C10024104 / invoice 10000

Reason: EC/JFT Referral For DiscussionIntern: SC History: Groot is a 7 year 1 month old MN Labradoodle presented for discussion following return of FNA of LMILN demonstrating metastatic carcinoma without identification of primary tumour.Groot was hospitalisation 18/1-22/1 for pyrexia, RPL lameness and lumbar pain. There was a prior hospitalisation at AEC for similar signs where Groot was treated with amoxicillin. Initial investigations found severe iliac lymphadenopathy, which was worse on the left and moderate right hock effusion. 19/1 – aspirates of lymph nodes and arthrocentesis of all small joints. Lymph node aspirates returned with an epithelial population, concerning for carcinoma metastasis and lymph node effacement. The right hock had moderate neutrophilic inflammation, the carpi were normal and there was haemodilution of the left hock.21/1 A full body CT to identify the source of the primary tumour and returned with large right iliopsoas muscle lesion. Aspirates of the muscle lesion returned neutrophilic inflammation (abscess) with no growth. CT Findings Summary: 1. Ill-defined swelling of the right iliopsoas muscle and the intra-pelvic hypaxial musculature with fluid-filled cavities. Most likely compatible with an infectious process (abscess, foreign body migration). A neoplastic process (hemangiosarcoma, soft  tissue sarcoma) is considered less likely. 2. Multifocal sub lumbar lymphadenopathy. Hepatic lymphadenopathy. Aortic lymphadenopathy. popliteal lymphadenopathy. Compatible with reactive hyperplasia, lymphadenitis, or neoplasia (metastasis). 3. Diffuse splenomegaly. Consider reactive hyperplasia, extramedullary haematopoiesis, splenitis, or reactive hyperplasia. 4. Bilateral otitis externa. 5. Swelling in the right tarsal region. Consider an arthritis (sterile vs early septic) or a traumatic origin11/2/26 – Groot reported to be going well at home. Examination demonstrated persisting moderate pain on caudal lumbar palpation with no joint effusion noted. CRP was improved (5.7) 17/2/26 – Persistent moderate pain response on caudal lumbar palpation. AUS demonstrated persistence of Left internal iliac lymphadenopathy 0.9cm x 2.9cm bilobed hypoechoic with heterogenous echotexture similar to size and shape to CT with slight reduction in length persistence of sacral lymphadenopathy enlarged 0.6cm height x 1.6cm length, round, hypoechoic with a heterogeneous echotexture and static compared to CT right and left MILN have normal ultrasound appearance improved compared to previous CT (left 4mm heigh x 23.7mm length) left and right iliopsoas musculature has normal ultrasound appearance mild asymmetry of inguinal lymph nodes with overall normal appearance RIGHT 2.7mm H x 17.7mm long, LEFT 1.4mmH x 15.1mm long splenic intraparenchymal nodule (8.9 x 11 x 14mm) which is hypoechoic and heterogenous in echotexture crystalline material within the renal diverticuli FNA of the left internal iliac node was performed and returned consistent with carcinoma. Past pertinent medical history: 16/1/26- presented to AEC for inappetence of 48h duration, pyrexia, lumbar spine palpation. Received supportive care including IVFT< pain relief, antiemetics and ampicillin. 18/1/26 – hospitalised for pyrexia, RPL lameness and lumbar pain. Treated with amoxycllin, enrofloxacin and supportive therapies. Dexamethasone IV after 72 hours amoxycillin and 24h enrofloxacin due to lack of response in pyrexia or pain due to progressive effusion and pitting oedema over the carpi and left hock.22/1/26 - The right hock returned with Serratia marcensens sensitive to marbofloxacin, TMS and gentamicin. It was suspected to represent a contaminate. Marked improvement was noted following commencement of marbofloxacin, paracetamol and fentanyl patch with resolution of hock effusion but persistent lumbar hyperpathia on caudal lumbar palpation. Clinical signs of hock effusion resolved 11/2/26Laboratory: (regular/referring veterinarian)18/2/26 SPECIMEN SITE: FNAB left medial iliac lymph node (4 slides)Cytology Reference: 206 - 01660MICROSCOPIC: Slides are highly cellular and well-prepared, primarilyconsisting of ovoid to cuboidal/columnar epithelioid cells seenindividually as well