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Dr.Fiona
Dr.Fiona, Dog Veterinarian
Category: Dog
Satisfied Customers: 6273
Experience:  16 years experience as a companion animal veterinarian in British Columbia, California and Ontario
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How to treat our dog who has hemangiopericytoma

Customer Question

We learned yesterday that the large lump, which is the size of a hen''s egg, on our little dog''s neck is a hemangiopericytoma and is at stage 2. It appears that several structures in her neck may well be involved and our vet said that operating on her could be very tricky given the position of the tumour. He is going to call a specialist surgeon tomorrow (Monday) for a second opinion about surgery. Trixie, our little terrier cross, is 13 years old and has always been in pretty good health though now is almost deaf and has cataracts but otherwise is really very lively for her age.

We really don''t want to put her through anything that might be futile, as we have been told that this type of tumour can easily recur, but don''t want her to be uncomfortable either. Is it possible that surgery, if feasible, + radiotherapy would be a good option, even if all of the tumour is not removed in surgery? I have also read that hyperthermia is a possible option and value your opinion. Dannie Wognum
Submitted: 6 years ago.
Category: Dog
Expert:  Dr.Fiona replied 6 years ago.

Hi there Dannie!

Welcome to Just Answer! I would like to try to help you and your small, senior dog with this question, but need a bit more information, please.

How was this diagnosis made?

When did you first notice the lump?

Where on the neck is the lump?

Fiona

Customer: replied 6 years ago.
Hi Fiona,
Thank you very much for your reply. In answer to your questions, our vet took a blood test (to see whether Trixie would be fit for an aneasthetic and then a biopsy and sent it off to a specialist vetinary centre in Bordeaux (we live in France) that deals with just biopsies. It was sent two and a half weeks ago and he did tell me that the results would not be back for between one and three weeks.
I am trying to remember when we first noticed the lump. I think it was originally the size of a sugar lump maybe and it was maybe two to three months ago that we first noticed it. At that point it was just one of those things that you mention when you next visit for something else.
Whereabouts on her neck? Well at the end of her jawline on the right side, sort of between her jaw and her shoulder - it touches her collar.

Hope that helps! Many thanks,

Dannie
Expert:  Dr.Fiona replied 6 years ago.

Dannie,

Merci XXXXX XXXXX that information! It has been very helpful.

I can understand how that location would be tricky with the jugular vein, carotid artery and vagus nerve all running right under the tumour. A biopsy is a great way to get an answer on what a lump is.

I am going to go work on your answer and will be back in about 30 min....

A bientot! Fiona

Customer: replied 6 years ago.
Merci XXXXX XXXXX !
I understand about all the surrounding structures - the vet did explain and I am an ex cardiac nurse :)
Thanks for your trouble.

Best regards, Dannie
Expert:  Dr.Fiona replied 6 years ago.

Hello again Dannie!

I'm so glad you have a medical background as that is going to make it much easier for me to explain.

Hemangiopericytomas are a soft tissue sarcoma. I am going to start with giving you a FAQ prepared by a veterinary oncologist FOR veterinarians. This article and the one below are from a website (http://www.vin.com/) that is for veterinarians to discuss medicine with other general practitioners as well as to ask advice from veterinary specialists such as oncologists and surgeons.

*****************************************************************************************************

Soft Tissue Sarcomas Medical FAQs

What tumors are we talking about here?

The three most common soft-tissue sarcomas (STS) are fibrosarcoma, hemangiopericytoma, and peripheral nerve sheath tumor. Less common STS include schwannoma, leiomyosarcoma, 'spindle cell tumor' (unspecified), neurofibrosarcoma, liposarcoma, and myxosarcomas. Hemangiosarcomas, rhabdomyosarcomas, and lymphangiosarcomas are also STS strictly speaking, but since they behave differently from other more typical STS, they are not covered in this FAQ.


 

What is the best way to approach surgery of soft-tissue sarcomas (STS)?

