It was clear that you not only felt for us-but with us.
Pamela and David
Upper Chichester, PA
Facing the holiday season for the first time following the loss of your beloved companion animal can be extremely challenging. The holidays represent a time for joy and reflection, but when you have lost your pet, you might feel unable to celebrate, because your lap or the space next to you is empty. Participating in traditional family activities is an ongoing reminder of what is missing from your life.
The following recommendations serve as a guide to help you through the holidays, while taking into consideration that grief is a unique and individual experience:
Acknowledge the Pain
Grieving the loss of a pet is agonizing at any time of the year and the holidays tend to intensify feelings of loneliness and sorrow. You may feel pressured to mask your true feelings, but pretending you are not brokenhearted will only delay you from moving in a forward direction. Ultimately, embracing the sadness can help with leading you out of the pain. Grief comes as a result of love and is a tribute to the remarkable relationship you shared with your companion animal.
Treasure the Memories
While your pet’s physical presence is gone, the love, memories, and lessons learned will always be with you. Do not be afraid to remember the favorable times with your pet, as this can be a source of comfort while experiencing extreme heartache. Reflecting upon and taking an inventory of the gifts you received from your faithful companion animal sparks the healing process. One way to honor the relationship between you and your pet is to acknowledge how your life has been changed for the better.
Revise Holiday Traditions
For many individuals, companion animals are a vital part of the holiday celebrations and it is almost impossible to comprehend the fact they will not be here this year. Recognizing the holidays will be different without your pet and planning ahead for the change may make it less overwhelming. While there is a great value in upholding holiday traditions, it might not feel right to participate in the familiar festivities after the loss of a pet. Grief provides the opportunity to pause and reexamine past traditions and create new rituals if the need arises. The goal is to make the holidays work for you in less than ideal circumstances.
Connect with Children
The holidays can definitely be hard for children, because they are experiencing sadness due to the loss, but at the same time feel the excitement of the impending celebration. Communicate with children to let them know it is okay to have fun without feeling guilty. With regard to modifying holiday traditions, keep in mind children depend on the familiarity of annual rituals, since it provides them with a sense of security. Before finalizing the holiday plans, listen to what is important to your children and try to incorporate their hopes and wishes into the celebration.
Establish a New Ritual
When a daily routine was centered on the relationship with a pet, the death can also be profoundly disruptive to one’s sense of home, safety, purpose, and identity. Find a way to include your departed pet into a new tradition by keeping his/her memory alive during the holiday season and beyond. In the matter of forming a new ritual, consider writing a gratitude list of the noteworthy experiences you enjoyed with your pet, lighting a remembrance candle at the holiday dinner, decorating a tree ornament with your pet’s picture, creating a picture book or video, and sharing wonderful stories about your companion animal with family and friends. Remember the love that you shared and make a difference in your pet’s honor by giving back, in terms of volunteering or donating at a local animal shelter.
Engage in Social Support
The need for support may be the greatest in the midst of the holiday season. Be honest with how you are truly feeling with the people you love and give them the opportunity to be there for you. After the loss of a companion animal, reaching out to family and friends can be a daunting task. If you know someone who is grieving over the loss of a pet, do not wait for an invitation for help, but show up and lend support by being present.
Practice Self Care
Navigating through the first holiday season following the loss of a pet can feel incredibly confusing and problematic. Grieving is an exhausting process and the pain invades all parts of your life, which is why it is essential for your mind and body to take a hiatus from dealing with the complicated thoughts and emotions. Plan an activity to bring a moment of comfort and joy that will allow you to take a much-needed break. Schedule the holiday around supportive family and friends, but balance it with quiet time as well. Try to streamline your life as much as possible in relation to the holiday preparations. Most importantly, be kind to yourself and realize your pain is entirely appropriate.
The first holiday season after the passing of a family pet is generally the most difficult. While there is not an easy solution to alleviate the heartache, you can manage the holidays better by taking charge of the season. Introducing new traditions to honor your pet’s memory may cause some tears along the way, but it can also provide healing as you strive to make it through the holidays.
My wish for you this holiday season is that you find peace in your heart and hope in new beginnings.
Losing a pet can impact the entire family, but it can be especially painful for children, since it is typically their first encounter with death. The relationship a child has with a companion animal determines the level of grief he or she will experience with the loss. Understanding the bond shared between children and their pets is the first major step in assisting them through the loss. Children require support and guidance to comprehend the loss and move forward in the grieving process while continuing to honor their pet’s memory.