as in cohesive rafts/sheets, linear palisades andcircular acini. These cells have plump ovoid nuclei approximately1.2-1.5 RBC diameter with lightly stippled chromatin, inconspicuous orsmall singular nucleoli together with mild to moderate amounts ofblue-grey cytoplasm and indistinct cellular borders. There numerousruptured nuclei in the background and occasional mitoses are seen withinthis population.INTERPRETATION: CARCINOMA.SPECIMEN:Iliopsoas muscle (direct smears x 5)MICROSCOPIC:These preparations are of moderate cellularity and consist of mainly(more than 90%) neutrophils (many of which are degenerate) andoccasional macrophages.  The background contains streaming nucleardebris. Bacteria, fungi or other microorganisms are not seen.INTERPRETATION:Neutrophilic inflammation (abscess)COMMENTS:These findings are consistent with an inflammatory lesion. Potentialcauses include a penetrating wound (or foreign body) and localisation ofa systemic bacterial infection. Despite the failure to visualisebacteria, a bacterial component cannot be ruled out. Bacterial cultureis pending.There is no obvious evidence of malignant neoplasia in thesepreparations. An underlying neoplasm with central necrosis andinflammation cannot be entirely ruled out though seems unlikely. BACTERIAL CULTURE       No growth after 36-48 hours incubation.      No growth after extended incubation      *************** FINAL REPORT **************22/1/26 MICROBIOLOGICAL EXAMINATION    Specimen: Joint fluid aerobic bottle & swab BACTERIAL CULTURE       Org 1: Serratia marcescens   (Aerobic bottle) SUSCEPTIBILITY                                        Org 1       Amp/Amoxycillin                    R       Amoxycillin+Clavulanic acid        R       Cephalexin                         R       Enrofloxacin                       R       Gentamicin                           S      Doxycycline                        R       Trimethoprim + sulfa                 S      Marbofloxacin                        S      Cefovecin                          R       *************** FINAL REPORT **************21/1/26 IN HOUSE BLOODSCREA 81umol/L (44-159)TBIL 11umol/L (0-15) 20/1/26 VETERINARY CYTOLOGYCytology Reference:   206-628SPECIMEN SITE:1. Synovial fluid, left tarsus (3 slides)2. Synovial fluid, right tarsus (1 x EDTA, 2 slides)3. Synovial fluid, left carpus (1 x EDTA, 2 slides)4. Synovial fluid, right carpus (1 x EDTA, 2 slides)5. Caudal iliac lymph node (9 slides)MICROSCOPIC:1. The submitted smears show marked haemodilution with low numbers ofnucleated cells in a stippled mucoproteinaceous background withwindrowing of cells. Nucleated cells appear largely consistent withblood-associated leukocytes with occasional large mononuclear cells.Neutrophil number and proportion appear subjectively slightly increasedrelative to the degree of haemodilution.2. The submitted smears show moderately increased number of nucleatedcells with no appreciable haemodilution in a stippled,mucoproteinaceous background. Windrowing is not observed. A smearestimate of total nucleated cell count is 8.6 x 10^9/L (ref <3.0 x10^9/L). A differential cell count consists of 84% non-degenerateneutrophils, 11% large mononuclear cells (macrophages and/orsynoviocytes), and 5% small lymphocytes. No infectious agents areidentified.3, 4.  The submitted smears show very low numbers of nucleated cellswith no apparent haemodilution in a stippled, mucoproteinaceousbackground. Smear estimates of total nucleated cell count are well below3.0 x 10^9/L. Differential cell counts are not performed due to thescarcity of cells, but nucleated cells consist predominantly of largemononuclear cells with <3% non-degenerate neutrophils.5.  The smears are of low nucleated cellularity, showing occasionalclusters of fragile epithelial cells arranged in clusters as well assparse macrophages (including rare multinucleated giant cell),neutrophils, and small lymphocytes in a markedly haemodilute background.Epithelial cells appear as clusters of bare nuclei in a background ofblue cytoplasm and occasionally form acinar-like arrangements. Theyexhibit minimal anisokaryosis, and no mitotic figures are observed.INTERPRETATION:1. MARKED HAEMODILUTION; SUSPECTED MILD NEUTROPHILIC INFLAMMATION.2. MODERATE NEUTROPHILIC INFLAMMATION.3, 4.  