Well, everyone, thank you so much for joining us for this webinar, Cancer in the ER. You've Got this. I'm Bill Saxon, and home analysis in the house, and we are very, very glad that she is, as you'll see.
And the genesis of this talk basically was, we were thinking one day about what would it take to make ER doctors more comfortable dealing with emergencies. And then we went back and forth in the email which we'll share and then Anne. Who is still at the Animal Medical centre in New York, where we, where we both met and did our training, came up with this crazy shot from back in the days.
And you wanna go ahead and like leave this off here. This is our intern graduation. I think Bill, if you hit, next slide, will show people where we are in this order.
That's me. That's Bill in the corner, and so we finished our internships in 1980. 7 and then both stayed on to do a residency and Bill went other places for even more training.
I've been stuck, at the Animal medical centre for about 40 years now and what this means so we're going to talk about what we do. Yeah, and what, what Anne being at the AMC for all these years means for us today is one, she's seen everything, she's handled everything, and so she will really be able to coach us through these kind of challenging cases. So we're basically gonna walk you through what to do when you're in the emergency room or seeing emergencies, and you have to deal with a patient that may or may not have cancer from sort of initial assessment to getting them to Anne, for example.
Yeah. So this is what happens. So, we started an email thread and my first four-way, foray to Ann was, what do you, how about we do a talk where, what do you do when a cancer patient shows up in the ER and Ann.
And, and this is true. ER does not like to see pets with cancer, but I'm gonna tell you that use your good ER judgement and you're gonna fix these patients. The potassium is too high, fix the potassium.
You know, they can't pee, pass a catheter. Just do what you would normally do, and it, it is really hard to screw up a cancer patient. See what I mean, you guys?
Already we feel better, right? So of course, Anne nailed it, and then, let's get him unstuck, yeah. So then, when she agrees to do this talk, I launch into my hysterical criticalist mode where everything I think is gonna come in, an utter disaster, and these are the ones that kind of were a fun challenge for me, but also a little nerve-wracking because I am not an oncologist.
And then Ann. I said, well, we could do all those things, but maybe how about just get a CBC. Yeah, so, oh, OK, right?
That was all her response to my crazy email was, how about just attempting a CBC? I'm like, good idea, right? So.
And it, it's also good to weigh the pet because lots of things we do depend on how the pet weighs, and if the pet has lost weight, well, that maybe the cancer is causing a problem, but the pet's gaining weight. Maybe it's got fluid or something else that's up to the weight. And then the other thing to remember is it is not always the cancer or the chemo that lands that pet in your ER.
And while Bill and I were having this exchange of emails, this came into the ER and this is a dog that has lymphoma getting chemo, and he went to the beach for the weekend. And probably most of you who are emergency people are going to recognise that this dog's GI tract is full of something which happens to be sand. And this dog had a sand impaction because it was at the beach and digging and eating sand.
So just keep in mind that cancer patients will get something else. The physical exam was the key because when they rectal this dog, do not forget the rectal, and we're gonna come back to that. There was sand on the rectal and they were like, whoa, let's get an X-ray.
Was your dog at the beach for the weekend? So this pet recovered because it had a non-cancer emergency, but it was an emergency. Right?
And I think, you know, and also putting the line in there about chemo is not as bad as clients think. I mean, if you're a client, you have a dog on chemo for lymphoma and anything goes wrong, you're gonna think in your human brain, OK, this must be related to the treatment because it's, you know, a different animal than people. So, and you wanna just kind of briefly.
Kind of emphasise that point to us, like, what do your clients worry about, you know. There are client surveys where they say to the client before chemo, what are you worried about? I'm worried my pet's gonna be sick and the, the, the bar is way up here.
And then they ask the same clients, how was chemo? And then the bar is way down here because they are, it, they're very worried, but it's really not as bad as the client thinks, and that's then they put that anxiety on you in the ER that it must be the chemo. And once again, don't forget your good ER training because you work through the case like a normal case.
Exactly. And that too, by the way, in there, you guys, is, for just administering go lightly to help get that sand out. Yeah, exactly.
Yeah, we got to unclog the door. OK, so as we mentioned, we're going to go through the patient that comes in that you don't know has cancer, and it's your job to sort of figure out among the myriad things an emergency patient can present with, if it's likely to be cancer, and then we're gonna Walk through, well, you know, it's a patient with cancer on chemo, and then you have to decide when they come in sick, what is it due to the cancer, the treatment, or unrelated. So, let's get rolling.
This would be a typical thing that in my experience was, it always happened on the busiest day. We're down at tech. Everything's going through, you know, crazy, and we've got this dog or a cat that comes in, sick, no history of cancer.
What do we do? Well, I think it's helpful to know, like, well, if it were a healthy animals, how likely is cancer? Not all that likely.
It's one of those diseases where I say it's like endocrine disease. They're not that common, but if your patient has an endocrine disease, you better figure it out, and that's the same with neoplasia. Maybe not the most common presentation in healthy animals, but.
It's there and if you don't find it, it's not great. And so, and you want to talk a little bit about what you want to pull out of this study. This is data from a study where Colorado State was screening a lot of dogs.
Notice there are 902 healthy dogs being screened. Screening a lot of dogs for entry into a cancer study that they wanted to see how many pets developed cancer. So they all got a big screening process to make sure they didn't have cancer when the study started.
And notice that they only found or suspected cancer in 2.7 to 6%, very low, and notice how high the number is where these cancers were diagnosed on physical exam and then confirmed, 83%. So this goes back to the dog.
Showed you with the sand impaction that if you do a good physical exam, a lot of the times it's going to tell you what, where the cancer is in the patient or give you a high likelihood that the pet doesn't actually really have cancer. So, I, I can't stress the importance of physical exam in. Cancer patients, but in any patient.