Helping Children Cope with a Pet’s Illness
- Discussions should be tailored to the child.
- Be straightforward and honest in all instances.
- Do not hide a pet’s condition from children.
- Carefully plan to include all family members and discuss all options.
- Decisions about family pets should not be made in haste.
- Children should be allowed to ask questions.
How to Prepare Children for Euthanasia
- Create an environment where a child feels safe to ask questions.
- Define euthanasia in the simplest of terms: a good death.
- Emphasize how euthanasia is a selfless and loving act of courage.
- Help children understand the need for euthanasia.
- Educate children what will occur before, during, and afterward.
- Explain the pet will die peacefully, without feeling hurt or scared.
- Avoid the common phrase, “put to sleep.”
- Communicate about the physical changes that occur after death.
- Younger children require a clear explanation of death.
Should a Child be Present When a Pet is Euthanized?
- Children are all unique and a parent knows the child best.
- The recommended age for a child is 10 years of age or older.
- If old enough, the child should be given the choice to attend.
- Children who do not wish to witness, may want to view the body.
- Having a final goodbye can help create a sense of closure.
Speaking Truthfully about a Sudden Loss of a Pet
- Communicate with the child as soon as possible.
- Select a quiet and familiar setting to avoid distractions.
- Focus on the facts using simplistic language.
- Listen carefully and remain silent while the child processes the news.
- Openly discuss feelings, which will prompt a child to share as well.
- Allow the child to express as much grief he or she is experiencing.
- Respond to emotions with comfort and reassurance.
- Be patient and supportive throughout the entire process.
How to Explain Cremation and Burial to a Child
- Keep the discussion at a level that matches the child’s understanding.
- Follow the child’s lead as you answer questions about cremation.
- Avoid using the words fire or burned in the details.
- Make it clear that the deceased pet is not hurt in the process.
- Describe how the pet will be sealed in a box and placed in the ground.
- Be prepared to answer questions on this topic at a later time.
The Healing Power of a Ritual
- Holding a ceremony for a pet can be an important step in beginning to heal:
- Reinforces the reality of the death.
- Acknowledges the loss within the family.
- Provides support from family and friends.
- Offers the opportunity to express feelings of grief.
- Encourages the sharing of memories that celebrate the life of the companion animal.
- Serves as a means to provide closure after the loss.
Helping a Child to Honor and Preserve a Pet’s Memory
- Design a special gravestone
- Create a paw print and save a lock of hair
- Frame a portrait
- Assemble a scrapbook or collage with photographs
- Write a poem or short story about a pet.
- Plant a tree.
- Make a donation in your companion animal’s name
- Volunteer at an animal shelter.
Understanding Grief and Loss from a Child’s Perspective
- The death of a pet is often a child’s first encounter with death.
- For most children, pet loss can be a deeply painful experience.
- As children mature, their knowledge base of death expands.
- Many children develop differently and it is crucial to follow their lead.
- Adults should be nurturing and empathetic regarding loss.
Supporting a Child after the Loss of a Companion Animal
- Recognize that pet death is a significant loss for children.
- Emotional responses to a pet’s death will vary depending on the relationship.
- Be available to listen and answer questions with care.
- Assure children they are not responsible for the pet’s death.
- Encourage the child to express his or her feelings and share memories.
- Permit the child to talk about what it is like without his or her pet.
- Realize a child’s reaction may be more intense with a sudden death.
- Enlist positive reinforcements by notifying relatives, friends, and teachers.
- Provide ongoing support weeks and months following the loss of the pet.
Suggested Readings for Children and Families
- Jasper’s Day – Marjorie Blain Parker
- The Day Tiger Rose Said Goodbye – Jane Yolen
- Dog Heaven – Cynthia Rylant
- Cat Heaven – Cynthia Rylant
- The 10th Best Thing About Barney – Judith Viorst
- A Special Place for Charlee: A Child’s Companion Through Pet Loss – Debby Morehead
- The Fall of Freddie the Leaf: A Story of Life for All Ages – Leo Buscaglia
- I Will Always Love You – Hans Wilhelm
- When a Pet Dies – Fred Rogers
- Children and Pet Loss: A Guide for Helping – Marty Tousley
- When Your Pet Dies: A Guide to Mourning, Remembering, and Healing – Alan Wolfelt
When to Adopt Another Pet
- Involving the entire family in the decision to adopt a pet is vital.
- Adopting a pet too quickly might deny the child’s right to mourn.
- Children may take longer moving through the grieving process.
- The decision to adopt another pet does not represent disloyalty.
- Remember, the previous companion animal cannot be replaced.
- Let the next pet choose you.
- Do not expect the pet to become an instant member of the family.
For further guidance and information, please contact Jennifer Durn, MSW, LSW by phone (610) 296-2099 or email jdurn@HopeVS.com
Signalment: 8-year-old male castrated Terrier mix (10.3 kg)
Presenting Complaint: sneezing and gagging for 1.5 weeks prior to presentation which progressed to nasal congestion.
History: Initial clinical signs included sneezing followed by gagging. At night nasal congestion was noted by owners. Initial medical management included enrofloxacin and Neo-Poly-Dex drops administered intra-nasally. No improvement noted and a nasal flush 1 week later flushed out mucoid nasal discharge. Increased frequency of sneezing and nasal discharge was noted after the nasal flush. Eating more slowly since the nasal disease started.
Medications: enrofloxacin (68 mg once every 24 hours)
Physical Exam Findings: Completely absent airflow from the left or right nostril with open mouth breathing. Bilateral mucopurulent nasal discharge.
Complete blood count: WBC 23.88 K/ul. (54.3 % Neu, 32.6 % Lym).
Thoracic Radiographs (performed by rDVM): No significant abnormalities.
Skull Radiographs (performed by rDVM): Increased soft tissue opacity within the nasal cavities bilaterally.
Assessment: Bilaterally obstructive nasal disease. Differential diagnoses included non-specific rhinitis (eg. lymphocytic-plasmascytic, suppurative, etc), nasal neoplasia, fungal rhinitis or nasal foreign body.
Recommendations: Nasal CT to be followed by rhinoscopy
Nasal CT was performed before and after intravenous administration of contrast media (Iohexol 240 mgI/ml).
There was fluid accumulation among the left and right nasal turbinates with complete occlusion of airspaces rostrally and only minimal turbinate destruction (Figure 1). A space occupying mass lesion was present in the nasopharynx just caudal to the caudal margin of the hard palate. This lesion had a hyperattenuating (bright) rim in both pre- and post-contrast images and did not demonstrate any significant contrast enhancement. Some contrast of the nasopharyngeal mucosa surrounding this structure was seen. CT findings in the rostral nasal passage were consistent with a non-specific bilateral rhinitis. Differentials for the mass lesion in the nasopharynx included a nasal foreign body, inflammatory polyp or neoplastic mass.
Figure 1. Transverse CT images viewed in bone window from rostral to caudal (A through D). Fluid is present among the nasal turbinates causing nearly complete occlusion of the airspaces within both the left and right nasal passages.
Figure 2. Transverse (A) and sagittal (B) CT images of the head viewed in a soft tissue window. A space occupying mass lesion within the nasopharynx just caudal to the caudal margin of the hard palate. The lesion is shaped like an upside down “witch’s hat” in the transverse image (A) with a hyperattenuating (bright) rim and completely occludes the lumen of the nasopharynx.
Flexible retrograde rhinoscopy was performed and with the endoscope retroflexed dorsally over the soft palate a foreign body was visible within the nasopharynx (Figure 3). A rat tooth grasper instrument was used to grasp the foreign body and retrieve it via the oral cavity. Marked circumferential swelling and bruising of the nasopharyngeal mucosa was noted in the location where the nasal foreign body had been lodged. The lumen of the nasopharynx also appeared significantly narrowed.
The patient was monitored in the hospital overnight and discharged the next day. A tapering dose of prednisone and several days of tramadol for pain were prescribed. Due to the severe nasopharyngeal inflammation and apparently narrowed lumen of the nasopharynx the owners were warned about the possibility of the patient developing a secondary nasopharyngeal stenosis. One week following retrieval of the foreign body the patient was reportedly doing well at home with minimal upper respiratory noise noted.
Figure 3. Retroflexed endoscopic view of the nasopharynx with a nasal foreign body completely occluding the lumen.
Figure 4. The retrieved nasal foreign body was determined to be the cap to an acorn.