Soft-tissue sarcomas (STS) often extend well beyond the visible mass, much like mast cell tumors. For this reason you should ALWAYS know when you are going to excise a STS - ie diagnose before excision. This can be done by performing a fine needle aspirate (FNA) and cytology on every mass before it is excised. FNA can often be easily examined in-house, although the practitioner's level of training, interest and experience in cytological diagnostic interpretation will strongly impact the likelihood of a correct diagnosis. If a clinician lacks experience, interest or appropriate staining techniques, or has any hesitation in the cytological diagnosis, the sample should be sent out for specialist interpretation. Many STS are difficult to differentiate from fibroplasia (a benign process), requiring specialist interpretation. Additionally, Diff-quik staining is inferior to Giemsa staining, and may also hamper accurate in-house diagnosis. Thus, clinicians are advised to make 2 sets of smears - one for in-house examination (if desired), and a second (unstained) for submission to a diagnostic pathology service.

Once a STS is confirmed, the tumor is excised with 3cm lateral margins, 1 fascial layer deep. This avoids going anywhere near the tumor during your surgery and thereby adheres to an important principle of cancer surgery - en bloc resection. Some oncologists prefer to perform an incisional biopsy and histopathology to obtain a histological grade prior to performing the excisional biopsy, for prognostic purposes and therapeutic planning.

However, clinicians should be aware the up to 40% of STS that have "clean margins" histologically, may recur ("clean but close" margins are obviously at higher risk for such local recurrence). It is important to notice that we will often recommend advanced imaging (CT or MRI) prior to excision of a STS, especially when the mass is large, firmly attached to the underlying tissue, and/or in a location where wide margins may be more difficult. Consulting with a boarded surgeon is also recommended in such situations. This also applies to ALL feline vaccine site sarcomas.


 

The pathologist has said that a tumor I excised is a STS and margins were dirty. What should I do?

STS (including hemangiopericytomas, schwannomas, nerve sheath tumors, fibrosarcomas, spindle cell tumors, leiomyosarcomas, but not hemangiosarcomas or lymphangiosarcomas) all tend to have several features in common:

1. They invade well past their visible or palpable margins ("tendrils").

2. They appear to be encapsulated but are not. The pseudocapsule comprises a layer of compacted but actively growing neoplastic cells. This is important because dissecting these out ("shelling") will result in local recurrence.

3. They are locally invasive but late to metastasize. If you effect local control, then you often have obtained a cure.

Thus, if surgical margins were dirty, the treatments of choice are to re-excise en-toto with wider margins all around the original tumor site and/or perform radiation therapy.

To treat these you need to

1. Perform a wide and deep resection. 3cm wide, 1 fascial plane deep. If you cannot do this because of tumor location then get an incisional biopsy and discuss your options with a surgical or radiation oncologist. In some cases, grafts or patches may be necessary to reconstruct the wound site.

2. Stay well away from the edge of the tumor at all times.

3. If necessary, perform radiation therapy to sterilize residual disease if margins were not clean.


 

What about if the margins are clean or "clean but close"?

If margins are clean, radiation therapy can be considered (see below). This is probably even more valuable if the margins are "clean but close" (high risk of local recurrence). Alternatively, careful monitoring of the site for recurrence, with re-excision can be employed.


 

Does chemotherapy help with treating STS?

Soft tissue sarcomas are not very chemoresponsive in general and best treated surgically with or without adjunct radiotherapy. Most studies show modest response rates in the range of 20 to 30%. There may be limited rationale for using chemotherapy in STS that appear highly malignant, or have high metastatic potential. It should generally be coupled with surgery and radiotherapy.

Other agents, such as the non-specific immunomodulator Acemannan, have not been critically evaluated, and are not recommended currently.


 

Does radiotherapy help with treating STS?

There is evidence that adjunct radiotherapy offers a prolonged disease-free interval and survival when used to treat microscopic disease following surgical resection. Several studies have documented long remission and survival periods (>1500 days median survival) in that setting, when postoperative radiotherapy is used. Additionally, it has shown benefit in limb-sparing tumor treatment, with 75% disease free at 5 years in one study. However, as a sole treatment, responses seem poorer than if combined with surgery. Oral STS appear to be associated with poorer prognosis.

Radiotherapy can also be used palliatively in non-resectable STS to offer pain relief, in addition to traditional analgesic therapy.

*************************************************************

So, as you can see from this article, STS's commonly are locally invasive, so it is not uncommon to have "dirty" margins with tumour cells extending past the margins and into the tissues. Ideally, treatment would be to surgicallly remove this tumour, as much as possible given the location. As you can see from the article, this means 3cm in EVERY direction. In this location it might be impossible, and I think that is what your vet wants to talk to the specialist about. In terms of radiation therapy, I will quote here from a 2003 conference proceedings.

************************************************************************************************

Clinical Radiation Therapy Western Veterinary Conference 2003 Karelle A. Meleo, DVM, ACVIM, ACVR
Veterinary Oncology Services
Edmonds, Washington, USA

Objectives

Reviewing the types of radiation available.

Identifying the tumors most commonly treated in veterinary radiation oncology.

Discussing treatment of radiation toxicity.

Overview of radiation therapy protocols.

Key Points

Either a Cobalt source or a Linear Accelerator is used for megavoltage therapy.

When a patient is treated with definitive radiation therapy, multiple fractions are needed.

Radiation is a localized treatment.

Combining radiation and surgery is often recommended.

The skin and mucous membranes are common areas of acute toxicity.

The eyes, lungs, kidneys, and the nervous system are of concern for toxicity.

Overview

Types of Radiation Therapy

Most institutions have either Cobalt or a Linear accelerator (Linac) available. These both produce megavoltage radiation.

Orthovoltage generally does not penetrate as deeply as megavoltage so does limit the types of patients that can be treated.

Some (but not all) Linacs can generate electrons. Electrons are particularly useful in treating superficial areas with sensitive structures (such as lung) underneath.

Definitive vs Palliation Radiation Therapy

We should consider definitive (given with the intent of long term control) therapy in patients:

1. With tumors of low metastatic rate or in tumor types in which the mets can reasonably be controlled with chemotherapy or;

2. For whom the above is true and surgery is not an option either due to the location of the tumor, or due to the owner's reluctance to consider aggressive surgery or;

3. In whom surgery has been performed and there are still neoplastic cells remaining at the surgical margin (especially if #1 above is true as well).

We can consider palliative (given with the intent of managing pain, improving function, and/or maintaining the quality of life) therapy in patients:

1. With tumors of high metastatic rate or known metastases and/or

2. In whom pain management is needed (such as bone tumors).

Tumors Commonly Treated with Radiation Therapy

Oral Tumors

Advances in surgical techniques such as maxillectomy and mandibulectomy offer many patients excellent long-term control for many of these tumor types. Radiation therapy can be offered as an alternative to surgery or as an adjunct to surgery for many of these patients.

Epulides: Biopsies of these lesions may be acanthomatous epulis, fibromatous epulis, ameloblastoma, or odontogenic tumor.When treated with radiation therapy, 85% are free of disease at 1 year and 67% disease free at 2 years.

Canine oral fibrosarcoma & squamous cell carcinoma: For both of these tumor types, soft tissue resection alone is usually inadequate, especially if the tumor abuts the bone. The reported median survival time for dogs with oral sarcomas treated with surgery and radiation therapy is 540 days.

Tonsillar squamous cell carcinoma (SCC) is a very aggressive disease and is resistant to therapy.

When using radiation therapy alone to treat dogs with SCC of other locations, survival times from 14-17 months have been reported. Younger dogs and those with smaller and more rostrally located tumors have a better prognosis.

Canine Oral Melanoma: Melanomas are considered "relatively" radioresistant. This means we must give a larger radiation dose per fraction than is traditionally used for other tumors. These large dose per fraction protocols usually limits the total dose that can safely be used. This results in fewer fractions (3-6 vs 14-21 normal protocols), being delivered. In one study, dogs given 3 fractions had a median survival time of 7.9 months. In a study where dogs were given 6 fractions of along with Cisplatin chemotherapy, the median survival time was reported to be approximately 12 months. Unfortunately, most patients still succumb to metastatic disease.

Nasal Tumors-Canine

The median survival time of dogs treated with megavoltage radiation is 12.8 months with a mean of 20.7 months. In some studies, dogs with sarcomas have been reported to have an improved survival time over dogs with carcinomas. This occurs even though sarcomas are not as radiation responsive as carcinomas. The slow growth rate of sarcomas compared to carcinomas likely explains this difference. It is not necessary to perform rhinotomy to reduce the tumor size prior to radiation therapy.

Nasal Tumors-Feline

The survival time for cats treated with megavoltage radiation is similar to that seen in dogs. 44.3% of cats treated are alive at 1 year after therapy and 16.6% are alive 2 years after treatment.

Nasal lymphoma is a notable exception. When radiation is combined with aggressive chemotherapy over 75% of cats are alive at 2 years. Cats treated with 3 radiation treatments did just as well as cats treated with 18 treatments.

Brain Tumors

In general, megavoltage is recommended over orthovoltage therapy, but many patients treated with orthovoltage have benefited from treatment. Survival times reported in the literature range from 150-412 days. Radiation may be used alone or combined with surgery. Dogs with meningioma have a better prognosis than dogs with glioma. Severe neurologic signs and/or multiple tumors are considered negative prognostic factors.

There are few studies on cats with brain tumors treated with radiation therapy. Surgery alone results in survival times of months to years in cats with meningioma.

Mast Cell Tumors

When treated with surgery alone, 50% of dogs with grade II mast cell tumors will have recurrence or metastasis within 1 year. As 50-60% of canine mast cell tumors occur on the limbs it is difficult to get a complete (2 cm or larger) resection on many of these lesions.

Radiation is indicated in dogs with grade II mast cell tumor who have incomplete resection and who have no metastatic disease. Studies have shown that 86-95% of dogs who are treated post operatively are free of cancer for at least 3 years after treatment.

Radiation is a local treatment and does not address metastatic disease.

Soft Tissue Sarcomas

Among other tumor types, soft tissue sarcomas include: Fibrosarcoma, Hemangiopericytoma, Nerve Sheath Tumor, Leiomyosarcoma, Liposarcoma, Hemangiosarcoma, Synovial Cell Sarcoma, Malignant Fibrous Histiocytoma, and Undifferentiated Sarcoma. With the notable exceptions of hemangiosarcoma and high-grade synovial cell sarcoma, these are characterized by a high rate of local recurrence but a low to moderately low rate of metastasis. Grade is important to prognosis.

In a study of dogs with soft tissue sarcomas treated with radiation following gross resection, 75% were still free of disease 5 years following surgery.

In some cases, it may be beneficial to use radiation prior to surgery. This is frequently true of vaccine-associated sarcomas in cats. It may be safer to treat a smaller field prior to performing surgery than a larger one postoperatively. Radiation will effectively treat the cells that are on the margins of the tumor as they are well oxygenated and often dividing rapidly. Surgery is then performed a few weeks after radiation to remove as much of the radiated field as possible.

Pre operative radiation is not recommended to make a tumor that is grossly unresectable resectable, but can be used to increase the probability that a grossly complete excision will also be microscopically complete. It also helps prevent seeding of tumor cells along the surgery site.

Palliative Therapy

Radiation therapy can be used to temporarily reduce the size of a tumor and stop or slow its growth. This can be helpful in improving a patient's quality of life by relieving pain (especially bone pain), decreasing bleeding, and/or relieving swelling or obstruction. One commonly treated tumor is canine osteosarcoma. Approximately 75% of dogs treated have improved limb function for a few to several months. Because lymphocytes are very radiation sensitive, palliative radiation can play a role for lymphoma patients as well.

For additional information on the use of radiation therapy to treat mast cell tumors and head and neck cancer, the reader is referred to proceeding notes on these subjects.

Radiation Toxicity

Acute Toxicity

The skin and mucous membranes are commonly affected during and immediately after therapy. Moist desquamation of the skin, similar to a "hot spot", is quite common. In areas that move or bear weight (such as the stifle or the carpus), lameness may result.

Skin reactions usually are treated with topical antibiotics and analgesics. In the early stages, vitamin E oil and Aloe Vera gel seem to reduce discomfort. When the majority of the field is involved, Silvadene® cream or similar can be applied B-TID. Preventing self-trauma is important, but bandaging should be used only if necessary. Oral antibiotics are rarely needed but can be used. Non-steroidal anti inflammatories can be used for pain, and the author often uses anti inflammatory doses of prednisone if there is lameness or a decreased appetite.

Mucositis is generally managed with anti inflammatory medications and soft food.

Depending on the radiation protocol, acute reactions should be well on their way to healing 10-14 days after the radiation is over. Although a lesion may still be visible, pain medication can usually be discontinued at that point. If the animal is still uncomfortable 3 weeks after radiation is over, consultation with a radiation oncologist is recommended.

KCS and conjunctivitis are common when the eye is in the radiation field. Both can be managed symptomatically. KCS may be temporary or permanent.

Acute pneumonitis may be seen if large volumes of lung are in the field.

Acute nephritis may occur soon after a kidney is irradiated.

Chronic Toxicity

The most common chronic toxicities we see are cosmetic. Alopecia, mild skin fibrosis, and a change of coat color are common.

The organ system that is responsible for most chronic toxicity is the vascular system. The vascular endothelium thickens after radiation, leading to narrowing of the vessel and increasing the risk of thrombosis and subsequent necrosis. The spinal cord is especially sensitive to this due to the lack of collateral circulation.

Anti-inflammatory levels of corticosteroids during and for several months following therapy reduce the probability of serious toxicity as they decrease the inflammation within the walls of the blood vessels.

Cataract formation 1 year or longer after radiation is expected when the eye is in the radiation field.

Fibrosis of the lungs is expected if this area is irradiated, however if the volume treated is low, this is not a clinical problem.

Summary

Radiation therapy can be used to prolong disease-free time in many common tumors. Treating soft tissue sarcomas and mast cell tumors with a combination of surgery and radiation can be very successful.

If your histology report says, "Tumor cells (may) extend to the excised margin" the best chance of preventing recurrence is immediately post op!

Palliative radiation therapy can be used to improve quality of life.

Acute toxicity is generally short lived and easily managed. Chronic toxicity is rarely serious if careful treatment planning is used

Speaker Information

Karelle A. Meleo, DVM, ACVIM, ACVR
Specialty Practitioner, Oncology
Veterinary Oncology Services
Edmonds, WA

***********************************************

So, as you can see from this article, radiation can be very useful, though it is still recommended to remove as much of the tumour as possible.

This all said, it is very encouraging that this tumour was a Grade Two (on a scale of 1 to 4). This means that it is not very aggressive yet, and the cells are only moderately different from normal cells. STS's are locally invasive but slow to metastasize (spread to other parts of the body). So, given that this is a Grade 2 STS, that is suggestive that this might not be a problem to your girl in the near future in terms of spreading. The concerns would be whether the tendrils would grow through the surrounding blood vessels and nerves, which migh result in sudden bleeding.

In summary, this tumour is likely to be slow growing locally and late to metastasize. It probably can not be completely removed so it is likely to recur. Surgery to remove all or part of the tumour might protect the delicate structures near it.. Alternatively, radiation would be helpful to slow down the recurrence of this tumour. Generally, radiation is given multiple times (in multiple "fractions" or treatments) over a short period of time. For example, your dog might need 15 fractions of radiation over 2 or 3 weeks. Each treatment requires an anesthetic. Thus it is likely your girl would be hospitalized at a specialty centre for this procedure.

If this has been helpful, please accept my answer and leave feedback. I will still be here to provide more information if you need it!

Fiona

Dr.Fiona, Dog Veterinarian
Category: Dog
Satisfied Customers: 6273
Experience: 16 years experience as a companion animal veterinarian in British Columbia, California and Ontario
Dr.Fiona and 5 other Dog Specialists are ready to help you
Customer: replied 6 years ago.
Hi Fiona,
Thank you so much for all that information. It is a lot to take in so I am glad I understand the terminology. When I go back to the vet on Tuesday, would it be fair to suggest that they try surgery + radiotherapy or radiotherapy first to try to reduce the size of the tumour prior to operating? I just want Trixie to be as comfortable as possible really, not prolong anything that would make her unhappy.

Many thanks,

Dannie
Expert:  Dr.Fiona replied 6 years ago.

Dannie,

You are SO welcome! It is a lot of information, isn't it? I'm the kind of person who wants a LOT of information when I am sick or my kids are sick, so I like to be able to provide that to others. I hope that it isn't overwhelming! I figured with your medical background you would be interested and able to wade through it. ;-)

In terms of where to start - either would be reasonable. Usually, in Canada and USA there is not immediate access to radiotherapy. Sometimes there is a wait of 1-2 months to get in for that. In that case, I would do surgery first to debulk the tumour, then start radiotherapy as soon as that was healed up (a couple of weeks). However, if radiotherapy is available more quickly in France, it would be good to debulk first.

I don't think there is a right or wrong answer to this one - it depends on exactly how intertwined the tumour is with the blood vessels and nerve, how much could be removed surgically, and how quickly radiation would be available.

One thing to consider is the anesthetic needed daily with radiotherapy. It is not a long anesthetic, but it is daily anesthetic needed. Dogs just do not stay perfectly still for this procedure which is why anesthetic is neeede.

In Canada/USA radiation facilities exist just for dogs and cats. They are run by vets. So, it is a vet giving the anesthetic. Check and see whether that is the case in France. If the facilities are used for humans but dogs are treated after-hours, I would check carefully to find out who gives the anesthetic! Your dog is not a small human, and I would not be comfortable with my dog having an anesthetic given by a human anesthesiologist.

I hope that this helps you! You do not need to "accept" this answer again even though the system will prompt you to do so. If you do, you will be charged another $15! Best wishes to you and your dog!

Fiona

 

Customer: replied 6 years ago.
Thank you Fiona,
You have reassured me a lot. I am not sure where Trixie would be able to get radiotherapy, so I will ask our vet, but I got the impression it would be at the vet practice or a vet centre in any case, and also that it would be readily available though he didn't actually say that.
Now I have more of an idea of what to ask and what to put forward to our vet. This is a great system you have developed here - it has been so useful, I cannot tell you.
Enjoy the remainder of your weekend. I may be back in a couple of days to let you know what he said :)
Many, many thanks again,

Dannie
Expert:  Dr.Fiona replied 6 years ago.

Dannie,

You are so very welcome!

Yes, Just Answer is a great system, isn't it? I just joined a few months ago, but it is a perfect fit for me. I have been a vet for 14 years, but am only working part-time now as I have 2 small children. And I am not quite ready to go back to full-time work, but this fills the gaps. I can do an hour or two here and there when the children are at playdates which means I don't have to give up either my time with them or my involvement with animals! :-)

I would love to hear from you in future! You can reply to this thread at any time, or you can start a new "question" with my name in the first line and it should find its way to me. Some days I am on here a lot, and other days not at all. So, if you have an urgent question, you can always post a new question open to any expert. But if I am around, I will be happy to help!

Best wishes, Fiona

Customer: replied 6 years ago.
Message for Fiona:
Hi Fiona,
I just thought I would update you about Trixie. We saw the surgeon on Tuesday this week. He gave her a thorough examination and then said that in order to decide whether she would be suitable for surgery or not, she would have to have an MRI scan. He arranged it with a centre 30 minutes from the surgery and we took her over and they did the scan just before lunchtime on Tuesday. They kept her there (while we went and had lunch!) and took something like 235 images of the tumour from various angles and also looked at her lungs and liver. There were no metasteses, but the tumour is very extensive. It skates alongside her trachea and up to her right ear and across to her 2nd cervical vertebra. It also goes fairly deep and is around 5cm in diameter.
She was so good the whole day and didn't complain at all about being prodded around and tested for all sorts, even though she had had nothing to eat or drink all day. Eventually we went from the scanner place (they gave us her results on a CD, it's amazing to look at) back to the surgeon and he explained that it would be a BIG operation, possible, but not likely to be successful given the extent of the thing and so she would need to have radiotherapy, 3 courses a week for a month after her surgery. The risks of surgery were also quite substantial too. We started to talk at the surgery, but he said for us to take our time to make a decision, but not too long! We were told to ring him back today.
Anyway, we decided that in view of her age, the intricacy of the surgery, the poor chance of removing all of her cancer, the risk of nerve damage or otherwise during the operation, the fact that she would be without us for a whole month not knowing if she would see us again (the radiotherapy would have to be as an inpatient in Paris) - well, we decided not to put her through all that. My husband rang the surgeon back today and told him what we had decided. He agreed and in also talking today with the doctor who had done the scan, it turns out that the cancer is already touching her spinal column - they had got a third opinion from a specialist in Luxemburg who just does scan diagnoses. So there would have been no hope of surgery being successful.
We asked what symptoms we could expect and he said firstly neurological; she will become unbalanced with a weakness on the right side, the side of her tumour. She also may do this thing where they put their paw on the ground kind of bent over (I can't remember what they call it but we do remember that as being a poor sign from when we watched Emergency Vets! I know, a bit sad that. These programmes are interesting though!) Actually, I told the surgeon that I had seen her do that just the day before.
Then she may have breathing difficulties as the tumour presses on her trachea.
They could give a bit of cortosine to reduce inflammation but really we are talking palliative care here. We just want our little girl to be comfortable and happy for the time she has left. It's about quality, not quantity.
In herself, she's still her usual sweet self and it's hard not to be sad or change the way we deal with her. She still follows me everywhere and sleeps when she wants and trots around when she wants so I think she's still OK for the time being. But making the decision will be very hard for us but not a real choice. I think you know when they are suffering and no longer enjoying life.
Thanks for all your support, Fiona.

Kind regards,

Dannie
Expert:  Dr.Fiona replied 6 years ago.

Dannie,

Thanks so much for updating me on Trixie! It sounds like you have some wonderful vets there!

I definitely think you have made the right decision for Trixie.

When I have a problem, I always want to take action to "fix it" but I know that is not always the best thing to do. In this case, doing surgery to attempt to "fix it" would not be a kindness to Trixie. It would almost be selfish to do that - so that you could feel you were taking action to fix it, even though she would have no understanding of what was happening or improvement in her quality of life from doing it.

So, as difficult as it is to do, you are doing the right thing by not pursuing surgery for her. And I think watching her quality of life is the best approach. When she has more bad days than good, then it is time ... with my own dog, I found it helped me to realize that it wasn't a question of IF I was going to have to euthanize her, but WHEN I was going to have to euthanize her. She had several medical problems that caused a gradual decline and it was very very difficult to decide when to let go.

I understand how hard this is!

My thoughts are with you, Dannie, and with Trixie. (((HUGS)))

Fiona

Customer: replied 6 years ago.
Hi Fiona,
I have just got back from my orchetsra music practice and saw your message.

Very many thanks for your sentiments, but also for all the information and support you have given. It is so appreciated, especially as you understand how hard this is for us. For us, Trixie is one of our family, one of our kids if you like as we don't have any, and we just want her to be happy. You are right, when there are more bad days than good, we will have to decide. We know it may be soon but in the meantime we shall just enjoy the time we have left with her. She has given us so much in the time she has been with us, the least we can do is offer her the same in return.
I am relieved that you think we are making the right decision about surgery. You just cannot explain to a dog what is or is about to happen. And to put her through all that would have not been for her, you are right. This way, we can at least help her to live out the remainder of her days in comfort.
Many thanks again & kind regards,

Dannie

P.S. Can you just remind me what that thing is called again that she has started to do with her foot. It is a neurological sign to do with the nerve being trapped I think?
Expert:  Dr.Fiona replied 6 years ago.