And, and what Ann doesn't realise, or maybe she does because she's bright, at the Animal Medical centre, at least back when we were there, you tell me if it's the same man, every animal admitted got a physical exam twice a day by somebody else, a different person twice a day, and we didn't miss anything because they got really good exams. And so just something as simple as a physical exam, methodical, and then repeat that serially if your patient's not stable to see if You can find a disease. Does that still happen, by the way, Anne, 2 physicals at least per day in hospitalised patients?
You know, oncology doesn't have very many inpatients, but yes, we still look at patients, multiple times a day. And speaking of the rectal, how the importance of that with sand impaction, this is another important study that I think Ann will want to go over with us. Well, this is, this is a study out of Penn.
And I think this is actually an ER study, and they looked at how often rectal exam was found to be abnormal and you can see that it was quite a high number and it very frequently, the last column here shows how it changed the treatment plan, how often it changed the treatment plan. 12%, in, in all the dogs in this study. So it's just reinforcing the fact that good physical exam, including a rectal, is critical in your ER patients because you're gonna find masses, you're gonna find sand, you're gonna find all kinds of other stuff that are gonna be helpful for you.
When I'm, when I'm giving lectures on cancer and there happens to be an oncologist in the room and when I show this slide, I always say, hey, oncologist, on this slide, what would you think is the most important thing to emphasise that is not to be missed, and uniformly, and the answer is. Rectal. Everybody just shout out rectal.
OK, so again, just to underscore that, but then I'm gonna pick one that I think is important and sometimes overlooked, and then maybe you can pick one. I'm gonna pick. Mammary tumours in cats, OK?
Make sure when we're palpating the mammary glands of cats, we're, we're doing a really good job because these cancers can be bad versus the mammary gland tumours that dogs can get. We want to find them when they're tiny, and they may be millimetres, and it may feel like no bigger than a nipple. So just do not race through palpating both mammary chains in cats.
If you're going to have a good outcome, find them when they're BB size, OK? And you pick one. so I think that, feet and toes are important, because like I've had cats come in and the people are like, oh, doc, it's got, you know, it's got a bad toe, and I'm like, let's get a chest x-ray, and they're like, no, no, no, no, no.
The toe, not the chest, that's a problem. And of course, this cat has the long digit syndrome and has a toe mat that then I find the chest X-ray. And then they don't think I'm so crazy anymore.
So, I, I think feet are a really important thing to look at as well. But, but I think Bill is really. Onto something on cat mammary glands.
If you find them small and you, the cat has a good surgery, we might not need any follow up care in the cat. They have a decent. I don't think we cure these cats, but I think they have a decent prognosis as opposed to waiting until the tumour is 2.
Centimetres and then the cat has a terrible prognosis. So, smaller is better and people always say, well, can't we just watch it and see what happens? Well, I can guarantee you it's going to get bigger.
It, it just, and I don't know how to convince people that, that acting is important. Yeah, and then I will say too, I got in the habit early on of just when I'm. Examining cats, just palpating the cranial thorax and giving a little squeeze, and it should be compressible, and therefore, when it isn't compressible, that's a clue that there might be a mediastinal mass, just little tiny things like that.
And then we, we had a hospital full of patients, we had lists a mile long of physicals to get through. This can be done really thoroughly and including Funding exam in a couple of minutes, OK? So we're gonna, now we've, we've got a physical exam on this patient that we're seeing as an emergency.
We're trying to assess it to see what it might have. And then, I'm a big fan of getting these, what we call the big 4 quick assessment tests or stat lab tests in all emergencies. And this is, all of these tests can be done on a couple of microhematocrit tubes that you fill in the flashback you get when you place a I'm, I'm, I'm with this, and I think it's important.
I don't, I haven't impacted on my residents yet for, for point number 2, which is to check the hematocrit tube after you spun it for hemolysis and icaris because every now and then your in-house chemistry machine has a brain seizure and says the patient has a, a, a bilirubin of 4, and I'm like, well, that's, I didn't see a 4 in that pad. And then I say, get the PCV. Tube out and look, because that is your quick check, because you should easily be able to see a 4 bilirubin on a tube, and then if you don't see a 4 bilirubin, then you know that your patient has had a brain seizure, or your machine has had a brain seizure and you, you've got to think of something else to do to get a, a better answer.
And the reason we do these tests is because if we don't fix these, these are the critical ones that determine things like oxygen delivery. And give you an indication of perfusion. So get these, and then we're looking for things that, you know, perineous plastic kind of things that could affect these would be, well, if you have an insulinnoma, your glucose could be low.
If you have a hepatoma, your glucose could be low. If you have a ruptured splenic hemang, your hematocrit could be low. And so these are things that are not specific for cancer, but could be cancer related.
And then as soon as it's safe and feasible to get the rest of your lab work rounded out, do that. One thing about the PCV is that the typical cat getting chemotherapy probably runs a PCV around 23 to 25, maybe 21. And so that's an important thing to keep in mind is cats on chemo will not have a normal hematocrit.
They won't be 1010 is a problem, but 21 to 25 is probably OK. Dogs probably have a little bit higher hematocrit on chemotherapy, you know, so maybe 26 to 30, but again, remember, if the pet's on week. 20 of 25 of CHOP, it's probably not going to have a normal hematocrit.