A range of diseases can affect the nasopharynx of cats and dogs with neoplasia and inflammatory disease being most common. A variety of neoplasias recognized in the nasal cavity and nasopharynx include lymphosarcoma, carcinomas, mast cell tumor, fibrosarcoma and osteosarcoma. Multiple inflammatory diseases can also be seen including suppurative rhinitis, lymphocytic-plasmacytic rhinitis, inflammatory polyps and fungal rhinitis. While neoplastic masses and inflammatory polyps are the most common cause of nasopharyngeal obstruction, nasal or nasopharyngeal foreign bodies and nasopharyngeal stenosis must also be included on that list.
The most common presenting clinical sign in animals with nasopharyngeal disease is stertor. Repeated attempts at swallowing or “hard-swallowing” may also be noted. Nasal discharge may or may not be present. Sneezing is not typical but may be present with concurrent disease of the nasal turbinates or if the more rostral nasal passages are also involved.
A thorough visual oral and pharyngeal exam under sedation or general anesthesia is warranted in patients tentatively diagnosed with nasopharyngeal disease. The nasopharynx can also be palpated for masses through the soft palate. The use of advanced imaging such as computed tomography (CT) in combination with flexible retrograde rhinoscopy has greatly facilitated the diagnosis of nasopharyngeal disease and therefore the recognition of potentially treatable diseases. CT findings typical of foreign body rhinitis include focal nasal turbinate destruction, hyperplasia of remaining nasal mucosa, and regional accumulation of fluid or mucoid exudates. Changes are typically unilateral unless the nasopharynx is involved rather than the left or right nasal passage. The nasal foreign body itself may or may not be seen depending on both size and composition. Endoscopy additionally allows for treatment of several of these diseases as demonstrated in the above case with endoscopic retrieval of the nasopharyngeal foreign body.
Submitted by: Chris Ryan, VMD, DABVP, DACVR
In 2016, an estimated over 1.5 million new cases of cancer will be diagnosed in the United States and almost 600,000 people will die from the disease.1 On the veterinary side, there are approximately 65 million dogs and 32 million cats in the United States, with roughly 6 million new cancer diagnoses made in each dogs and cats annually.2 Although we often see ourselves in the veterinary world as “catching up” to the human side, veterinary cancer medicine has actually co-evolved with human cancer medicine. November is Pet Cancer Awareness month, which is always a good time to reflect upon our progress and standing as a profession. The following provides a (rather) abbreviated overview of where we started, where we are, and where we’ve still yet to go.
Historical accounts of human cancer date back some 5000 years ago to the scribes of Egyptian physicians.3 These records included descriptions and illustrations of uterine and breast cancers and the physical suffering they caused. Ancient physicians used a variety of terms to describe tumors, including ‘‘carcinos’’, the Greek word for crab, which alluded to the crab leg-like extensions emanating from breast tumors, and “onkos”, the Greek word for swelling.3 Obviously these terms and derivations of them are still with us today. Although their observations were astute, the early Greeks’ initial approach to cancer treatment was rudimentary. Surprisingly, this undeveloped methodology remained static over the following centuries and cancer treatment consisted of surgery, cautery, blood-letting, and herbal medicines only.3 Fortunately, science and technology advanced enormously once the 1700s came around, however, it was still not for over 200 years that chemotherapy became established as a legitimate tool of modern cancer medicine.
Paul Ehrlich, a German physician known as the “Father of Chemotherapy”, coined the term chemotherapy and was one of the earliest pioneers to screen medicinal chemicals in animals.3 In 1915, Germany – the home nation of Ehrlich – became the first country to use mustard gas on the battlefield during World War I. It is actually upon this act of war that the era of modern chemotherapy is founded. Almost 100,000 people lost their lives to this poison gas during the war. Fortunately, several autopsies were performed and found that mustard gas exposure caused severe lymphoid depletion, neutropenia, and bone marrow aplasia. Unfortunately, it took 20 more years before the idea of therapeutically using mustard compounds was realized. The chemical research that went on following the war found that nitrogen mustard, a close but less toxic derivative of mustard gas, had antitumor activity against lymphoma in mice. Then in 1943, a mustard compound was used for the first time in a patient with non-Hodgkin’s lymphoma at Yale University Medical Center. Impressive, but only temporary, regression was observed in this and subsequent lymphoma patients. Then in 1947, aminopterin, a folate analog initially used for pernicious anemia, was first used by Dr. Sidney Farber to treat pediatric patients with leukemia. His successes were met with a lot of resistance, but eventually led to expansion of cancer medicine and the discovery of several other chemotherapy agents, including methotrexate, vinca alkaloids, and procarbazine, in the 1950s-60s. 3
