See Something, Do Something: Why wait? Aspirate!
Dr. Sue Ettinger is a practicing veterinary cancer specialist, international speaker and book author. She is one of about 300 board-certified specialists in medical oncology in North America and is currently practicing at the VCA Animal Specialty & Emergency Center in the Wappingers Falls, New York.
A veterinary oncologist's inspiration for a campaign to detect cancer earlier and save more lives.
I messed up. Big time. I missed a tumor in my own veterinary technician's dog. I failed Smokey and Amanda. How could I, a cancer specialist, have missed this tumor?
Smokey was my inspiration for a new cancer awareness program called See Something, Do Something. I am on a mission to help us all detect tumors earlier-whether you are a veterinarian, a veterinary team member or a pet owner.
Dr. Ettinger and Smokey.A history of benign masses
At the time, Smokey was a handsome 10-year-old white pit bull that belonged to one of my head technicians, Amanda. I adored them both. Smokey was one of those amazing, soulful dogs that spread sunshine with every wag of his tail. Everyone who met Smokey loved him. He was Amanda's once-in-a-lifetime dog.
I had aspirated more than 10 skin masses on Smokey over the years, and the masses had always been benign fatty lipomas. When Amanda mentioned she was bringing Smokey in to check out a new mass a few weeks earlier, none of us were worried. Actually the first day Amanda brought Smokey in, the clinic was so busy that we never got to Smokey's aspirate. We assumed it was just another benign lipoma. We got complacent. All the other masses were benign. Why would this one be different?
When Smokey returned the following week, I examined the 7-cm mass that was deeply attached to the underlying tissue on his left flank area. Honestly it didn't look like a malignant tumor. But as I did my aspirate, I could see blood collecting in my needle and syringe. I immediately knew this was not a lipoma. I aspirated the mass in a few more areas, and we submitted the slides to the laboratory for cytologic examination.
I told Amanda that my clinical hunch was a tumor. Tears welled up in her eyes. As veterinary professionals, we deal with cancer in dogs and cats every day, but nothing can prepare you when it is your pet. I could see Amanda's mind start to race and shut down at the same time. I gave her a huge hug, and we waited anxiously overnight for Smokey's cytology results.
The cytology came back as a soft tissue sarcoma. Soft tissue sarcomas are malignant and develop in a variety of connective tissues. They can be found all over the body, from head to trunk to paws. Most of these tumors are aggressive locally. They are also prone to come back if they are not removed with wide margins.
The good news is that the low- and intermediate-grade versions of these tumors are not such a bad tumor for a dog to have since soft tissue sarcomas typically don't metastasize. Low and intermediate grades of soft tissue sarcomas are very treatable. Surgery can be curative if the mass can be removed completely. That is much easier to do if we find it when the mass is smaller.
For Smokey, the next step was a biopsy to confirm the tumor type and help our soft tissue surgeon appropriately plan his surgery. I ran blood and urine tests and ordered thoracic radiographs and an abdominal ultrasonographic examination to make sure the cancer hadn't spread-all clear!
On surgery day, Smokey had a CT scan to help the surgeon plan the surgery. Smokey's 7-cm tumor required a really big surgery to obtain 3-cm margins, but everything went well.
We focused on his recovery and anxiously waited for his biopsy results. The biopsy report confirmed great news: a low-grade (grade 1) hemangiopericytoma with wide and clean margins. He did not need more treatment-no postoperative radiation or chemotherapy. I just recommended regular monitoring of the scar and periodic thoracic radiographs.
Smokey in the intensive care unit after surgery to remove his soft tissue sarcoma.Smokey's inspiration
Even though Smokey's surgery had a happy ending, his malignant tumor really hit me hard. In hindsight, if we had aspirated this earlier when the mass was smaller, his surgery would have been simpler. How could I, a cancer specialist, have missed this tumor?
Were there guidelines I had forgotten? I pulled out my cancer books, journals and cancer notes from my medical oncology residency. No, there are no guidelines for veterinarians or pet owners for when to aspirate or biopsy a mass on a dog or cat. The current recommendations for doing an aspirate include generalities-“recommend if a mass is changing in size or appearance, or bothering the patient.”
Owners are often told to keep an eye on it. But what does that mean? Keep an eye on it for how long? How much can it grow before we should do something?
I hear all too often that a mass does not look or feel malignant. The pet owner should just monitor the mass and wait until it is bothering the pet. This is not good enough! Even an experienced cancer specialist like me cannot look at or feel a mass and know what it is. I am not a microscope.
When tumors grow, what could have been removed with a simple surgery may now require a bigger surgery and sometimes more treatment such as radiation or chemotherapy afterward. Even worse, the tumor may become too big to be removed or treated at all. I see this all the time.
We all must do better. We need guidelines. We must find tumors earlier when they are small. We must aspirate them. With the input of fellow specialists, I have developed See Something, Do Something. And I dedicate it to Smokey:
> See Something-If a dog or cat has a mass that is the size of a pea (1 cm) and it has been there one month …
> Do Something-Go to a veterinarian and get it aspirated or biopsied.
Do not get complacent like I did. Even after many benign aspirates, the next one can be malignant. Most skin and subcutaneous tumors can be cured if diagnosed early when masses are small. Let's find them earlier and aspirate them when they are small.
Sue Ettinger, DVM, DACVIM (oncology), is the head of the Oncology Department at the Animal Specialty Center in Yonkers, New York. Also known as Dr Sue Cancer Vet on Facebook and Twitter, she is a co-author of The Dog Cancer Survival Guide, 2nd Edition, and co-hosts The Pet Cancer Vet, an Internet radio show on radiopetlady.com. Join in with See Something, Do Something at #whywaitaspirate.