It's not going to be 10, but if it's in the 20s, it's probably OK. Now, I know that in some places in the world, it's not common to have these microhematocrit tubes and this special centrifuge, and so I just wanted to show for those of you that aren't familiar, it's so helpful to have this because again, The only blood you may get from a patient for a while, especially when it's unstable with hypotension, is the blood you get back when you place the catheter, and you can get all those tests run on those samples. And then subsequently, you might want to do these tests every 30 minutes, every 60 minutes until the PET's stable, and that means getting just a very small amount of blood versus a blood draw big enough to put the sample in your in-house analyse or analyzers.
Also, one quick thing, the If you can't get urine on it, let's say sick animal can't get urine, but you want to know, could there be ketones or ketones in this patient if it happens to be a diabetic? OK, going off the cancer thing for a minute. You can, without urine, you can measure glu ketones in the serum if you break off the tube above the hematocrit line and spit the serum in that tube onto the ketone pad on the urine dipstick, just a little hack there if you're not unable to get urine and you want to assess an animal for ketosis.
OK, so I want to go back to the diabetes thing, and that is. That cats on steroids, which many cancer cats are on steroids, you know, are frequently hyperglycemic. And usually they don't get ketotic, but if you have a very hyperglycemic cat, keep in mind it might be the steroids that the oncologist is using to treat the cancer.
Really good point. And then when you get the rest of your lab, back. Again, nothing super specific for neoplasia on your CBC chem panel and UA, but definite clues.
And Anne, I'm going to let you go through your CBC, like check this and see, and then what their indications that there might be neoplasia. What do you specifically look for in your CBCs? So we've already talked a little bit about anaemia that's common in cancer patients.
The other thing that I had not too long ago was a dog who had a raging lymphoma, and yet the dog's hematocrit was normal, and the, it had a big reticulocytosis, and I was like, well, this is really weird. Well, what it ended up having was renal lymphoma and a secondary increase in erythropoietin production from the renal lymphoma. And so, on, on one side.
I have a fairly high tolerance for anaemia in my cancer patients, but a cancer patient with a normal hematocrit makes me say, oh, could this have a perineoplastic erythrocytosis? Because they don't usually have a normal hematocrit, and that was what clued me into that thought process. Thrombocytopenia can be the cancer or the treatment, and so, and it also could be perineoplastic if you've got DIC or if you've got a hemangiosarcoma that is bleeding and thrombocytopenia.
Pancytopenia is a, a big clue to you that maybe the bone marrow has a problem. Lymphocytosis, you know, since the advent of flow cytometry, we have, such a much better tool at looking at lymphocytosis. Really great tool in dogs, and it's OK in cats because as usual, cats are medically underserved and we don't have as many markers in cats.
But, what I'm gonna tell the ER team is you probably don't need to make the decision to send out flow cytometry, however. When you have a lot of lymphocytes in blood, those lymphocytes will live in the blood very happily, like kind of over the weekend, and so you might wanna save that purple top and send it back to the referring vet with the blood or send it with the dog or send it with you to the oncologist because. Lymph node aspirates that you put in the flow juice, those cells are not that sturdy, but the lymphocytes in the blood are probably gonna make it to the lab for flow cytometry for a couple more days than a lymph node aspirate.
So save that purple top. Monocytosis, so I think that the in-house machines, which I think most ER people are going to use in-house CBC machines. Monocytosis may be a clue to the next line here, which is unclassified cells, because if those in-house CBC machines are making a mistake, they're going to read cancer cells potentially as monocytes.
So too many monocytes should prick your ears about the presence of some cancer cells in circulation. And then schistocytes and acanthocytes are common in DIC, although the, the machines are not going to give you schistocytes and acanthocytes. So unless you've got a crack tech who's looking at your CBCs or it goes out to the reference lab, I'm not sure how many of these that you guys are going to see.
Yeah, there's, there is a, a new analyzer that IDex has that's called the IV. Blood morphology does blood morphology and some other stuff and they just released the schistocyte and the camphocyte, so that 1 may help you with that, but yes, in general, you got some cells, red cells going through damaged circulation, either a funky mass or DIC causing some You know, membrane changes. Chemistry panel wise, I think we kind of all get the gist here.
Hypercalcemia would be a big flag potentially for neoplasia, and then you see how I bolded increased Idex SGMA as a clue for cancer, we'll cover that on the next slide. Because there's some new information that's kind of interesting, and then the urinalysis, try to get one, of course, and mainly it's just to round out to help you interpret the rest of your findings. Like you cannot interpret azotemia without specific gravity.
You want to identify proteinuria and then quantify it with the urine protein creatinine ratio, and then morphologically, doing a fresh urine sediment exam either with your microscope or with the digital analyzer, getting some information. About potential, your epithelial carcinoma. So what's the story with this?
Go back a second before you go on to SDMA. I, I think two things that we maybe forgot under the UA would be, I'm interested in, does my cancer patient have an infection because, say it only had 20 neutrophils. So then we're worried about infection and a UA is going to.
Send you down the path of, oh boy, I need a urine culture. -hum. And then the other thing that the urine is gonna help you with would be glucose ketones in the urine in case we've got somebody who's become diabetic.
We currently have an oncology patient now who had a pancreatectomy for an insulinoma and who now it needs insulin. And we're just waiting for the insulinoma to come back and we'll know that it's back when the dog doesn't need insulin anymore. But, it, that will, the, the urine will help you on that point as well.
And I guess the third thing is, Chemo drugs, which we're going to come up to, so just make a note to pay attention to cytoxan, cystitis, and now we can talk about SDMA. Yeah, OK, thank you for rounding that out. So whenever you see an increase in SDMA, remember, your first thought should be, there's something that is causing a decreased GFR in this patient, whether it's a pre-renal cause, dehydration, hypoperfusion to the kidneys, post renal cause obstruction, or renal.
