C10017363 / invoice 10000

Reason: reassessment Intern: History: Polly is a 3y 8m FS French Bulldog who presents for ongoing management of a L nephroblastoma with suspected vascular invasion and seeding of the abdominal wall. Nephrectomy surgery 16/9/25, commenced adjuvant vinc/doxo protocol 2/10/25. PD detected Dec'25 and commenced metronomic cyclo/palladia 3/1/26.10/07/25: Artificial insemination at local vet. 23/08/25: Presented to RV for pregnancy US - 37mm mass noted on L kidney vs ovary, no foetuses observed. Well otherwise, minimal history. 03/09/25: Presented to ARH IM for investigation of a suspect renal mass. Generally clinically well, acute development of mild PU/PD, 2 week history of pruritis and mild erythema of axilla and inguinal regions. Chem 17 WNL. CT identified large left renal mass, no overt involvement of left adrenal gland or contralateral organs, no overt metastasis identified. FNA from L renal mass collected, cytology returned embryonal or epithelial neoplasm, favouring nephroblastoma or renal cell carcinoma. Urinalysis: pH 5.0, protein trace, blood negative, glu negative, ket negative, SG >1.050. No evidence of bacteria, casts, crystals, fungal hyphae or abnormal cells. Referred to oncology/surgery for nephrectomy +/- alarplasty and spay. Imaging Summary: 1. Left renal mass. DDx neoplasia such as nephroblastoma, renal carcinoma, lymphoma 2. Bilaterally enlarged axillary lymph nodes with heterogeneous enhancement. DDx reactive hyperplasia or secondary neoplasia 3. Spleen with reticulated contrast enhancement. DDx lymphoid hyperplasia or infiltrative disease process 4. Other findings - see reportFocal US of spleen was unremarkable. QML lab reference: 25-59373424 SPECIMEN: Left kidney: 4 FNA smears INTERPRETATION: Embryonal or epithelial neoplasm 05/09/25: Presented to ARH oncology. Blood collection for autotransfusion performed, nephrectomy scheduled for 16/9. 16/09/25: Presented to ARH for L nephrectomy, OVH and rhinoplasty/alarplasty. No significant intraoperative complications:SUPPLEMENTARY REPORT - 26/09/2025 10:06AM HISTOLOGY ACCESSION No. VQ25-011318 MICROSCOPIC Six sections of kidney and associated structures are examined. The cortex is focally and markedly expanded by a densely cellular, unencapsulated, mildly infiltrative mass composed of vague cords and trabeculae, and dense sheets of cuboidal to polygonal cells on a sparse fibrovascular stroma. There are occasional possible glomerular tufts (remnant glomerular versus blastemal cells). Proliferating cells have small to moderate amounts of pale eosinophilic homogenous cytoplasm, with paracentral round nuclei with 1-3 prominent nucleoli. Proliferating cells exhibit mild pleomorphism, and the mitotic count is approximately 40 per 10 consecutive high-powered fields (total field area 2.37 mm2). There is central haemorrhage and necrosis. Focally, neoplastic cells protrude into the luminal blood vessel not clearly covered by an endothelial lining (possible early metastasis). Immediately adjacent renal parenchyma exhibits moderate to marked tubular loss and parenchymal fibrosis. Sections of ureter exhibit no significant histologic findings. DIAGNOSIS FAVOUR RENAL TUBULAR CARCINOMA, SEE COMMENT WITH POSSIBLE EARLY METASTASIS17/09/25: Continued hospitalisation. Developed tachycardia, free peritoneal effusion, and a decrease in glomerular filtration rate overnight on 17/09/2025. managed for compensatory shock, suspected to be haemorrhagic. An abdominal tap revealed a haemoabdomen with a PCV of 27%, compared to a peripheral PCV of 33%. PCV/TP 33/31Creatinine 124 (cf 134 on 18/09/2025 at 05:41) umol/L 44 - 159 PT (11-17): 13.0 seconds Abdominal fluid haematocrit: 27%. Urine appeared to be pigmenturic, consistent with haematuria on visual inspection. APOCUS [09:00]: Small volume of free fluid present around the spleen. One corrugated area of small intestine noted. Bladder deflated (urinary catheter in situ). APOCUS [13:00]: Marginal increase in FF cf earlier. Ongoing medical management for haemabdomen, AKI, compensated haemorrhagic shock, post-operative tachycardia, intermittent second-degree AV block (Mobitz type II), post-operative peripheral oedema, haematuria. 