Dannie,

It sounds to me like she is "knuckling" on her foot. When we test for this, we call it a "placing" test. Inability to right the foot is a proprioceptive deficit. Essentially, what happens is that the message is not getting from the receptors in the foot up to the brain to tell the brain that the foot is upside down. So, the dog does not turn the foot over. In a normal dog, you can barely place the foot upside down before the dog rights it. The fact that she is knuckling just tells us that the message it not getting to the brain because there is a problem somewhere along that nerve pathway.

I'm not sure which Emergency Vet show you have watched, but I was on one called "Animal ER" which was filmed about 8 years ago when I was working at the Vancouver Animal Emergency Clinic in Vancouver, BC, Canada. It was not widely watched! ;-)

Kindest regards, Fiona

Customer: replied 5 years ago.
Dear Fiona,
I just wanted to let you know that Trixie passed away very peacefully with us at our vet's yesterday evening.
Although she had this horrible tumour, she never complained about it and she enjoyed being with us at every moment. In the end it was her inability to move around that helped us to decide the time was right. Yesterday she just could not stand for more than about a minute without falling over and then she couldn't get herself back up again. She still ate, though much less but it was nice to be able to give her a piece of good strong cheese, which she always loved, just before our vet gave her a small anaesthetic. He was wonderful with us and her and he left us for a few minutes after the aneasthetic, which he explained would be to help her sleep and then came back later to administer the euthanasia.
As he pushed in the last millilitre of the syringe she gave a little kick of her back leg, just as she had done so often when dreaming. "There she goes, running off to Paradise", he said. We can't think of a nicer way to go or a nicer man to help it along.
We miss her terribly, but we know we did the right thing for her. In the end it was like she had 'sad' eyes and was asking us to do something for her.
Thanks again for all the information and support you gave all those months ago, it was hugely helpful. What makes us very happy is that Trixie survived from diagnosis six or so months ago, to the end yesterday, with NO medical treament needed whatsoever. What a blessing.

Best regards,

Dannie
Expert:  Dr.Fiona replied 5 years ago.
Dannie,

Oh, I am so very sorry that Trixie is gone. I am so sorry for your loss! However, it really sounds like you did the right thing for her, at the right time, and that she enjoyed the days she had. Still,
I can only imagine the hole in your daily lives where Trixie used to be.

My thoughts are with you ...

When I lost my beloved dog, Sprite, I found some comfort in this poem and I hope that it brings you comfort:
Rainbow Bridge
Just this side of heaven is a place called Rainbow Bridge.

When an animal dies that has been especially close to someone here, that pet goes to Rainbow Bridge.
There are meadows and hills for all of our special friends so they can run and play together.
There is plenty of food, water and sunshine, and our friends are warm and comfortable.

All the animals who had been ill and old are restored to health and vigor; those who were hurt or maimed are made whole and strong again, just as we remember them in our dreams of days and times gone by.
The animals are happy and content, except for one small thing; they each miss someone very special to them, who had to be left behind.

They all run and play together, but the day comes when one suddenly stops and looks into the distance. His bright eyes are intent; His eager body quivers. Suddenly he begins to run from the group, flying over the green grass, his legs carrying him faster and faster.

You have been spotted, and when you and your special friend finally meet, you cling together in joyous reunion, never to be parted again. The happy kisses rain upon your face; your hands again caress the beloved head, and you look once more into the trusting eyes of your pet, so long gone from your life but never absent from your heart.

Then you cross Rainbow Bridge together....

Author unknown...

Thanks for taking the time to update me.
((HUGS))
Fiona
Customer: replied 5 years ago.
Thank you so much, Fiona. Needless to say I am in floods again ...
But no regrets, we have only good memories of her.
Hugs gratefully accepted :)

Dannie

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