That should always be your first thought, but, STMA is a product of normal protein turnover that occurs in every cell in the body at a constant rate. And so things that increase protein turnover may increase SGMA independent of a change in GFR. So what could that be?
Well, that could be growth, so puppies have a higher normal value for SDMA than adults because they're growing, more protein turnover, but also cancer. Those cancer cells dividing rapidly, turning over more proteins, raising the SDMA and this is been shown in lymphoma, and then a couple of other studies recently, maybe other neoplasias, but the point is, see an increase in STMA, think and rule out causes of decreased GFR. If you don't find any other evidence of a kidney issue, especially if the STMA is significantly elevated, like above 25, 28, and everything else looks normal, you might want to consider evaluating further for lymphoma.
And it's an example of that is. A dog that comes in, it's not feeling well, generalised lymphadenopathy? Is it lymphoma?
Is it tick-borne? What is it? You're just going to start working the dog up.
And if you see these results where the SDMA is significantly elevated, above 20 is a big deal. So, this is getting close to 30, but nothing else on the panel looks like there's a problem with GFR, then I'm thinking, this dog's lymph nodes, I'm going down the cancer path. So, Anne, so far, have you had an experience where you've Notice this or this has helped you in some.
Don't, don't tell my other friends at IDE, but we pretty much don't look at SDMA in our lymphoma patients because we know they have lymphoma and we don't pay a lot of attention to it. I just wanna go back though on this, panel. Notice that this is a Boston who probably is gonna have lymphoma and notice he's already sort of anaemic.
And so he, he fits our typical cancer patient where he, Is already anaemic at the beginning of treatment, and once we treat him, he's going to be more anaemic, and I'm just going to roll with that because you become very tolerant of abnormal CBCs when you're an oncologist. The other thing that's interesting on here is it looks like this pet might have some GI disease. And the reason I say that is total protein is low, and his retic haemoglobin is low.
And retic haemoglobin gives us a clue that the patient might be iron deficient. And when we look at this dog's MCH and MCHC, we see both are below the reference range and the MCV is barely normal. All those things give you a hint that this dog might be iron deficient.
Maybe there's GI bleeding going on. Maybe he's got some sort of GI disease which causes bleeding or causes iron. Not to be absorbed.
So, maybe we can make this stock better by giving him a smidge of iron. Just a couple of pearls from looking at CBCs. He's also already thrombocytopenic.
So this is going to be a treatment challenge, let me tell you. Yeah. Yeah.
And I'm glad it's in your ER, not my office. So, yeah, so that platelet count's a little at the lowish and, not likely to, It's low, but not likely to cause bleeding. So we've got time on this guy, and all the things Ann pointed out are great in helping us like determine extent of disease.
And then the estimate increase situation thing is just like pointing us down, well, this is likely related to neoplasia. And then there is a, now we'll talk about this more later, but there is now a blood-based test you can run to screen dogs. for lymphoma.
So we'll get to that in a minute. So, we're going through our procedure, we've got our quick assessment test done, we've got the rest of our lab work done, we're putting the picture together in this patient, we don't know what it has, we're looking for signs of neoplasia, and then we've got imaging would be next. I think there's no surprises here as to what you might find, unless, and you think there's something worth really pointing out here that sometimes gets overlooked or, you know.
No, I think that in general, we are not very good. I included are not very good at looking at X-rays, and of course I've got a crutch because I've got a, a, a dark room full of radiologists a couple floors down from me, which makes my life really easy so jealous, so. One thing, it would be their ability to read radiographs, and I think that cannonbave pulmonary metastasis are really easy to find that they're in your face, but it's some of these really subtle pulmonary metastasis that are hard to see and often get missed.
And Ann's point about, you know, the, ability to be really good at reading radiographs, don't feel bad. Like I knew when I was a senior in vet school, that wasn't my thing, and I was like, may I just always practise where there's a radiologist, and I give talks with radiologists now. I'm very fortunate to be able to do that, and they'll be standing up there and they'll be pointing out some lesion and I'll just be like, I don't see that, right?
So it is any doubts, get your films reviewed, and then when it comes I always wanted to know from Ann and from radiologists, like how many views do we really need of the chest? What's your answer to that? Ever more than 3, Anne, or what?
Mine is still 3. I don't know that the 4th 1 helps me. But again, radiology is really not my strength.
I did, I did ask a radiologist who recently came to one of my talks. I'm like, do you ever recommend more than 3? He said, just 3, just get 3.
So you can forget the DV, right? So some people say there's a difference between a VD and a DV and the aeration of the lungs and seeing things. In different sections of the thorax, and he's like, just get the VD in both laterals and you're good to go.
So now, Ann, help us, we've identified something that we don't like, we need to get cells. Help us get the best sample for you. So, so I think everybody knows how to do what we call an aspiration cytology, but I just wanted to show you this video, which is the non-aspiration technique, or some people call it the woodpecker technique.
And I, I think, yeah, Bill can make this play. Notice that we've got this skin mass in a golden retriever. What a surprise.
And so she's woodpecking in and out of this mass to fill up the needle with the cells that we have. If you, if you look closely, you can see this was a cyst, and so it also filled up with fluid. But that particular technique, I find very good for some of these skin masses and for lymph nodes.
Now, lots of people want to talk about like how big a needle do we need? So for something soft and squishy, this is being done with a 23 gauge needle, but you could use a 25. If you've got some tough, gnarly soft tissue sarcoma, you think.
Then a 22 gauge needle is probably better to really try and ram through that, that, tough tissue to get a better sample. Now, if you're doing a non-aspiration technique, you only need enough, a big enough syringe to squish the stuff on the slot. If you're aspirating, a soft mass 3 to 6 cc syringe will probably be fine.
And if you've got one of these soft tissue sarcomas, these hard, firm lesions, go to a 12 and put a tonne of suction on it to try and suck some cells out of there because they are notoriously difficult to get good samples from. And can you, are you able to get with a non-aspiration technique in some of those really gnarly sarcoma-y ones? Are you able to?
Get cells using that technique, sometimes, yeah, I tend to use the non-aspiration technique much more for lymph nodes, and because I think the lymph nodes in big lymph, the lymphocytes in big lymph nodes get squished really easily, and so suction just rips them apart and so I would use the woodpecker technique for, especially for lymph nodes. Awesome. So, we've got some barriers to getting good samples, and some of it is the mass or the, the abnormality that you're aspirating.
And, and we've already talked about the firm lesions don't give you very few cells. And then like if you had a cutaneous hemangiosarcoma, you might only get blood and, and you might never get any mesenchyma looking cells. If you got some big lesion, you might just get necrotic stuff in the middle, so maybe stay closer to the edge on a really big idea.
And then if you have a well differentiated malignancy, you may just get well differentiated cells and the clinical pathologist is going to say, can't rule in or out cancer. These cells look kind of bland. What?
Not getting a definitive diagnosis on cytology? I've never, what? Not getting a definitive answer with cytology?
What are you talking about? And then if you have a lot of inflammation in your cancer, the inflammatory cells may overwhelm the tumour cells and not meet the clinical pathologist's criteria for saying this is a malignancy. So, you'll get lots of inflammation and then they'll say there's a couple of cells that look a.
Little wonky in here, but they don't meet my criteria for malignancy. So, that's, that's just some of the barriers we have based on the, the lesion alone that we're looking at. And, and, and Anne, would you say it's important before you send the slide in to just verify there are cells on it?
Like, do you, do you recommend that, like that we do some unstained slides, stainless slide, at least one, and make sure there are actual cells before you send that, that's a really good point. So, I am spoiled and we have a a laboratory with like a human being clinical pathologist 3 floors down. So if we're working on a patient and the clinical pathologist says you don't, with no cells here, we can run back to the clinic and get more cells from that patient.
If the patient's going home from the ER, then I think it's totally reasonable to . And you should do that, make sure you're sending the right thing in. And you don't have to know what the cells are at all.
Just like find cells, make sure there's cells in the sample, and then send that off if you're uncomfortable with your cytology skills like I'm. So I would say the top picture here is another example of when you need another aspirate because notice that these cells have been squashed and those long strands are actually strands of DNA squished out of the cell, and this is an uninterpretable cell. If you look at the picture, the bottom picture on the left, that's the macro slide, and then the micro slide is just wads of cells plastered on top of each other.
And so again, too thick and not readable by your clinical pathologist, no matter how good they are. So, things to worry about is stick with the needle and syringe size that I suggested. Do at least 4 redirections of the needle when you're doing the woodpecker, because that is gonna increase your chances of getting a good sample.
Also, remember if you're aspirating, release the suction before you come out of the mass, so all the cells don't up into the syringe. And don't squish the cells when you prep them and consider, you know, can you roll them a little bit on the slide with a Q-tip? Can you put the slide up against them and draw them out like making a CBC, and, and then don't put too much material on the slide.
So if the first slide has a lot of stuff on it, squish, squish the needle again and see if you get a smaller sample, which would be. The clinical pathologists hate formalin, and they want you not to send your cytologies with your biopsies because the formalin makes your cytology get really ugly looking and they can't interpret it. So if you're sending biopsies from the day of surgeries with cytologies, they go in different containers.
Super helpful, super helpful. And then we now have more sort of blood based. Ways to screen or diagnose cancer, which are available in some areas.
So, and you want to walk us through when it might be good to consider some of these, since you got the animal there, you've got the sample and you want to set him up for a referral, potentially. So, Cancer DX is an IA product that I don't use because people come to me already with a cancer diagnosis. So I don't have a tonne of experience with it.
But I think it can be added on to a CBC chem, and if you have a high suspicion, it's gonna come back in a couple of days in the US. Is it, is it, international yet, Bill? OK, so in the US it comes back in a couple of days, so that might be something to consider.
TR is a test that can be done on a cytology prep or a biopsy, and those cells don't need to be alive. So, that is sometimes the default that the ER clinician has, but it can be done on samples you've already collected in the ER. Flow cytometry, I've already talked a little bit about, and that needs, Live cells.
And so, if you're seeing something in the ER on Friday night, you may not be able to get flow because the cells might not make it till Monday to get out. They, they just don't live that long. The, the exception that I sometimes try on, at, on Friday is a CBC with a lot of lymphocytes on it.
You might be able to get that for flow on Monday. Biopsies, you may do a biopsy in the ER. It just depends on the situation.
Look, there's always a lot of questions surrounding immunohistochemistry, but remember, first the biopsy comes back, and when the biopsy comes back, it will often say the pathologist select suggests immunohistochemistry. And that's something to run by the oncologist before you submit it because pathologists don't manage patients. They, they do biopsies and so they have a good reason for recommending, but it may not change treatment.
So run, and it, it costs a bunch of money, so run that by the oncologist. BRAF and BRAF plus we use all the time. We pretty much don't do any kind of cell or biopsy testing of bladder masses anymore except those that are negative on these two tests.
And the new Q test is a very cancer specific test, and it only screens for hemangio and I forget what else osteo. There's 3 or there's 4 or so that it screens for. I think hemangio, osteo.
I forget which, and this one, just remember this one you guys, this is a test for markers that some tumours will excrete, but also inflammatory cells. So this is one where if you have Concern about inflammatory condition, there could be some false positives here. It's useful in some instances, more specific tests are maybe preferred, but I have a question and just back to the BRAAF thing.
How often do you get a negative BRAF that comes back positive on BRAAF plus? Like, not uncommon. Oh, cool.
OK, so you should be able to do both. OK. But the way that test runs is if the BRAF is negative, I think they pretty much just, it's like a reflex QC6, and, and so they, they will just do the BRAF plus, but, but we definitely see that there is still a small number of dogs that are BRAF.
Plus MBRAF negative and then we got to figure out how to make a diagnosis in those. But, but that will not be a crisis for the ER to manage because it's gonna take a few days for that test to come back and then the oncologist or the GP person is going to figure out how to do that. Yeah.
So just a quick thing about that cancer DX test. This is a blood test. You need to have both serum and hope.
Blood to run it. And this does test for specific markers for lymphoma in dogs, and mast cells now and then others later. And the ideal candidate for this test might be a dog you want to screen for neoplasia because it's of a certain age, 7 or older, or a high-risk breed of dog, 4 or older, or you just have a suspect lymphoma like our dog that had the high SMA and all those changes suggesting iron deficiency and potentially GI bleeding, and you want to get some less invasive way to convince yourself and the owner, it's time to talk to an oncologist, and then also you can use it to monitor treatment, because when you're in remission, and the cancer cells go away, then the markers also go away.
So it's useful, and mostly a GP kind of like test. Or deciding, do I need to pursue cancer? Should I talk to an oncologist?
And the oncologists that I've talked to that know about this test, if you are a GP and you have a positive result for this test, and you call the oncologist, they will say, please send dog, versus you call an oncologist with like, I got a dog with big lymph nodes, it's Friday, I'm getting slammed. Can I send it to you? And they're like, maybe you should do.
Some other stuff. So it can help you more efficiently get your dog seen by an oncologist. Now, like to Anne's point earlier, poor cats, we don't have a lot of data.
So, so far this is just dog-only stuff, but working on it. So eventually, maybe with time and enough sample, we'll be able to get some useful blood-based screening for cats as well. And this test is designed.
To have a very low false positive rate. So the highest metastaticity, 99% means if you get a positive result on this test, there's only a 1% chance it's a false positive, and that's because owners tend to flip out a little bit when you talk about cancer, so you don't want to unnecessarily worry them. And with a sense Sensitivity of around 80%, that means you're going to miss 1 in 5.
So 1 in 5 dogs with lymphoma will test negative and then, OK, that's, we'll have, we have other ways, the traditional ways to make a diagnosis. So Anne, when you see this, are you happy as an oncologist with the leaning toward emphasising specificity? Well, yes, because not only is the dog owner who has a positive result flipping out, but I'm gonna spend, you know, in New York City dollars, which I understand is not the same dollars as elsewhere.
I'm gonna spend $3500 X-raying, ultrasounding, and blood testing this dog to try and figure out where the cancer is. And so I don't want to. Spend that money unnecessarily because that's $3500 minus that I don't have to treat this patient.
And so, you know, we know in veterinary medicine that cost is a real issue. In, in the US, the economy is, is tight and people don't have as much money to spend on their pets. So I want to spend that money taking care of pets, not testing to.
Oh, I didn't find anything. So that's why a high specificity is so important. Yeah, yeah.
OK, we've got it, you guys. We've gone through our patient. We didn't know it has neoplasia.
We've worked it up using our good clinical skills and all the tools at our disposal, and everything points toward neoplasia. Now it's time to have a discussion with the owner and, and, and walk us through your ideal setup in this situation to get the owners on board and to proceed. So, there, there's some research that shows that pet owners want to be referred to a specialist when their pet has cancer.
And, and that could be a surgeon if it's a, if it's an, you know, it's a cancer that needs surgery, it could be an oncologist if it needs chemotherapy, but they want to be referred. They may not choose to treat that pet, but they want that expert opinion. The other thing that's important to them is that their regular vet, their neighbourhood vet, their primary care vet is still involved in that cats or dog's treatment plan, because that's like, I'm a scary person in a big hospital, and what they want is something in their time of distress.
They want someone who they know and care about. So, it's important to keep the, the oncologist in the loop. Send them to the oncologist and keep the primary care veterinarian in the loop.
And I think that things that you can do to kind of allay their fears is remind them that chemotherapy, people are very worried about chemotherapy, but that most pet owners whose pets had chemo, ultimately think it was not nearly as bad as they were worried about. I think it's important to keep an open line with the oncology specialists in your neighbourhood because they will be able to help you have some ballpark idea of cost. And cost varies a lot across the United States.
And so that's important when the client says, oh, how much do you think it's gonna cost? And, and so that's an important line of communication, not only referring, but also to understand what the cost, the wait time for appointments are and things like that. Then in the ER you need to fix the urgent problems.
So, if we go back to Bill's tests, if the patient has a very low PCV and it needs a transfusion, then you need to do that in the ER. You need to treat the hypercalcemia so that the kidneys don't give up the ghost. Whether or not you start chemotherapy in the ER, I think depends on the skill of the ER team, access to drugs and access to other therapies.
And so, you know, if, if you have someone who used to be an oncologist, but they really wanna be an ER specialist, then, then maybe you do that, but management of patients in the clinic is all about. The expertise, the access to equipment and supplies and the skills of the team for you to decide. And then I think you have to figure out what other tasks you want to do.
So, what we did was we took some of the more, no, you can go. We took some of the more common cancers that we think that ER people might see in the ER and we made this little chart to help you guys. So, this is a crib sheet, and we're not going to go through it line by line, but this would be something to photo and have on your phone so that when you're presented with one of these cases.
Which would be common to see in the ER. You can have this at your fingertips or tape it on the wall if you want to print it out, because that will help you talk to pet owners a little bit more educated without needing an oncologist to, to back you up on that conversation. I would have loved to have this chart, but this is the dog one, so everyone take a screenshot, take a picture.
This is the cat one. When I was in practise, because the only survival stuff I could remember was with Hemangio where it's 3 months without chemo and 6 months with chemo. That's the only one, right?
But owners really want to know like what is going to happen and so this I thought was a super useful thing and Ann fiddled with the times and I think this is probably as good as you're gonna get in a quick, easy reference. And then, as Ann will share with us, you've, sometimes it's You know, let's proceed because if it does turn out to be what we think it is, there's a good, there's a better prognosis, and sometimes, I mean, sometimes it just really isn't good and maybe there's even the, a reason to suggest euthanasia. So, Anne, walk us through how you want us to handle that scenario.
So when Bill and I were interns, lymphoma was a disease. It was a single disease. We treated all lymphoma the same.
That is no longer true. And so we see some lymphomas that actually have better prognosis, and, and the classic one is T-zone lymphoma, which is an indolent lymphoma common in golden retrievers and Shih Tzus, but can occur in any dog. And this is a lymphoma that we don't very often treat or we treat minimally, and these dogs will live a very long time and rarely die of this type of lymphoma.
Then keep in mind that the English bulldog has a polyclonal B cell lymphocytosis, that's not cancer. So if you have a bulldog in your ER and the machine spits out a huge lymphocytosis, yes, the pet needs a workup and it's gonna need flow cytometry, but tamp back lying down a little bit because it might not be that bad. And then remember that T cell CLL does better than B cell CLL.
And so again, your machine is gonna spit out a lot of lymphocytes and you tell the owners that needs more work, but even B cell CLL still can live a long time. And then there is a disease called splenic marginal zone lymphoma, which presents as a gigantomundo spleen, and you guys might be the ones who see that spleen or the spleen ruptures. And then you take that spleen out, and if you take the spleen out, these dogs can live a very long time.
So in the cat, remember that small cell GI T cell lymphoma. Carries a really good prognosis and that's on the chart that we had. Nasal lymphoma, which can present as a stuffy, snotty-nosed cat, has quite a good prognosis as well.
And, and, real quick, is, is the GIT cell more common than B cell GI lymphoma in a cat? Like what's you would not, it, it would be very rare to see a B cell lymphoma in a cat. Doesn't hardly ever occur.
Oh, good to know, . And in the cat, B versus T is not a predictor necessarily like it is in the dog. And so we will often get a nasal lymphoma biopsy and the pathologist will say, well, you could do immunohistochemistry to look at B versus T, but the answer is most nasal lymphomas are B, and most of them, and, and they seem to respond well to treatment, so we don't do that.
Yeah. That's an example of checking with the oncologist for the immunohistochemistry. Now you guys are gonna see some bad stuff in the ER, and when you have pleural and peritoneal carcinosis, carcinomatosis can be really bad, and if that carcinomatosis is associated with effusion, those pets have a really poor prognosis, probably in terms of days, not weeks.
And unfortunately, that's what all of us have to do sometimes is tell owners that things are grim. So, keep in mind that carcinomatosis and especially with effusion is not going to be a happy story for the pet owner and euthanizing would be OK. Yeah, so real quick, I think we know the list of cancers that can cause hypercalcemia.
Kind of long, but the top two are the big ones. And when do you need to address that in the emergency room? My cutoff in our units in the states is about 13 or more, because that's when I'm really concerned about frying the kidneys.
And if we're going to address that, just start by correcting volume and hydration deficits, and if you had to pick a fluid, try sodium chloride, because it's going to help enhance. Renal calcium excretion. Once the animal's hydrated, volume replaced, if you still have a scary calcium, then we take measures to lower it, and probably your most effective, although they may take a day or so to work, are the bisphosphonates, and alendronate is one that we like a little bit more because it has a shorter infusion time.
The question always, and then I'm just gonna say real quick, I'm not a fan anymore of using furosemide in these guys because, not that effective. Just keep them hydrated and we don't want to dehydrate them by overdoing the furosemide and potentially exacerbating the kidney consequence of high calcium. And please tell us when or if we should ever consider glucocorticoids as a calcium lowering treatment in the emergency room prior to a diagnosis.
I, I would be really rare, but if you have a high suspicion for lymphoma, you have a golden retriever, it's got big lymph nodes, it's got a mediastinal mass and it's hypercalcemic, I think I would aspirate a whole bunch of stuff, put samples in flow juice, put Samples on slides potentially for par, and then you just may be forced to give glucocorticoids. And so, that, but that is sort of my last resort until I have a, a handle on the fact that this really does have the lymphoma I think it has. Great, great.
OK, then, like Anne mentioned earlier, like the only time I have done emergency inductions, if you will, in the emergency room is when I had a patient who had upper respiratory issues due to massive submandibular lymph nodes that I could not alleviate with keeping the patient cool and light sedation and oxygen and all those things. It just wasn't happening. And so I would give, probably vincristine or Espar in that setting, that was it.
And are there any other things that you think, We should be aware of, like, have this on hand and do this if you, you know, encounter this sort of cancer patient. No, I, I think respiratory disease is probably the hardest one. Most of the time, if you have a patient who is obstructed from like a TCC, then you, most of the time, you probably have to heavily sedate or anaesthetize them.
Someone can get a catheter, a urinary catheter in that patient. And see if we can make it better, but certainly if you had a dog that was obstructed from a TCC, I would give that pets, NSAIDS to try and use that anti-tumor effect in that patient and see if we can unobstruct it while you're waiting for it to get stinted or maybe radiation therapy. I'm.