In many ways, veterinary medical oncology has closely followed the advances in human medical oncology. For example, the first reported use of chemotherapy in a veterinary cancer patient (a dog with lymphoma treated with urethane) was in 1947, the same year Sidney Farber treated his first pediatric patient with aminopterin. The first use of asparaginase for treatment of canine lymphoma was reported in 1967. During these early years of development of veterinary chemotherapy, single agent chemotherapy was still the standard of care in human oncology until the MOPP (Mustargen, Vincristine, Procarbazine, Prednisone) combination protocol was developed in the mid to late 60s. The first reported use of combination chemotherapy for canine lymphoma involved chlorambucil plus prednisone and was published in JAVMA in 1968. A far more sophisticated combination chemotherapy protocol for canine lymphoma using 5 different drugs was reported in 1975. The first report of doxorubicin use in dogs was published in the veterinary literature in 1976. In time, this drug became the backbone of multidrug protocols for a wide variety of canine and feline tumors. The evolution in sophistication of the drug protocols used in dogs mirrored what was transpiring in human medical oncology at about the same time. However, as in human cancer medicine, the problem of drug resistance in veterinary oncology is very real and typically the limiting factor in being able to successfully eradicate individual cancers with conventional chemotherapy alone. This problem may be even more magnified in veterinary oncology given the limits (natural and applied) on chemotherapy dose intensity.
Over time, researchers have uncovered the fact that cancer can arise from any number of genetic aberations, and often is due to a combination of errors that ultimately lead to unregulated cell growth. Now, with dramatic improvements in DNA technology, researchers and physicians can analyze an individual patient’s tumor to determine what genetic abnormalities are present. Using genomic profiling, instead of simply applying the broad-brush approach of surgery, radiation, and one-size-fits-all chemotherapy protocols for specific cancers, physicians can now more accurately match targeted treatments to individual patients. For some cancers, the protein products of genetic mutations are identifiable targets in cancer cells that can be “blocked” with specific drugs. Such molecularly targeted drugs have provided patients, in particular those with advanced disease, an option to help control cancers that have failed traditional chemotherapies and radiation. This is what personalized medicine is all about, and this is also becoming more readily applicable in veterinary medicine. A still fairly recent and no doubt exciting development in veterinary chemotherapy was the introduction of toceranib phosphate, also known as Palladia, by Pfizer (now Zoetis) in 2009. This drug was the first targeted chemotherapy agent developed specifically for dogs and is FDA-labeled for the treatment of advanced canine mast cell tumors, although its current application in veterinary oncology spans several tumors types in both dogs and cats.4 Although molecularly targeted drugs are certainly a step forward, they too are not a cure-all, as there are mechanisms of resistance and evasion by cancer cells to these drugs as well.
Potentially the most promising approach in clinical cancer medicine is immunotherapy. This modality incorporates a patient’s own immune system into the fight against the tumor, oftentimes along with radiation, chemo, and targeted molecular therapies. Immune-based therapies involving monoclonal antibodies, checkpoint inhibitors, cytokines, and many others, have already transformed the treatment for several human cancers. These are therapies that we are now evaluating in companion animals and gradually adding to our arsenal for veterinary cancers. In veterinary medicine, we have Merial’s Oncept®, a USDA-approved vaccine against malignant melanoma that has significantly improved outcomes for dogs with this highly aggressive cancer.5 While initial attempts at developing monoclonal antibodies against canine B-cell and T-cell lymphoma have thus far fallen short, several companies have gone back to the drawing board and are working on second-generation monoclonals with the intent of developing the veterinary version of rituximab (Rituxan®), the monoclonal antibody that has revolutionized the treatment of B-cell lymphoma in people.
Other areas of interest in veterinary cancer research include bone marrow transplantation, complementary and alternative therapies such as herbals like Yunnan Baiyou and polysaccharopeptide (PSP), an extract from the mushroom coriolus versicolor and the key ingredient in I’m Yunity®,7 acupuncture, and diet therapy.
Undoubtedly, light years of progress has been made since mustard gas was first used in World War I, yet as we all know, we still have so much further to go in the war against cancer.
