Dr. Phil Zeltzman’s Blog
I met Oliver, a 9 year old Yorkie, in late January of 2019.
His family vet had incompletely removed a mass on the gum of the lower jaw (aka mandible). It turned out to be malignant melanoma, an aggressive type of cancer (you may have heard of it in the skin of people or pets).
An aggressive cancer requires an aggressive treatment…
Therefore, more tissue, i.e. part of the jaw bone, had to be removed. This is called a partial mandibulectomy.
Below is an X-ray that shows the extent of the surgery (between the red arrows).
Surgery was uneventful and Oliver recovered smoothly.
Just a few hours after this invasive surgery, Oliver ate!
His nurse wrote: “Oliver is awake and walking around in his cage. I offered him small amounts of his own blenderized dog food and he ate it when I hand fed him. He also ate a little of the boiled chicken that his owner brought.”
Would you have believed that a dog would eat a few hours after a big part of the jaw is removed?
His super dedicated owner then chose to give Oliver the melanoma vaccine.
This is a very rare situation. We actually have a vaccine… against cancer!
It’s definitely not cheap, but it’s very effective.
About 4 months after surgery, Oliver’s owner wrote:
“He had his checkup exam today and chest radiographs. I am extremely happy to report everything looks good.
X-rays are clear and he is running around like a puppy, playing, eating and is unaffected after his surgery.
He is back to eating his kibble (not softened) and chewing on his toys.
I cannot thank you enough for your patience, professional advice on how to proceed, and your amazing skills as a surgeon.
Then I didn’t hear much about Oliver, now 10 years old, until early May 2020.
His owner reached out to me because he started gagging, coughing and having difficulty breathing while awake, and making weird sounds while sleeping. He also couldn’t bark anymore…
His family vet did an exam of the mouth, and found a big mass, apparently attached to the roof of the mouth. Clearly, it was blocking his airway.
We performed emergency surgery the very next day.
The mass was the size of a walnut, which is huge for such a small dog. Upon further exam, under anesthesia, the mass was actually not attached to the roof of the mouth, but to the right tonsil.
Here is a picture of Oliver just before surgery – you can vaguely see the mass inside the mouth. You can also see the plastic tube which delivers oxygen and anesthesia gas.
WARNING – what follows is graphic, read further at your own risk !!!
Here is a close up of the evil mass – I don’t think you need an arrow to see it…
Surgery was rather tricky, but we were able to remove the mass safely.
Here is a postop picture. At the end of the red arrow are the stitches.
And this is the actual mass, just before we sent it to the lab for a biopsy.
About a week later, the biopsy confirmed the suspicion: the mass was the same as last year, a malignant melanoma of the right tonsil. The only good news: we got it all.
The tonsil really behaves like a lymph node.
Since the initial cancer was in the right lower jaw, the theory is that this second mass could have spread from the initial mass, even though it had been removed completely at the time. Of course, it’s hard to prove, which is why it’s only a theory.
Shortly after surgery, Oliver could breathe much better.
Oliver is now recovering and we wish this cancer survivor the very best.
Phil Zeltzman, DVM, DACVS, CVJ, Fear Free certified
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
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
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
Tucker, a 15 year old Shih Tzu, had a concerning mass on his behind. Every time he sat somewhere, he would leave a bloody spot. He was otherwise healthy. He enjoyed going for a 1 mile-long walk every day.
His owners noticed a small lump forming on the side of his anus. He also developed a larger mass behind the other one. The smaller mass became ulcerated (meaning it broke open) and started to bleed.
Tucker’s family vet took a cell sample (aka a “Fine Needle Aspirate”) and wisely sent it to the lab. The results showed that the mass was benign, meaning there was no obvious sign of cancer!
Encouraged by the good news, Tucker’s loving owner decided what few pet owners would do on a 15 year old dog: she decided to have the masses removed!
So Tucker’s family vet asked me to remove the masses. Since Tucker had a heart murmur (treated with medications), there was a concern for placing him under anesthesia. He had preop blood work and a comprehensive physical exam prior to anesthesia. Both were good.
Surgery was done to remove both masses. The smaller ulcerated mass was first removed, then the larger one.
Grandpa Tucker recovered smoothly from anesthesia and went home to heal.
He needed to wear a plastic cone and stay very quiet during his 3 week recovery.
A week later, the results of the biopsy came back: the small mass was a perianal adenoma (aka circum-anal adenoma, aka hepatoid tumor), which arises from the sebaceous glands around the anus. No cancer was found and the tumor had been successfully removed completely.
The larger mass was a lipoma, ie a benign fatty tumor.
So both masses were benign – the best news we could have received.
Three weeks after surgery, Tucker went to his family vet to have the incision rechecked. Everything looked good, so he was allowed to resume normal activity and enjoy his walks again.
As I always say, “age is not a disease.”
Tucker can enjoy life without a painful, raw, bleeding mass on his behind.
And Tucker’s dedicated owner was rewarded for her decision to help her 15 year old dog.
Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified