Difficult and Interesting Cases – Part 2

Difficult and Interesting Cases - Part 2

Jonathan M. Chapman, DVM, MPH, CPHSmall Animal Veterinarian Intern

VCA Arboretum View Animal HospitalVeterinary Medical Case Review Seminar

June 21, 2016

The case of the dog with the mysterious mass

Presentation outline

• Patient signalment• Evaluation at VCA Lake Shore Animal Hospital• Evaluation and medical care at VCA Arboretum

View Animal Hospital• Discharge instructions• Patient follow-up• Summary and recommendations

Patient signalment

• Species: Canine• Breed: Bull terrier• Age (at presentation): 11 years • Sex: Neutered male

VCA Lake Shore Animal HospitalChicago, IL.

Day 1

• The patient initially presented to VCA Lake Shore Animal Hospital on Tuesday, March 1, 2016

• The owner reported that directly prior to presentation, the patient was unable to urinate• The patient also had a history of…

– Keratoconjunctivitis sicca OU– Grade I-II/VI heart murmur

• Physical exam abnormalities– Enlarged, firm urinary bladder on abdominal palpation– Enlarged, firm prostate on rectal examination– Injected sclera OU– Grade I-II/VI heart murmur

• Diagnostics were performed and included…– In-house

• Abdominal radiographs– Antech

• Urinalysis• Urine culture


Day 1

• Diagnostic tests– Abdominal radiographs


Day 1



Day 1



Day 1

• Diagnostic tests– Urinalysis• Sent to Antech for analysis

– Urine culture• Sent to Antech for analysis


Day 1

• Treatment– A urinary catheter was placed and urine was drained from the

urinary bladder– Carprofen (50 mg/mL): 2.67 mLs SQ– Tramadol (50 mg): 2 tablets PO BID-TID– Baytril (136 mg): 1.5 tablets PO SID– Clavamox (250 mg): 2 tablets PO BID– Carprofen (75 mg): 1 tablet PO BID– Optimmune ointment: ¼ strip OU BID– Artificial tears: ¼ strip OU BID– Monitored overnight in the hospital


Day 2

• The urinary catheter was removed in the morning

• The patient was…– Pollakiuric, stranguric with a weak urine stream– BAR– Eating well


Day 2

• Diagnostic tests– Urinalysis

– Lab results still pending• Urine culture


Day 2

• Recommendations– VCA Lake Shore Animal Hospital recommended…• Patient transfer to VCA Arboretum View Animal

Hospital– Further consultation and diagnostic testing– ICU hospitalization with medical care and monitoring

– The owner agreed to all recommendations

VCA Arboretum View Animal HospitalDowners Grove, IL.

March 2, 2016: The patient was transferred from VCA Lake Shore Animal Hospital to VCA Arboretum View Animal Hospital for further diagnostic testing and treatment.

“ER doctor, please pick up line 1 for a possible patient transfer.”


Day 1

• TPR– Temperature: 100.4 F– Heart rate: 120 bpm– Respiratory rate: 24 bpm– Weight: 30.7 kg

• Physical exam abnormalities– Eyes: Injected sclera OU– Rectal exam: Palpably thickened urethra within the pelvis and only

able to feel firm brim of pelvis– Circulatory: Grade I-II/VI heart murmur– All other physical exam findings were within normal limits


Day 1

• Problems and differential diagnoses– Stanguria, pollakiuria: Neoplasia, prostatitis,

urethritis, cystitis, reflex dyssyngeria– Urethral swelling: Neoplasia, urethritis, prostatitis– History of grade I-II/VI heart murmur– History of keratoconjunctivitis sicca


Day 1

• Recommendations– Blood pressure– Bloodwork– Abdominal ultrasound– +/- thoracic radiographs– +/- urethroscopy and cystoscopy– +/- biopsy– +/- urethral stent placement


Day 1

• Diagnostic tests– Blood pressure

• 170 mmHg– Chem 8 in-house

• Na: 142 mmol/L (ref. range 138-160 mmol/L)• K: 5.0 mmol/L (ref. range 3.7-5.8 mmol/L)• Cl: 109 mmol/L (ref. range 106-127 mmol/L)• iCa: 1.4 mmol/L (ref. range 1.12-1.4 mmol/L)• TCO2: 23 mmol/L (ref. range 17-25 mmol/L)• Glu: 106 mg/dL (ref. range 60-110 mg/dL)• BUN: 19 mg/dL (ref. range 7-25 mg/dL)• Crea: 0.9 mg/dL (ref. range 0.3-1.4 mg/dL)• Hct: 42% (ref. range 35-50%)• Hb: 14.3 g/dL (ref. range 12-17 g/dL)


Day 1

• Diagnostic tests– Total body function (CBC, chemistry, T4) to Antech


Day 1

• Diagnostic tests– Total body function (CBC, chemistry, T4) to Antech


Day 1

• Diagnostic tests– Abdominal ultrasound


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• Diagnostic tests– Abdominal ultrasound• Normal prostate, hypoechoic structure just caudal to

prostate (unable to visualize well due to structure being primarily within the pelvic canal), enlarged and hypoechoic sublumbar lymph nodes, and normal liver/spleen/kidneys, but unable to assess other organs due to full GI tract


Day 1

• Diagnostic tests– Thoracic radiographs


Day 1



Day 1



Day 1

• Diagnostic tests– Thoracic radiographs• Radiologist report


Day 1

• Diagnostic tests– Lab results still pending• Urine culture


Day 1

• Assessment– The patient had stranguria and a palpable urethral mass– Further information was gained from additional diagnostic testing

• Mass present in the pelvic canal• Sublumbar lymph nodes enlarged and hypoechoic• No abnormalities present with prostate• No pulmonary metastasis

– Some diagnostic tests were still pending• Urine culture

– Overall, concerned for intraluminal urethral transitional cell carcinoma• Less likely paraprostatic cyst, prostatic neoplasia, prostatitis, urethritis, others• Prognosis approximately 6-10 months with urethral stenting and chemotherapy (ex.

Vinblastine, mitoxantrone, NSAIDS such as piroxicam)– Recommended further diagnostic testing and treatment

• Urethroscopy and cystoscopy +/- biopsy of mass• Urethral stenting would be necessary for treatment if urethral mass was present

– Chemotherapy would not be effective soon enough to prevent full urinary obstruction


Day 1

• Plan– Hospitalization– Place urinary catheter– Transfer to Internal Medicine for urethroscopy,

cystoscopy +/- biopsy and urethral stenting– Discontinue Rovera

• Due to the high probability of prescribing piroxicam or steroid therapy

– Start Plasmalyte-A at 115 mLs/hr IV for 12 hours prior to anesthesia


Day 1

• Medications– Tramadol (50 mg): 2 tablets PO BID-TID– Carprofen (50 mg/mL): 2.67 mLs SQ– Baytril (136 mg): 1.5 tablets PO SID– Clavamox (250 mg): 2 tablets PO BID– Carprofen (75 mg): 1 tablet PO BID– Optimmune ointment: ¼ strip OU BID– Artificial tears: ¼ strip OU BID– Fentanyl (50 mcg/mL): 2 mLs IV once for urinary

catheter placement


Day 1

• The patient did well throughout the remainder of the day


Day 2


• Physical exam abnormalities– Rectal exam: Mass-effect palpated on urethra– Circulatory: Grade I-II/VI heart murmur– All other physical exam findings were within normal limits


Day 2

• Diagnostic tests– Urethroscopy and cystoscopy


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• The urethra was mostly normal along the distal aspect– There was some trauma to the urethra, likely from previous

catheterization• The prostatic urethra had an abrupt narrowing that continued

until near the trigone– No growths were noted within the lumen of the urethra

• The ureteral openings into the urinary bladder were visualized and were normal

• The urinary bladder wall had some minor irregularities– Biopsies were collected and submitted for histopathology and culture


Day 2

• Diagnostic tests– Urethrogram


Day 2



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Day 2


• An 8Fr introducer sheath was placed and a urethrogram was performed with the bladder full

• The distal urethra measured approximately 10 mm in diameter

• A stent device was passed through a 0.025 guidewire• A 12x80 mm stent was deployed in the proximal urethra

against the urethral narrowing• Post-stent placement urethrogram revealed adequate

urine flow through the entire urethra


Day 2

• Diagnostic tests– Abdominal Ultrasound


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Day 2

• Diagnostic tests– Abdominal Ultrasound• There was a scant amount of abdominal effusion, mild

pyelectasis in the left kidney, and prominent medial iliac lymph nodes• No other abnormalities were noted and the urethral

stent remained in the proper position• Cytology samples of the prostate and medial iliac lymph

nodes were obtained via fine-needle aspiration


Day 2

• Diagnostic tests– Urinary bladder wall histopathology

• Sent to Colorado State University for analysis– Urinary bladder wall culture

• Sent to the Ohio State University for analysis– Prostate cytology

• Sent to Antech for analysis– Medial iliac lymph node cytology

• Sent to Antech for analysis– Lab results still pending

• Urine culture


Day 2

• Assessment– Urethroscopy and cystoscopy revealed proximal urethral compression

caused by an extraluminal mass effect• Presumptively due to prostatic carcinoma

– However, the prostate appeared normal on abdominal ultrasound

– Repeat abdominal ultrasound showed no additional changes and confirmed proper positioning of the urethral stent

– Some diagnostic tests were still pending• Urine culture• Urinary bladder wall histopathology • Urinary bladder wall culture• Prostate cytology• Medial iliac lymph node cytology

– The patient was prescribed omeprazole and piroxicam, discontinued from carprofen, and continued on all other medications


Day 2

• Plan– Start omeprazole and piroxicam– Discontinue carprofen– Continue all other prescribed medications– Discharge the patient for at-home care– Re-evaluation in 1 week with repeat abdominal

ultrasound– Any further recommendations were pending the

diagnostic tests


Day 2

• Medications– Pre-op, intra-op, and post-op medications

• Plasmalyte-A: 84 mLs/hr IV pre-op and post-op• Fentanyl (50 mcg/mL): 3.1 mLs IV bolus once• Midazolam (5 mg/mL): 1.2 mLs IV once• Propofol (10 mg/mL): 15 mLs IV to effect• Plasmalyte-A: 307 mLs/hr IV intra-op• Fentanyl (50 mcg/mL): 3.1 mLs/hr IV• Sevoflurane gas

– Prescribed for at-home use• Baytril (136 mg): 2 tablets PO SID (dose increased)• Clavamox (250 mg): 2 tablets PO BID• Tramadol (50 mg): 2 tablets PO BID-TID• Optimmune ointment: ¼ strip OU BID• Artificial tears: ¼ strip OU BID• Piroxicam (5 mg): 1 capsule PO SID• Omeprazole (20 mg): 2 capsules PO SID

Discharge instructions• Exercise

– As usual• Diet

– As usual• Medications

– Baytril (136 mg): 2 tablets PO SID x 14 days– Clavamox (250 mg): 2 tablets PO BID x 14 days– Tramadol (50 mg): 2 tablets PO BID-TID x 7 days– Omeprazole (20 mg): 2 capsules PO SID x 21 days– Piroxicam (5 mg): 1 capsule PO SID until directed otherwise– Optimmune ointment: ¼ strip OU BID– Artificial tears: ¼ strip OU BID

• Additional instructions and rechecks– Return for re-evaluation in 1 week with repeat abdominal ultrasound– Any further recommendations were pending the diagnostic tests


Day 2

• Diagnosis– History of keratoconjunctivitis sicca OU– History of grade I-II/VI heart murmur– Urethral obstruction likely secondary to proximal urethra

compression due to presumptive prostatic carcinoma– Medial iliac lymphadenopathy likely secondary to

metastatic neoplasia vs reactive process– Mild left renal pyelectasis likely secondary to urethral

obstruction– Scant amount of abdominal effusion likely secondary to

urethral obstruction

VCA Lake Shore Animal HospitalChicago, IL.Test Results

• Diagnostic tests– Urine culture


Test Results

• Diagnostic tests– Cytology of medial iliac lymph node aspirates


Test Results

• Diagnostic tests– Cytology of prostate aspirates


Test Results

• Diagnostic tests– Urinary bladder wall histopathology

– Urinary bladder wall culture


1st Follow-up

March 9, 2016• The patient had been doing well at home and had been

urinating without a problem


1st Follow-up


• Physical exam abnormalities– Rectal exam: An approximately 6 cm mass-effect palpated on urethra– Circulatory: Grade I-II/VI heart murmur– All other physical exam findings were within normal limits


1st Follow-up



1st Follow-up



1st Follow-up



1st Follow-up



1st Follow-up



1st Follow-up

• Assessment– Mass effect over urethra appeared unchanged

• Difficult to fully assess mass effect due to intra-pelvic location• Consider CT scan to further evaluate intra-pelvic mass

– If no mass was present, urethral obstruction likely functional rather than mechanical (ex. Reflex dyssynergia)

• Alternatively, consider empirical radiation therapy for probable prostatic carcinoma

– Recommended weekly rectal exams to monitor progression of mass effect over urethra

– Repeat abdominal ultrasound in 1 month for re-evaluation


1st Follow-up

• Plan– Perform weekly rectal exams to monitor

progression of the mass effect over the urethra– Repeat abdominal ultrasound in 1 month for re-

evaluation


1st Follow-up

• Medications– No changes• Baytril (136 mg): 2 tablets PO SID• Clavamox (250 mg): 2 tablets PO BID• Tramadol (50 mg): 2 tablets PO BID-TID• Optimmune ointment: ¼ strip OU BID• Artificial tears: ¼ strip OU BID• Piroxicam (5 mg): 1 capsule PO SID• Omeprazole (20 mg): 2 capsules PO SID


1st Follow-up

• Diagnosis– No changes

• History of keratoconjunctivitis sicca OU• History of grade I-II/VI heart murmur• Urethral obstruction likely secondary to proximal urethra

compression due to presumptive prostatic carcinoma• Medial iliac lymphadenopathy likely secondary to metastatic

neoplasia vs reactive process• Mild left renal pyelectasis likely secondary to urethral

obstruction• Scant amount of abdominal effusion likely secondary to urethral

obstruction

Discharge instructions

• Exercise– As usual

• Diet– As usual

• Medications– Continue all medications as previously prescribed

• Additional instructions and rechecks– Perform weekly rectal exams to monitor progression of the

mass effect over the urethra– Repeat abdominal ultrasound in 1 month for re-evaluation

Further patient follow-upMarch 16, 2016

• The patient started becoming progressively more urinary incontinent• Likely secondary to improving mass effect, however rectal palpation showed no improvement• Recommended to start Proin (50 mg) 1 tablet PO TID and continue at-home monitoring and care

March 28, 2016• The patient finished the prescribed course of antibiotics and omeprazole and then began having a

decreased appetite and intermittent anorexia– Recommended to...

• Discontinue piroxicam and if appetite improved, restart piroxicam EOD• Restart omeprazole• Submit a urine culture or restart antibiotics

• All recommendations were followed and a urine culture was submitted

VCA Lake Shore Animal HospitalChicago, IL.Test Results

• Diagnostic testing– Urine culture


April 8, 2016• The patient was euthanized– Due to continued anorexia and poor quality of life in

spite of recommendations

Summary and recommendations• Summary of the patient case

– The patient had urethral obstruction which resolved after urethral stent placement and medical treatment

– Patient improvement was noted directly post-op, but progressive decline occurred weeks following treatment

– A definitive diagnosis was never reached prior to the patient being euthanized

• Recommendations based on medical care provided at VCA Lake Shore Animal Hospital and VCA Arboretum View Animal Hospital– Consider CT pre-op or post-op urethral stent placement– Consider pursuing empirical radiation therapy for suspected prostatic

carcinoma earlier in the course of disease

Acknowledgements• Joao Felipe de Brito Galvao, MV, MS, DACVIM• Kathleen Van Lanen, DVM, DACVECC• Rachel Sternberg, DVM, DACVIM• Elizabeth Casey• Melissa Dodd, DVM• Christina Mazulis, DVM• Scott Wood, DVM• The entire staff at VCA Arboretum View Animal Hospital

Any questions?

Documents

Difficult and Interesting Cases – Part 2