19/09/25: Discharged home. Continued on maropitant, paracetamol 25/09/25: KTL STO - Polly doing well post-operatively, no significant concerns. Advised of results of histopathology, recommended IHC and adjuvant chemotherapy - owner consented to IHC, scheduled appointment for medical oncology. SUPPLEMENTARY REPORTIMMUNOHISTOCHEMISTRY REPORTImmunohistochemistry has been performed on the following markers.MNF 116: 80% of neoplastic cells exhibit positive immunoreactivity.Vimentin: Approximately 40% of neoplastic cells exhibit positiveimmunoreactivity.MARGINSNeoplastic cells do not extend to the histologic margin in theexamined sections, minimum histologic margin <0.5 mm of connective tissue.COMMENTIHC findings are equivocal -the presence of positive-staining forvimentin in any of the neoplastic cells is suggestive ofnephroblastoma, however as discussed at consensus rounds, epithelialmesenchymaltransition within a carcinoma cannot be completely excluded.Reviewing the original histology and the presence of possibleglomerular tufts, I have slight preference for nephroblastoma despitethe absence of a prominent stromal component.Please feel free to contact me if you would like to discuss this casefurther.Vincristine/doxorubicin alternating protocol commenced 1/10/25. 26/11/25: Polly staged clear, however developed a grade 3 neutropaenia (non febrile) day 7 post vincristine, Enrofloxacin commenced. 28/11/25: She had remained grade 1 neutropenia day 9 post vincristine, discontinued enrofloxacin. 17/12/25: At chemotherapy revisit, Christie raised concern regarding the multiple cutaneous masses at the ventral abdomen. She remained well otherwise. FNA of the 4 cutaneous masses show similar population and confirmed neoplasia, concerning for seeding from previous transabdominal aspirate. Cytology Reference: 205-11874SPECIMEN:12 FNA smears from 4 ventral abdominal cutaneous masses (slides not differentiated)MICROSCOPIC:All smears show similar findings of high numbers of tissue cells, the majority of which occur in monolayer sheet-like arrangements with ill-defined cell borders and many bare nuclei, while some smears show the same population occurring in cohesive sheets and ribbons. The cells have a small (1.5-2.5xrbc) ovoid nucleus of stippled chromatin with an indistinct nucleolus and, when intact, small to moderate amount of mid blue cytoplasm sometimes showing few punctate vacuoles. Anisocytosis and anisokaryosis are moderate. Occasional binucleates and mitoses are seen. There are interspersed macrophages containing phagocytic debris.INTERPRETATION: 4 lumps: Malignant neoplasiaCOMMENT: Findings on all slides show the same population of neoplastic cells which, when considered in light of previous renal cytology for this patient, can reasonably be assumed to represent metastatic seeding of the previously identified renal neoplasm (nephroblastoma or renal carcinoma).29/12/25: CT staging and in summary:- Multiple abdominal wall masses, as described- Few pulmonary nodules- Multifocal lymphadenopathies - most prominently involving the left superficial cervical (prescapular), right axillary, and left superficial inguinal lymph nodes- Mild splenomegaly - congestion (sedation) and other benign etiologies prioritized- Non-obstructive gastric bone foreign material- Prior left nephrectomy- Stifle degenerative changes- Congenital thoracic vertebral anomalies- Persistent left cranial vena cava, incidental congenital anomalyAdditional CommentsThe abdominal wall masses are consistent with those described on the physical examination. Primary neoplasia (mammary?), or metastasis and/or aspirate-related seeding from the previous nephroblastoma, are both considered. The caudal lesion extends through the abdominal wall abutting the spleen. Multifocal lymphadenopathies and pulmonary nodules are highly concerning for metastasis. Granulomatous etiologies are not excluded but unlikely. Further investigation could include sonographically-guided aspiration or biopsy of the left inguinal and superficial cervical lymph nodes, and possibly the right axillary lymph node if accessible.3/1/26: Metronomic cyclophosphamide and palladia commenced as palliative intent. 13/02/26: Polly presented for 2 weeks reassessment. She has been well at home, EDUD normal. No concerns. O noted abdominal lesion has become a little bigger and gets traumatised when Polly bumps it. 17/02/26: Polly has a large, ulcerated ventral abdominal mass which the owner reports has rapidly increased in size, particularly overnight. The owner is concerned because the mass is now bleeding daily and sometimes has a purulent discharge. The owner states the mass gets wet, then dries up. The owner notes that Polly was slightly lethargic this morning but still ate normally. Due to the lethargy, the owner administered an anti-nausea medication. Polly received her chemotherapy drugs today. The owner is also questioning why surgical removal of the mass was not pursued, as it was an original plan before lung nodules were discovered. Otherwise, no