C10017530 / invoice 10000

Reason: 3 Month StagingAppointment Notes: msg left for estimate AGSEST: $1900 for staging under light sedation IMGNotes complete Bill completePet Primary Diagnosis/Suspected Diagnosis/Location:Suspect cause:Any other conditions being treated (if any): Known health concerns: Date of first clinical signs (if known):DRAFTIntern: History:Loki is an 11yr4m MN Miniature schnauzer currently managed for MCT disease and SCC of the digit. 29/10/20 - Initial presentation at ARH for incompletely excised cutaneous MCT (low grade, Grade 2) of the dorsal aspect of P3 LPL. 4/11/20 - LPL P3 amputation and scar revision with MJT + popliteal lymphadenectomy and R lateral scapula mass biopsy. Histopathology returned narrow margins and metastatic disease to L POP LN. 3/12/20 - Commenced vinblastine/palladia/pred protocol. Palladia was discontinued partway through the protocol on 18/01/21 due to GI toxicity. He had dose escalation of vinblastine to 2.2mg/m2 from the 6th dose on 25/02/21. He completed the protocol on 25/03/21. 11/03/21 - Staging - two subcutaneous masses on cranial chest and prescapular region observed. Aspirates were non-diagnostic. Masses regressed. 18/06/21 - Developed mass within falciform fat - aspirates showed necrotic lipoma/pannicultis. Mass regressed. 3/12/21: Repeat staging. MCT identified on L prescapular region with L prescapular lymphadenopathy on U/S. 14/12/21 - MCT excision with L prescapular lymphadenectomy. Histopathology returned complete excision with no metastasis. 25/03/22 - Repeat staging. Clear. 06/04/22 - Presented for small mass at left point of shoulder. FNAB showed granulated mast cells. 11/04/22 - L shoulder MCT excision. Histopathology returned mass cell tumour (low grade, grade 2), completely excised. 01/7/22 - AUS showed cystic structure near pancreas, measured 0.44 x 1.17cm. 7/10/22 - Repeat ultrasound - pancreatic lesion static. 09/2/23 - Presented for new mass on RPL medial aspect of digit 2 proximally. FNAB yielded thick sebaceous material, mostly keratin with occasional spindle cell. Recommended to monitor. 22/3/23 - Presented for assessment of swollen LPL digit II. Initially commenced on amoxyclav and metronidazole by RV with little response. The digit was grossly swollen and the nail removed with digital manipulation. Purulent discharge was observed from the nail bed. Radiographs of the paw showed lysis of P2. Chlorhex soak performed and culture & incisional biopsy obtained. Returned mixed growth of Pseudomonas aeruginosa, Enterobacter cloacae complex + Staphylococcus pseudintermedius scant. Commenced enrofloxacin 75mg PO SID. Histopathology indicated squamous cell carcinoma. 28/03/23 - Digit amputation and L popliteal LN extirpation performed. The left inguinal and left medial iliac LN's were also aspirated due to increase in size sonographically, but returned as reactive from QML. Histopathology indicated complete excision of SCC and hyperplastic draining LN (non-metastatic).11/10/23: staged clear on AUS and thoracic radiographs. FNA of right perianal mass consistent with lipoma. Unable to aspirate mass on right mandible or left ear. 22/11/23: newly noted 2mm lesion to left cranial point of shoulder. In house FNAB noted multiple well granulated mast cells. Chlorpheniramine 2mg PO BID and famotidine 20mg PO BID commenced. 27/11/23: left cranial shoulder mass excision by MJT. Histology consistent with:Mast cell tumour: Grade I (Patnaik)/Low-grade (Kiupel). Complete excision performed. 10/01/24: Repeat staging. O reports several new lumps: ~1.4mm x 2mm firm ovoid subcutaneous lesion right lateral shoulder - FNAB poorly cellular, non-diagnostic. ~3.5cm x 3cm x 0.5cm soft ovoid subcutaneous (presumed lipoma from U/S) left lateral quadriceps overlying muscle. 10/04/24: Repeat staging: AUS found cystic LMILN: 0.46cm x 0.86cm isoechoic, normal shape, central cyst: 0.18cm x 0.21cm, cystic R ING LN: 0.23cm x 0.65cm, central cystic structure 0.18cm x 0.15cm and enlarged L CAUD ABD LN: 0.48cm x 0.58cm, mildly hypoechoic and plump 2/10/24: Staged clear. Progression of cystolith noted, and work up recommended at PCV. New lesion noted to caudal LTL. O to monitor for growth/change in size. 12/12/24: ACTH stim test performed by PCV:  Dog ACTH STIMULATION TEST TIME (Hours) CORTISOL (nmol/L) 0 165 (30-100) 1 406NORMAL DOG:Post-ACTH cortisol: 200 - 380 nmol/LReportedly also had a cystocentesis performed at PCV which was WNL. 8/1/25: Repeat staging WNL. Previously noted pancreatic cyst remained static in size. 20/6/25: Repeat staging WNL. Mild hyperglobulinaemia detected (47g/L). 