Submitted by Christine Mullin, VMD, Diplomate ACVIM (Oncology)
- National Cancer Institute. Cancer Statistics. https://www.cancer.gov/about-cancer/understanding/statistics
- National Cancer Institute Center for Cancer Research. Comparative Oncology Program, For Pet Owners. https://ccr.cancer.gov/comparative-oncology-program/pet-owners/what-is-comp-onc
- Morrison WB. Cancer Chemotherapy: An Annotated History. J Vet Intern Med 2010;24:1249–1262. http://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.2010.0590.x/full
- London CA, Malpas PB, Wood-Follis SL, et al. Multicenter, Placebo-controlled, Double-blind, Randomized Study of Oral Toceranib Phosphate (SU11654), a Receptor Tyrosine Kinase Inhibitor, for the Treatment of Dogs with Recurrent (Either Local or Distant) Mast Cell Tumor Following Surgical Excision. Clin Cancer Res 2009;15(11):3856-3865. http://clincancerres.aacrjournals.org/content/15/11/3856.long
- Bergman PJ and Wolchok JD. Of Mice and Men (and Dogs): development of a xenogeneic DNA vaccine for canine oral malignant melanoma. Cancer Ther 2008; 6:817-26.
- Griffin MM and Morley N. Rituximab in the treatment of non-Hodgkin’s lymphoma – a critical evaluation of randomized controlled trials. Expert Opin Biol Ther 2013;13(5):803-11. https://www.ncbi.nlm.nih.gov/pubmed/23560506
Brown DC and Reetz J. Single agent polysaccharopeptide delays metastases and improves survival in naturally occurring hemangiosarcoma. Evidence-based complementary and alternative medicine 2012; Article ID 384301:1-8. https://www.hindawi.com/journals/ecam/2012/384301/
A 7-year-old female spayed 14-kilogram mixed breed dog was presented to HOPE Veterinary Specialists for a surgical consult after a recent diagnosis of a right auricular mass. She initially presented to her local emergency clinic for an acute episode of lethargy, pale mucous membranes and increased respiratory effort. Radiographs at that time showed a characteristic “globoid” heart shape and a focal thoracic ultrasound revealed pericardial effusion causing cardiac tamponade. Pericardiocentesis was performed, she was evaluated the following morning by a cardiologist and an echocardiogram revealed a 3 x 4 cm right auricular mass. Bloodwork showed mild hypoalbuminemia but no evidence of anemia. Cytology of the pericardial fluid was consistent with hemorrhage and no neoplastic cells were noted. Pericardiocentesis was required three additional times over the next few days.
Based on the presentation, echocardiogram findings, and repeated hemorrhagic pericardial effusion, cardiac hemangiosarcoma was suspected. She was transferred to a referral center at which time she was hospitalized and received a dose of Doxorubicin. After discharge from the referral center, the owners presented to HOPE for discussion of surgical options. The treatment for the tamponade component of this disease has historically been repeated pericardiocentesis or a pericardial window/subtotal pericardiectomy via thoracotomy in combination with adjuvant chemotherapy. However, due to the poor prognosis with cardiac hemangiosarcoma, many owners are reluctant to pursue surgical intervention because of the invasiveness and postoperative morbidity of a thoracotomy.
Instead of an open thoracotomy, the owners were offered minimally invasive thoracoscopy and after a discussion about the prognosis and the options for treatment, they elected to proceed with the procedure. In this procedure, three small incisions are made in the thorax to allow placement of ports for passage of a rigid endoscope and thoracoscopic instruments. Through this approach, the pericardium is able to be grasped, elevated and resected to create a pericardial window. The goal is to allow the pericardial effusion to drain into the pleural cavity thereby avoiding cardiac tamponade in the future. A sample of pericardium can also be obtained for biopsy.
A: Pericardium grasped and elevated.
B: Mild amount of pericardial effusion visible.
Figure 2: Portion of pericardial window completed.
D: Thoracostomy tube.
Video 1: Pericardial window
Because of the small size of the incisions, local blocks with bupivacaine were used at each of the sites to provide multimodal analgesia. The patient recovered well from anesthesia and within two hours of surgery was able to stand and go for a walk outside. She was maintained on intravenous doses of methadone overnight, her chest tube was removed the following day, and she was transitioned off intravenous narcotics at that time.