vomiting or diarrhoea noted. Polly presents today for chemotherapy recheck.Polly has been EDDU as normal. The mass is still ulcerated, will bleed/ooze every couple days. Owners are currently cleaning it every day. Owners have noticed the mass in her inguinal area has grown in size since her last visit.Past pertinent medical history: - 16/12/24: BOAS (staphylectomy alone) - 19/2/25: BOAS review, immature scar tissue of soft palateExamination Findings: Demeanour: BAR Weight:     BCS: 6/9 T:  38.3 C                  MM: Pink, MoistP:  96 bpm              CRT: 1-2 s R:  28  Cardiovascular: no auscultable murmur or arrhythmia, femoral pulses strong and synchronousRespiratory: clear bronchovesicular sounds bilaterally across lung fields, mild referred URT noise, respiratory effort normal. Mild intermittent sterterous respiration. Abdomen: WNL; soft and comfortable to palpate, no immediately palpable masses or fluid wave Peripheral LNs: L inguinal LN firm and palpably enlarged measures 1.5cm- static. R inguinal LN slightly prominent. Remainder of peripheral nodes palpate normally. Eyes: WNL; eyes clear and symmetrical, no ocular discharge, inflammation or blepharospasmEars: Internal pinna erythematous, moderate volume of ceruminous discharge present in R canal (less prominent in L canal). Otoscopic examination not performed.  Integument: CURRENT (17/2)- large ulcerated cutaneous mass measuring 3 x 2.2cm adjacent to the right fourth mammary gland (was 2.5cm 13/2/26). There is mild bleeding from the mass as per previous visit. There is an area approximately 2.5cm caudally along the abdominal wall that is thickened and firm to palpate. There is a 1mm firm nodule along the body wall under the L inguinal LN. Mild erythema underneath mandible, axilla. -  (24.12.25): L ventral abdomen adjacent to third left mammary gland, there is 1 cm cutaneous mass. Adjacent to the main mass, there are another 2 smaller vascular cutaneous masses, measuring 4mm and 5mm. There is another 4mm cutaneous mass. - Photos taken for reference. - 16/1- the masses are now in clusters with 2x 2.2cm distribution, the two masses with small amount of bleeding - (30/12/25)- two 5mm cutaneous masses palpable at right triceps region- 16/1/26- there is moderate erythema with papules throughout the forelimbs and ventral abdomen; pustules noted at inner thigh - 17/1/26 - moderate erythema noted at inner thigh and ventral abdomenOral exam: WNL; mucous membranes pink, dentition WNL  Musculoskeletal: WNL; weight bearing x4 limbs, no noted muscle asymmetry, no noted neck pain on movement. Full MSK examination not performed. Gait: WNL; ambulating well, no observed lameness or ataxiaNeurological: WNL; mentation appropriate, response to environment appropriate. CPs appear intact, menace and palpebral intact. Full neurological examination not performed. Rectal exam: not performed Laboratory:  Inhouse IDEXX CBC - see attached results HCT %NEU - x10^9/LPLT - Blood pressure - 132/96 (MAP 109)Inhouse Urinalysis:Dark yellow, clearUSG 1.046Dipstick: PH 6Protein 1+All other values -veTreatment: Continue:Cyclophosphamide 7mg capsules PO SID with frusemide 0.5mg/kg PO SID (on liquid, 0.44ml)Palladia 20mg PO MWF Dispensed by KR, checked by KOCFor use as needed: Maropitant 16mg PO SID Ondansetron 4mg TM BID-TID Pro Kolin 3ml PO BID Assessment: L renal neoplasia - favour nephroblastoma - CT staging 3/9/25- L nephrectomy performed 16/09/25; margins clear - VMIx2 cytokeratin and vimentin: MNF 116: 80% exhibit positive immunoreactivity. Vimentin: 40% exhibit positive immunoreactivity. --> Favour renal tubular carcinoma with possible early metastasis, MC = 40- Commenced chemotherapy (vincristine/doxorubicin) 01/10/25 - vincristine #1 @ 0.5mg/m2 Chemotherapy: - Vincristine #1 01/10/25, #2 22/10/25- Doxorubicin #1 08/10/25 *mild acute hypersensitivity reaction, resolved with chlorpheniramine - Vincristine #2 - dose escalation to 0.6mg/m2 - G3 neutropenia- Doxorubicin #2 5/11/25 - no reaction- Vincristine #3 @ 0.5mg/m2 on 19/11/25--> day 7 nadir: N: 0.95--> day 9 nadir: N: 1.67- Doxorubicin #3 03/12/25  - no reaction  - Vincristine #4 17/12/25 @0.45mg/m2--> day 7 nadir: N 1.52Staged clear on 26/11/25. PD 30/12, concerned for seeding from transabdominal aspirate- CT restaging (30/12) concerning for pulmonary metastasis, also developed cutaneous lesions at the right triceps region  - commenced metronomic cyclo/palladia 3/1/26, continue to develop PD 17/2/26Client communication: Plan:    Vital Signs    Weight: 9.6;       MMColour: Pink;       Temperature: 38.3;       HeartRate: 96;       RespirationRate: 28;       CRT: <2;