go under anesthesia or get major surgery.
The reason vets recommend certain tests is not to drain your bank account.
The reason is to reduce the risk of complications – including death – as much as possible.
The reason is also to improve comfort, decrease pain and increase quality of life.

Are you still with me? Then you totally deserve to look at more cute kittens.

So, what’s a concerned pet lover to do?
. Make sure you compare apples to apples. If you get a $200 estimate from one clinic and a $1,000 for the one across town, don’t assume that one vet is a nice guy and the other is a crook.
. Ask for an explanation of every line item on the estimate. You have a right to understand what you are getting into.
. Ask questions about the procedure itself. Who is doing it? How many times have they done it? What is their success rate with this procedure? Dare to ask these tough questions!
. Ask questions about complications. What are the most common (theoretical) complications you should be prepared for? What (actual) complications has this particular vet observed? What will they do to reduce the risk of complications?
. Ask questions about the things that are usually skipped on “cheaper” estimates: what pain management protocol will they use to make sure your pet is comfortable? Will your pet be monitored during anesthesia? By whom? With what qualifications (or what letters after their name)? Will they do it start to finish, or whenever somebody remembers to do it, or never?
. If you would like to provide the gold standard to your pet but you’re concerned about being able to afford it, then please get pet insurance – a great plan preferably – it will solve 99% of the problem.

Bottom line: make sure you understand the full story behind an estimate, and what it means for the safety of your pet and the success of the procedure.

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

www.DrPhilZeltzman.com

Dr. Phil Zeltzman

Dr. Phil Zeltzman is a traveling veterinary surgeon in Pennsylvania & New Jersey. An award-winning author, he loves to share his adventures in practice along with information about vet medicine and surgery that can really help your pets. Dr. Zeltzman specializes in orthopedic, neurologic, cancer, and soft tissue surgeries for dogs, cats, and small exotics. By working with local family vets, he offers the best surgical care, safest anesthesia, and utmost pain management to all his patients. Sign up to get an email when he updates his blog, and follow him on Facebook, too!

Why is my dog crying after surgery?

“Doctor, I don’t know what to do, my dog keeps crying ever since coming home from surgery.”

This is a concern we occasionally hear after surgery. So why do dogs cry (or vocalize) after surgery? Note: we do not mention cats below, because, well, cats are different, so only part of what follows applies to cats.

1. Dysphoria

Dys what?

Dysphoria.

Dogs who wake up from surgery are discombobulated. They have no idea what happened to them. They’re spacey or groggy or loopy while the anesthesia medications wear off. They may not know who you are and where they are.

If you’ve ever had anesthesia, you likely felt the same way. You may also have seen videos of kids or adults waking up from anesthesia, after dentistry or surgery, and they say the weirdest or funniest things – which they don’t even remember later.

Since dogs don’t understand what’s happening, it causes anxiety. And they don’t know how to express that, except through whining.

While it’s stressful to any pet lover, the good news is that it should go away after a good night sleep.

If you doubt it, let me give you a classic example.

If we only sedate a dog (not even full anesthesia) to take X-rays or change a bandage or trim their nails, and reverse the drugs, they may experience dysphoria. We haven’t done anything painful, yet they cry like they’re in severe pain.

Why is that?

Well, it’s exactly for the reasons explained above. It’s dysphoria. They’ll get over it.

Bottom line: This type of crying should stop when you sit next to your dog, or you call his or her name.

2. Pain

Pain can definitely cause crying. Now, if your vet or your surgeon takes pain seriously, and provided appropriate pain control, the crying is most likely not due to pain.

As I always say, “pain is unacceptable in 2020.” We have enough pain medications available. We routinely dispense 2 or 3 pain medications to make sure your dog is comfortable after surgery.

If you are convinced that your dog is in pain, please call your vet and get an additional pain medication. That’s an easy solution.

Bottom line: This type of crying does not stop when you sit next to your dog, or you call his or her name.

3. Attention-seeking

Some dogs, like some babies (or older kids!) are quick at learning that if they whine, it makes you stop what you’re doing and you pay more attention to them. You pet them. You use your funny voice. You give them a treat.

It’s a learned behavior, which you encourage by “giving in.”

Bottom line: This type of crying should stop when you sit next to your dog, or you call his or her name.

4. Other reasons

There are other reasons for which your dog might cry after surgery. It can mean anything from “I hate this stupid cone around my head” to “I hate being locked up in a room/in a crate” or “Why do I have a 10 pound bandage on my leg?” or “I am bored to tears in here!” or “Why don’t you understand that I need to pee?”