NO OVERT CYTOLOGIC ABNORMALITIES.5.  SUSPICIOUS FOR CARCINOMA; SEE COMMENTCOMMENT:1-4. Definitive inflammation is identified in the right tarsal jointsmears, and suspected inflammation is present in the haemodilute lefttarsal smears. The carpal joint fluid appears unremarkable. Thesefindings are suspicious for immune-mediated polyarthritis, particularlyif infection is excluded by culture (in progress).5. The iliac lymph node smears show an epithelial population with noevidence of lymphoid tissue sampling, flagging concern for effacement ofthe lymph node by metastatic neoplasia. The appearance of the epithelialcells is highly suspicious for apocrine gland anal sac epithelium, and Iam primarily concerned for metastasis of apocrine anal sacadenocarcinoma or less likely other epithelial tumour. Carefulassessment for an anal sac mass or any other potential primary tumoursite is recommended. If no other lesion is found, sampling of thenode/mass for histopathology would likely be of value.SPECIMEN:  CSFClear colourless fluidNucleated cell count: 2 x 10^6/L (reference range <6 x 10^6/L);Red cell count: 43 x 10^6/L;Protein: 0.47 g/L (reference range cisterna magna <0.30 g/L, lumbar<0.45 g/L).MICROSCOPIC:A cytospin preparation of fluid shows low numbers of erythrocytes andnucleated cells, the latter comprising several small lymphocytes andseveral monocytes. No microorganisms or haemosiderin are seen.INTERPRETATION:Normal CSF cellularity with mildly elevated CSF proteinCOMMENTS:Aside from minor acute/iatrogenic haemorrhage, the CSF cellularity isnormal, without evidence of severe generalised inflammation orexfoliating neoplasia. The protein concentration is slightly high, ascan occur with inflammatory, degenerative, compressive and neoplasticprocesses.Dr Susan Boyd BVSc MANZCVS Diplomate ACVP (Clin Path)Veterinary Pathologist, Registered Specialist18/1/26 In House Chemistry TBIL 22umol/L (0-15)CRP > 1000mg/L (0-10)16/01/2026 AEC bloodsNEU# 13.81x10^3/uL (3.62-12.30)NEU% 82.3% (52.00-81.00)EOS#  0.01x10^3/L (0.04-1.62) EOS5 0% (0.50-10.00)LYM% 8/1% (12.00-30.00)MCHC 38.9g/DL (20.00-28.00)PLT 114x10^3/uL (117-409.00)CHOL 8.52mmol/L 92.80-8.30)ALP 464U/L (0.00-212.00)AMY > 3000U/L (400-1500)LIPA > 30UL (0-125)Today the owner reports that Groot has been EDDU and back to normal self. The owner reports there is occasional soft faeces that is yellow but reports this is not out of the ordinary, and that Groot has a sensitive stomach. He will develop diarrhoea with changes in food, or foods that are higher in fat.  Current medications: Nil Examination Findings: T: 38.6             MM: pink, moist P: 120bpm        CRT: 1-2 s R: pant Demeanour: BAR Weight: 29.7kg, BCS: 5/9 Ocular: WNL Aural: WNL Nasal: WNL Oral: WNL Cardiovascular: No evidence of murmurs or arrhythmias. Femoral pulses strong and synchronous. Respiratory: Lung sounds clear in all 4 quadrants with no evidence of any crackles or wheezes. Abdomen: Comfortable on palpation. Lymph nodes: Peripheral LN palpate normallyIntegument: WNL MSK: Mild muscle wastage hind limbs, no effusion in any joints detected Gait: WNL Urogenital: WNL Neurological: WNL Rectal: pea-sized firm mass left anal gland Assessment: AGASACA LMetastatic LMILNProblem List:- Lumbar hyperpathia - resolved- Neutrophilic arthritis right hock - palpably resolved, cultured Serratia marcescens (suspect contaminant)- Multiple small joint effusion - palpably resolved- Caudal iliac lymphadenopathy - suspect carcinoma on FNA- Right iliopsoas muscle lesion - suspect inflammatory/infectious (bacterial abscess, foreign body) vs inflamed neoplasia Groot presented today for evaluation following confirmatory cytology of the left inguinal lymph node returning as metastatic carcinoma. On rectal examination today there was a palpable firm pea-sized mass in the left anal gland, which is assumed to be the primary tumour (apocrine gland anal sac adenocarcinoma). The AGASACA is likely unrelated to the previous infection/joint effusions as we would expect a paraneoplastic process to be immune mediated and require ongoing therapy or treatment of the underlying neoplastic process for resolution. Client Communication:We advised the