24/9/25: Repeat staging WNL. Newly noted mass <2mm to right ventral thorax too small to reliably FNAB. Elected to monitor. Serum protein electrophoresis performed due to mild persistent hyperglobulinaemia: PROTEIN ELECTROPHORESIS Sample: Serum Alpha-1 Globulins 4 g/L (2-5) Alpha-2 Globulins 15* g/L (3-11) Beta Globulin 18 g/L (12-22) Gamma Globulin 6* g/L (8-22) Vetnostics North Ryde NATA Accreditation Number: 14599. Results apply to the sample as received. Measurement of uncertainty (MU) may be applicable when interpreting borderline changes in results. Please refer to www.vetnostics.com.au for MU information. The electrophoresis trace shows an increase in the alpha 2 band (acute phase proteins) with a mild broadening in the beta 2 band but with total globulins not elevated. This is a mild polyclonal pattern. A copy of the electrophoresis trace will be emailed separateLoki presents for repeat staging today. Loki has been well at home. Owner reports that Loki had a 24 hr period of diarrhoea and inappetance approx 2 weeks ago but has been otherwise well. EDDU normal and had trazadone at 6am this morning.Current medications: NilDiet:RC urinary s/oExamination Findings: Weight 9.1 kg Demeanour: BAR T: 38.3C P: 108bpm R: 32MM: moist, pink CRT: <2sOral: Minimal gingivitisCardiovascular: Grade I/VI left sided systolic murmur, regular rhythm, SSFP. Respiratory: Lung sounds clear in all 4 quadrants with no evidence of any crackles or wheezes. LNs: Peripheral LN palpate normally (L prescapular and L popliteal LN previously removed) Abdomen: Soft and comfortable on abdominal palpation. Integument: Clean coat with no evidence of ectoparasites. -No recurrence on left hind limb toe amputation site or L prescapular region. - all digits palpate normally-Fibrosed tissue (advanced healing) over LTL cranial elbow - no recurrence palpable. -Small 2mm firm lesion lateral R stifle (previously aspirated as keratin). -Small 2mm mobile lesion over the R temporalis m. -Small 2mm mobile cutaneous raised mass at the proximal aspect of RPL P2 medially-Site of amputated digit 2 LPL palpates normally New 19/07:- Left lateral metatarsus, firm, immobile raised mass approx 5mm- Right forepaw, medial aspect of paw by dew claw has a firm, immobile, raised mass, approx 2-3mm- Pinpoint, raised cutaneous lesion, approx 1-2mm between scapulae New 11/10: -Small 1-2mm wart like mass on ventrolateral right cheek (in beard)-Small 1mm lesion at base of left ear-Small 1cm soft mobile mass at right ischial tuberosity - lipoma22/11/23:- surgical scar from left cranial point of shoulder (prev MCT), palpates normally10/1/24: ~1.4mm x 2mm firm ovoid subcutaneous lesion right lateral shoulder ~3.5cm x 3cm x 0.5cm soft ovoid subcutaneous (presumed lipoma from U/S) left lateral quadriceps overlying muscle. 10/04/2024: - 2cm left lateral thorax, subcutaneous - lipoma- 1.5cm left caudal tibia, subcutaneous - lipoma- 2.5cm right thorax, subcutaneous - lipoma- 2.7 cm x 3cm mid pectoral region - lipoma3/07/2024: - 5mm firm thickening to L cranial scapula lesion - not a discernable mass - FNAB acellular debris and keratin 2/10/24: - LTL: 3mm ovoid soft lump caudal distal antebrachium overlying SDFT.8/1/25: ~3mm raised pigmented ovoid cutaneous lesion to lumbar spinal region. 26/3/25: ~5mm raised pink smooth lesion to ventro-cranial chest. UPDATED TUMOUR MAP 20/6/25-No recurrence on left hind limb toe amputation site or L prescapular region. - all digits palpate normally-Site of amputated digit 2 LPL palpates normally - surgical scar from left cranial point of shoulder (prev MCT), palpates normally-Small 1-2mm wart like mass on ventrolateral right cheek (in beard)-Small 1mm lesion at base of left ear-Small 2.7 x 3cm soft mobile mass at right ischial tuberosity - lipoma- 8 x 12.2cm soft ovoid subcutaneous (presumed lipoma from U/S) left lateral quadriceps overlying muscle.  - 2.7 x 2.8cm left lateral thorax (caudal axilla), subcutaneous - lipoma- 1.5cm left caudal tibia, subcutaneous - lipoma- 3.6 x 4.1m right thorax (caudal axilla), subcutaneous - lipoma- 4.2 x 6.7cm mid pectoral region - lipoma- LTL: 5mm ovoid soft lump caudal distal antebrachium overlying SDFT.~3mm raised pigmented ovoid cutaneous lesion to lumbar spinal region. - mid ventral sternum, subcutaneous fluctuant mass 1cm- 1-2mm minimally raised cutaneous lesion mid to slightly right ventral thorax Masses assessed with HT Vista1.2.3.4.5.6.7.  MSK: ambulatory and weight bearing, full exam not performed Urogenital: WNL Neurological: BAR, normal gait. Rectal: Not performed. Diagnostics:Sedation: 0.2mg/kg torb s/c prior to stagingRadiographic findings:Thorax:Normal with no radiographic evidence of metastasis or lymphadenomegalyThoracic wall lipomaUltrasound report: AUS performed by KOC: Performed 10/12/25 and is compared to the 24/9/25 and represents a 3 month re-evaluationBladder: Lumen measures 3.61cm, wall measures 0.16mm. Hyperechoic gravity dependent structure within lumen (ddx: cystolith) unmeasured today. Prostate: Heterogeneous and ovoid, measures 0.68cm x 1.94cmDescending colon: Wall thickness 0.13cm, normal wall layering L Kidney: 4.38cm (longitudinal), normal CMJ, no pyelectasia or cystic lesions. R Kidney: 4.76cm (longitudinal), normal CMJ, no pyelectasia or cystic lesions. L adrenal: 0.52cm (caudal pole), 0.36cm (cranial pole) normal echogenicity R adrenal: 0.54cm (cranial pole), 0.41cm (caudal pole), normal echogenicitySpleen: subjectively normal size, homogenous echogenicity, no capsular distortion (1.51cm width)Liver: normal parenchyma and relative echogenicity. Small volume FF present adjacent measuring ~0.34cm. Gall bladder: lumen measured 2.56cm diameter, moderate degree of hyperechoic organising sediment present as previous. Mild cystic mucinous hyperplasia (wall <2mm). Pancreas: right limb measures 0.97cm, slightly heterogenous, single cystic lesion previously seen noted again today ~3mm Stomach: normal wall layering, wall thickness 0.30cm SI: Wall thickness 0.23cm, normal wall layering Duodenum: Wall thickness 0.39cm, normal wall layeringLMILN: 0.41cm x 1.53cm, isoechoic, normal shape RMILN: 0.39cm x 1.55cm, isoechoic, normal shape. L ING LN: isoechoic normal 0.3cm x 2.10cm, R ING LN: isoechoic 0.23cm in width x 1.41cm total lengthL popliteal region (previous LN) - a little thickened area 0.28 x 0.90cm (static compared to previous findings) R popliteal LN: 0.35 x 1.06cm, fusiform and isoechoic Lipoma to the left hip: heterogenous and ovoid as previous. Unmeasured. Interpretation:No gross evidence of metastatic diseaseGall bladder sludge and mild cystic hyperplasiaPancreatic cystAssessment:Cutaneous MCT (low grade/grade 2 MI<1) dorsal P3 LPL with early metastases to L POP LN -Incomplete excision 01/10/21 -P3 amputation + L POP lymphadenectomy 04/11/20 Vinblastine/palladia/prednisolone commenced 03/12/21 -Palladia discontinued 18/01/21 due to GI toxicity -Vinblastine dose escalation 2.2mg/m2 dose 6 onwards -Protocol completion (total 8 doses) 25/03/21 Cutaneous MCT (low grade/grade 2) left prescapular region, no metastases to L PS LN -Complete excision + L PS lymphadenectomy 14/12/21 Cutaneous MCT (low grade/grade 2) left point of shoulder region - Complete excision 11/04/22 - not local recurrence palpated today Cystic like lesion near pancreas Squamous cell carcinoma of digit 2 LPL- Complete excision 28/03/23Cutaneous MCT left cranial point of shoulder - FNA consistent with MCT- Surgical excision 27/11/23; low grade (Kiupel), grade 2 (Patnaik), complete excision- Thickening to skin 03/07/24 - FNAB keratin and acellular debris LTL caudal antebrachial mass- FNA consistent with keratin cyst/ infundibular follicular cyst  Cystoliths 2/10/24, 26/3/25, 20/6/25, 24/9/25Staging: - Most recent 10/12/25 --> clear Treatment:Trazodone 50mg PO given by O prior to coming into the clinic this morningClient communication:It is pleasing that Loki has staged clear again today. Melissa elected to forgo the HT Vista today in lieu of ongoing proactive monitoring. There has been no change in the appearance and size of mass to ventral thorax. We have discussed that due to Loki's numerous masses, it is difficult to ascertain formation of a mast cell tumour within an existing lipoma. Melissa has elected to pursue HT Vista under sedation at next staging for all masses. Discussed that this will involve a widespread fur shave, which Melissa may do prior to consultation. Loki's bladder cystolith remains static in size. We will continue to monitor each staging appointment. Plan:Revisit in 3 months - HTVista for all cutaneous/ subcutaneous lesions, FNAB of any concerning lesions found. Discussed moderate sedation. Repeat 3x CXR and AUS. O to organise drop off.    Vital Signs    Weight: 9.1;       MMColour: pk;       Temperature: 38.3;       HeartRate: 108;       RespirationRate: 32;       CRT: <2;