So these are “benign” reasons that make them anxious. Again, they don’t know how to express their frustration besides crying. Other reasons include not feeling well, being unsteady, feeling nauseous, feeling cold.

Some breeds are more sensitive than others. And some individuals are more sensitive than others (“every patient is different”).

So depending on the situation:

. You may bring water or food closer. Some dogs need help when they wear a cone (which you should not take off). Handfeeding may help.

. You may want to give your dog a (safe) chew toy to prevent boredom.

. You can use white noise to drown out the normal sounds of the household.

. You can’t do anything about a bandage, although if it’s too tight, it can cause pain, so you should seek medical attention.

. You should absolutely follow your vet’s or your surgeon’s instruction to keep the cone on 24/7, or to keep your dog confined 24/7.

. If your dog needs to eliminate, then obviously you should allow that. Remember, you’ve trained your dog to be potty trained, so they may absolutely refuse to go on the floor or in their crate.

But be careful, as some smart dogs can learn that “whining = I can escape from jail and go outside” and they may take advantage of that.

Bottom line: This type of crying should stop when you sit next to your dog, or you call his or her name… or your take them outside to eliminate.

These are the main reasons for which a dog may cry. If you’re still not sure what’s going on with your dog, please call your vet clinic and brainstorm with a nurse to try to figure out why it’s happening.

The good news is that if you follow the rules, the whining should stop overnight or within a few days. If it doesn’t, then I’ll give you 2 more options:

. The reason for the crying is not listed above, and you need to figure out what the cause is by talking to your veterinary team.

. All we need is a mild sedative or tranquilizer to “take the edge off” and help your dog relax and accept their new fate: the plastic cone, confinement, a bandage etc.

After all, waking up from anesthesia is not fun for humans, so there is no reason to believe that it’s any more fun for a patient who has no idea what just happened.

Again: this is normal and it will get better with time, so hang in there!

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

Dr. Phil Zeltzman

Dr. Phil Zeltzman is a traveling veterinary surgeon in Pennsylvania & New Jersey. An award-winning author, he loves to share his adventures in practice along with information about vet medicine and surgery that can really help your pets. Dr. Zeltzman specializes in orthopedic, neurologic, cancer, and soft tissue surgeries for dogs, cats, and small exotics. By working with local family vets, he offers the best surgical care, safest anesthesia, and utmost pain management to all his patients. Sign up to get an email when he updates his blog, and follow him on Facebook, too!

Why did Reagan have a toe removed?

Reagan, a 6 year old Doberman, was seen for swelling in one of her left front toes. It wasn’t painful, but it was clearly larger than normal.

A full physical, blood work and radiographs were performed. The physical exam was unremarkable – except for the swollen toe.

Blood work was normal, so she was a good candidate for anesthesia. X-rays showed a concerning area in one of the bones of the toe (what would be your pinky). The bone was clearly abnormal. Look at the red arrows and notice how rough the edges of the bone are compared to the bones in other toes. This can indicate a variety of concerning diseases, from a fungus to cancer.

Based on the concern that this was most likely bone cancer, we recommended removing the toe. Sadly, there was no other treatment option. Please be warned, the pictures below are GRAPHIC.

The surgery was straight forward. The entire toe was removed and sent out to the lab to identify the abnormality.

Postop, the foot looks pretty cosmetic.

Reagan recovered smoothly from anesthesia. She was given pain medications and antibiotics. She went home with an Elizabethan collar to ensure that she did not cause trauma to the surgery site or cause an infection.

About a week postop, the biopsy results came back. Was bone cancer confirmed?

Amazingly, the report explained that it was all benign. The bone reaction was “reactive and inflammatory”. The changes may have been due to an old fracture of the bone – even though Reagan’s owner never noticed any limping…

Although we don’t have a definite explanation for the swelling and the changes in the bone, the good news is that Reagan made a full recovery and went back to her normal, happy life with a great outcome.

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

Dr. Phil Zeltzman

Dr. Phil Zeltzman is a traveling veterinary surgeon in Pennsylvania & New Jersey. An award-winning author, he loves to share his adventures in practice along with information about vet medicine and surgery that can really help your pets. Dr. Zeltzman specializes in orthopedic, neurologic, cancer, and soft tissue surgeries for dogs, cats, and small exotics. By working with local family vets, he offers the best surgical care, safest anesthesia, and utmost pain management to all his patients. Sign up to get an email when he updates his blog, and follow him on Facebook, too!