Bruce, a nine-year-old male Indie was referred for Sonography after being non-responsive for treatment of Tick Fever. The dog apparently showed typical signs suggestive of tick fever including fever, anemia, splenomegaly, and anorexia for about 2 weeks. Ultrasonography of the abdomen revealed diffuse multifocal hypoechoic granulonodular texture at the cranial pole of the enlarged spleen and the left lateral lobe of the liver. A radiograph of the latero-medial view of the abdomen revealed irregular splenic margins suggestive of a splenic mass. A re-examination three days later revealed diffuse mixed echogenic lesions in more than one liver lobe. A fine-needle aspirate of the splenic pathology revealed inconclusive findings of lymphoid cells but didn't rule out malignancy.
The path ahead was to explore the abdomen and attempt a splenectomy and/or liver lobectomy or let Bruce slide away in a couple of painful days. The owner took a brave call and let us operate on Bruce. It was a tough call to take. I felt like an imposter for having given even a glimmer of hope to the owner. Yes, I'm an accomplished surgeon but I honestly hadn't attempted or even heard of a liver lobectomy being performed by anyone in my close circle. I felt I just had to begin somewhere because having given up hope on two similar cases in the past 4 months had given me enough sleepless nights. And it was my convincing as much as the owner's wish that made them opt for surgery, thus providing a smidge of hope to Bruce's chance of making it through.
The actual surgical anatomy and procedures are seldom as described in texts. With all dew respect to my gurus, the veterinary education we receive is shoddy, to say the least. And despite attending renowned continuing education programs and workshops, our proficiency as surgeons is understandably inferior compared to specialists who are lacking in India. The vascular anatomy of the liver is complex and I spent a few sleepless nights trying to figure it out. It was a bittersweet feeling to trace out the course of the portal vein during surgery, something I should have done during my surgical training but never once got an opportunity to do the same. Anatomy during undergrad was intimidating enough to completely ignore the nuances. Little did I know then that I would need to have a level of competence to perform a liver lobectomy. But things have changed now and I wanted to get into the shoes of specialists and perform advanced procedures.
Poignance prevailed while preparing Bruce for surgery. The parents hoped it wasn't their final moments with him and pinned their trust on us to keep their hopes, and Bruce alive. Bruce was taken into the OR, scrubbed, intubated, and the leads of the multipara monitor connected. A mid-ventral approach was chosen, extending from just cranial to the xiphoid to the pubis caudally. The intraoperative site gave me the jitters. It was hemabdomen, a surgeon's nightmare. One or more of the tumors that were present on the spleen or liver had ruptured and were spilling blood into the abdominal cavity. This masked the visibility of the organs greatly. Three large ulcerative masses were found on the left lateral, right lateral lobes of the liver and the caudal pole of the spleen. However, the tumor had metastatized to all lobes of the liver. We performed a splenectomy and a partial liver lobectomy to arrest bleeding and excise the tumor which helped control the bleeding but there were plenty of small nodules that were about to ulcerate and bleed in the coming days. Any further excision of the tumors risked a possibility of fatal hemorrhage. The future looked grim. The tumor had metastatised extensively in a matter of days rendering the decision to operate moot.
We closed up the incision routinely and informed the owners about the poor prognosis. As the case is with most concerned pet parents, the owners didn't want Bruce to suffer its way through postoperative recovery only to breathe its last soon after or even before the healing of the surgical wound. Compassion fatigue is very real and it was heartache injecting the bolus of Thiosol and Succinylcholine - the euthanising agents.
The more a vet is passionate and willing to work out of his skin, the more ethical dilemmas he's likely to face. The decision to operate was one such dilemma. Since no metastasis was confirmed, an exploratory laparotomy wasn't irrational after all. Since sonography revealed lesions on the spleen and only one lobe of the liver, a splenectomy, and partial liver lobectomy seemed to be a good course of action but the aggressive nature of the tumor meant that the tumor had spread diffusely across all lobes of the liver by the time we operated 2 days later. Referral to a hard-to-find oncologist would have been the other option. I guess I was consumed by perception bias considering I am a surgeon although I would assume the prognosis to have remained pretty much the same.
The histopathology report read as follows - 'Sections studied from liver show parenchyma with an infiltrating tumor composed of irregular anastomosing vascular channels lined by atypical endothelial cells. Also seen are cells arranged in sheets and nests surrounding the congested blood vessels. These cells are pleomorphic with vesicular nuclei, prominent nucleoli, and moderate eosinophilic cytoplasm accompanied by mitosis. Stroma shows moderate lymphoplasmacytic cell infiltrate. Areas of necrosis noted. Splenic tissue is infiltrated by tumor having similar morphology as described above.' The final impression suggested features of Angiosarcoma with spleen being the primary foci and metastasis to the liver.
Given that the owners weren't up for chemotherapy or palliative care of any sort, surgery or euthanasia were the only two options left. As much as the owners wanted to opt for the latter initially, they were enticed to consider surgery which would offer them a smidge of hope. Unfortunately, it wasn't meant to be. For me, what's more shocking is why even Indie dogs are culminating with such fatal tumors in the first place. We can only suspect our lifestyles which is rubbing off on them but I wish I had a definitive answer. Partial liver lobectomies, which seemed daunting were performed without much fuss but Bruce needed much more than that. For someone who had never performed such an invasive procedure before, this gives me a lot of positives moving ahead. By no means though, are they easy. I realized things go awfully wrong and referral is always advised if available. Dogs that do get diagnosed early on in the course of the disease before metastasis do have a good prognosis with surgery depending on the type of tumor.
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