owner that unfortunately we have identified a mass in Groot’s left anal gland. This is suspected to be the primary tumour that has metastasised to the left inguinal lymph nodes and is most likely an apocrine gland anal sac adenocarcinoma (AGASACA). This tumour is separate to Groot’s recent infection managed successfully by our internal medicine department. AGASACA is an aggressive malignant tumour of the anal gland of the dog. The tumour tends to be locally invasive with a variable rate of metastasis, with 26-96% of affected dogs having gross evidence of metastatic disease at diagnosis. The internal iliac lymph node, which is confirmed to have metastatic disease on multiple FNAs, is a common site of metastasis. If the owner wishes to be proactive a repeat CT can be performed to further the stage, the disease and assess for infection nidus of infection. The options for treatment were briefly discussed and include:  1. Surgical excision of the primary tumour and left internal iliac lymph node extirpation. Approximately 50% of LN will reoccur without adjunctive therapy. This is a valid option when O is willing to remove LN again if recurrence noted. MST variable pending recurrence. Any further treatment following recurrence (sx/ RT/ chemo) had a MST of ~12 months2. Radiation therapy can be used to "clean up” the tumours cells remaining post operatively in the lymphatic bed to reduce recurrence The recurrence rate is still reported as 30% . We know there are tumour cells within the lymphatic bed due to confirmed metastasis to the left internal iliac lymph node. MST ~12 months3. Low dose chemotherapy was not strongly recommended due to recent infection of unknown origin. There is concern that a potential nidus of infection maybe present, even if CT is clear and immune suppression associated with chemotherapy medications may result in recurrence of infection.  4. Palladia can be used to “hold” the disease i.e. reduce the rate of growth/progression. There have been several studies investigating the use of tyrosine kinase inhibitor Palladia with AGASACA. Elliot et al found that 13/15 dogs with stage V disease had a clinical benefit  with a mPFS of 354 days. Heaton et al investigated its use in 36 dogs and  found that dogs treated in a macroscopic setting had a mPFS 255 days and MST 350 days with 69% of dogs having clinical benefit. Dogs that responded to Palladia with PR or SD had longer survival. Palladia is not a chemotherapy agent or immunosuppressive. Therefore, it does not carry a risk of infection recurrence. Palladia works by preventing angiogenesis (blood vessel growth) of the tumour, which is vital for growth. Palladia is an oral medication that is administered at home on Monday, Wednesday and Fridays.  Palladia has minimal side effects but gastrointestinal signs (i.e. vomiting, diarrhoea, inappetence), increased blood pressure and renal disease can occur in some cases. As a result regular monitoring of complete blood count, urinalysis and blood pressure is performed fortnightly for the first month and then extended to monthly provided Groot tolerates the medication well. An increased MST of up to 12 months is reported with palladia. The owner has expressed that they do not wish to put Groot through anymore extensive diagnostics, surgeries or therapies. The owner will discuss with the family in regards to palladia.We advised the owner that the progression of disease is likely to look similar regardless of whether treatment is commenced, but the time until progression with be increased with therapy. Progression at the local site presents as narrow faeces, constipation, straining and anal gland abscessed. Progression at the left internal iliac lymph node presents as pain, abscessation and the potential for the lymph node to act as a bacterial nidus. With distant metastasis signs of progression are vague but likely to be similar to how Groot presented initially i.e. lethargy, inappetence, withdrawn, loss of interest in normal activities.Plan:O to decide on ongoing therapy.If commences treatment, recommend ionised Ca    Vital Signs    Weight: 29.7;       MMColour: pink;       Temperature: 38.6;       HeartRate: panting;       RespirationRate: 120;       CRT: 1-2sec;