Although it is relatively new in veterinary medicine, thoracoscopy has been used in humans for over 100 years. It was initially used for lysis of pleural adhesions due to tuberculosis and in the 1990’s, started to be used to perform video-assisted procedures1. In veterinary medicine, this approach is currently used for a variety of thoracic procedures including pericardial window, subtotal pericardiectomy, lung lobectomy, and to obtain pleural, mediastinal or lung biopsies2,3,4. There are several disadvantages to thoracoscopy including the initial cost of the equipment and steep learning curve. However, there are numerous advantages including decreased postoperative pain, a faster return to activity and a decreased hospital stay which results in a lower cost for the client. Additionally, the small incision size allows us to provide local anesthetic blocks at the incision sites which results in a decreased need for intravenous opioids. Especially in cases where the surgical treatment is palliative, the advantages of thoracoscopy make it a good choice for our patients.
While cardiac tumors in dogs are uncommon in comparison to other tumors, hemangiosarcoma is the most common type of cardiac neoplasia in dogs. The initial presentation is often for signs related to acute cardiac tamponade including lethargy, pale mucous membranes, and collapse. These patients may be anemic however the anemia may not be as profound as it is in cases of splenic hemangiosarcoma because the amount of hemorrhage needed to cause cardiac tamponade is relatively small. Thoracic radiographs show a globoid cardiac silhouette and identification of the mass is achieved via echocardiography. Although it can occur in any region of the heart, the right auricle is the most common location.
Treatment options for this disease are limited. Mass excision, pericardial window, subtotal pericardiectomy and chemotherapy have all been reported and all of these are intended to be palliative as there is no effective long-term treatment for hemangiosarcoma.
Due to the aggressive nature of the disease (the median survival time is often reported as 3-4 months) and reported presence of distant metastasis in up to 75% of cases of cardiac HSA5, owners are often reluctant to pursue open thoracotomy for mass excision, subtotal pericardiectomy or pericardial window. These owners often decline surgery because of the concern of prolonged postoperative morbidity during the relatively short expected survival time. A recent retrospective study6 evaluated the effectiveness of Doxorubicin alone in the treatment of cardiac hemangiosarcoma and found a median survival time of 116 days compared to 42 days for dogs that were not treated with chemotherapy. Based on these results, this appears to be an appropriate option for patients who do not have recurrent episodes of cardiac tamponade. However, for patients with recurrent tamponade, short term treatment of the pericardial effusion is necessary through repeated pericardiocentesis or a pericardial window. With the introduction of thoracoscopy, we are now able to provide a long-term solution to eliminate recurrent tamponade with minimal postoperative morbidity. In the future, the combination of minimally invasive thoracoscopy and adjuvant chemotherapy may provide a more effective approach for the palliative treatment of this disease than previously available.
Submitted by: Brian Bretz, DVM, DACVS
2.Skinner OT, et al. Pericardioscopic Imaging Findings in Cadaveric Dogs: Comparison of an Apical Pericardial Window and Sub-phrenic Pericardectomy. Vet Surg 2014; 43(1):45-51. https://www.ncbi.nlm.nih.gov/pubmed/?term=Pericardioscopic+Imaging+Findings+in+Cadaveric+Dogs%3A+Comparison+of+an+Apical+Pericardial
3.García F, et al. Examination of the Thoracic Cavity and Lung Lobectomy by Means of Thoracoscopy in Dogs. Can Vet J. 1998; 39(5):285-91. https://www.ncbi.nlm.nih.gov/pubmed/?term=Examination+of+the+Thoracic+Cavity+and+Lung+Lobectomy+by+Means+of+Thoracoscopy+in+Dogs
4.Atencia S, et al. Thoracoscopic Pericardial Window for Management of Pericardial Effusion in 15 dogs. J Small Animal Prac. 2013; 54(11):564-9. https://www.ncbi.nlm.nih.gov/pubmed/?term=Thoracoscopic+Pericardial+Window+for%E2%80%89Management+of+Pericardial+Effusion+in+15+dogs
5.Yamamoto S, et al. Epidemiological, Clinical and Pathological Features of Primary Cardiac Hemangiosarcoma in Dogs: A Review of 51 Cases. Journal of Veterinary Medical Science 2013; 75(11):1433–1441. https://www.ncbi.nlm.nih.gov/pubmed/?term=Epidemiological%2C+Clinical+and+Pathological+Features+of+Primary+Cardiac+Hemangiosarcoma+in+Dogs
6.Mullin CM, et al. Doxorubicin Chemotherapy for Presumptive Cardiac Hemangiosarcoma in Dogs. Veterinary and Comparative Oncology 2014; Dec 18. https://www.ncbi.nlm.nih.gov/pubmed/?term=Doxorubicin+Chemotherapy+for+Presumptive+Cardiac+Hemangiosarcoma+in+Dogs