I'm not sure how good chlorambucil is for obstruction of lymph nodes, obstructive lymph nodes or masses. That drug works slowly. It works, but I don't know that it is an ER drug for us.
Vincristine and Elspar are, are potentially ER drugs, again, depending on the skill set of the team that's taking care of the patient. Yeah, and I like, and, and when we're developing this talk, I like this phrase, treat around the cancer, right? So, you know, most of the time it's not necessary to actually start chemo, but all the other supportive treatments that we do in any critical patient would apply here as well.
I think that's super useful. OK, and then, and then, and, what do we need to set you to, to do to help you have the best chance at getting these patients straightened out? I think I kind of already talked about that, and, and that is know, know who you're referring to, so that you know what tests they like.
And can move those forward before the patient even gets an appointment with the oncologist. And then it's important to keep the regular vet involved and the oncologist involved because that, we know that's what the pet owner wants in order to be satisfied. Keep in mind that people whose pets have cancer have an enormous.
Desire for information enormous. And so look for information that you can share with them. Either your oncologist has it.
The World Small Animal Veterinary Association has an oncology committee. They've got resources for you as well. And so look for things that you can print out and give to the pet owners because they will love you for it.
Yeah, I, I, that is so helpful, and my concern always when I was starting a workup would be like, what is the oncologist gonna repeat? Like, do I need to have, you know, are they just going to repeat everything I'm doing so the patient has to, the owner has to pay twice for the radiographs and the blood work, so that's where getting to know whether your oncologist actually prefers their own set of radiographs and labs or it's OK with yours, like that's super helpful at eliminating unnecessary expense. All right, I think we got our patient who we didn't know had cancer like squared away.
Let's move on in our, I think we have a few few minutes left. I think we can get through this. This is a patient on chemo, and these are the ones where I'm busy, the client comes in, patient's sick, the record's this thick, and I'm supposed to fix it.
And I'm like, whoa, this is a lot right now. So we're going to try to streamline that process as well. And you wanna, you know, like we've mentioned earlier, it could be related to the treatment, could be related to the cancer, or something else completely.
And then you want to kind of go through how these guys usually present if they're sick due to their chemo. So, when patients getting chemo, there are a few common reasons it's gonna come to the ER. First would be fever, and of course, right away you're honed in on neutropenia, but remember these patients are at risk of infection and sometimes we see cancer fevers.
And then, I lost a patient, a cancer patient, to lepto not too long ago, and it came in with a fever and was yellow as a banana. So, just keep in mind that again, chemo is a high on the list, but cancer and other things is, is possible. And then when they're ain't doing right, and that will be the pet's not eating, it's kind of lethargic and the people are just worried.
And again, the list is very simple. Similar infection, I cannot explain why, but neutropenic patients are often. Lethargic, even if they don't have a fever.
Why that is true, I have no idea. And how do I know when the neutropenia resolved? Because if people call up and say, hey, he's a lot better today, and then the white blood cell counts up.
No explanation. Know that it's true. I would say vomiting and diarrhoea.
Cancer pet owners are on high alert constantly for a puke or diarrhoea, and we just have to work through it. We would not send them to you for one puke or one diarrhoea, and we usually have given. The medicine to use in those situations, but they are so up-regulated that they can't control themselves and so they're gonna come to the ER and you need the first question for the vomiting, diarrhoea cancer patient is, have you given the medications that your oncologist prescribed?
Then, urinary signs, remember we've got bacterial cystitis, we've got pyelonephritis in these patients, and we also have a chemical cystitis which comes from cyclophosphamide. And then the swollen leg could be an abscess. It could be chemo out of the vein.
Could also be a big lymph nodes causing lymphedema. And then again, the swollen leg could be broken because the people let it off the leash and it got hit by a car. So any of these things are possible.
So remember that when you think about chemo, you can think about it in 3 big buckets, bone marrow suppression. And that could be any type of cytopenia. We also can see alopecia, but that's the worst in poodles and doodles and old English sheepdogs, but the Labrador, no one would recognise it's getting chemo, and then we get GI upset, which is most common 3 to 5 days after chemo is given.
And then if the owner happens to know what chemotherapy drug the pet got, that helps you to hone in on the unique things that chemo drugs do. And So bone marrow suppression happens because cancer drugs are not specific to cancer. They kill any rapidly dividing cell, which are also the cells in the bone marrow.
And so the first thing you see is neutropenia, and then you see thrombocytopenia a bit later, and then anaemia, that's significant, is rare, and we've already talked about that today. So, most people, oncologists will do a CBC before they give chemo, and if the neutrophil count is bigger, greater than 1500 to 2000, they're going to go ahead and give chemo. And that number shows you the tolerance that oncologists have for abnormal, because those are not normal counts, but in my world, they're beautiful.
And if the platelets are above 500,000 to 100,000, I'm gonna go ahead and give that chemo. We'll often do a white count after chemo a week later just to see where we are after the chemo. And usually we'll see that somewhere 7 to 10 days after treatment.
And, and you'll do that even if the animal's doing well clinically. We'll, we'll often do it on the first chemo. If the animal is doing fine, we're not gonna see it after every single chemo.
Some people talk about the double nader in carbo. I cannot find the paper that says that. And I have looked.
So, people talk about it. I don't know if that's real. And then both dogs and cats actually can have a delayed neutropenia after CCNU administration and it can hang around for a long time.
So, if, if you see a patient in your ER who is 7 to 10 days post chemo and it's got more than 1000 neutrophils and doesn't have a fever, send the CBC to the oncologist and send the PET home. Neutrophils less than 1000 and the PET's well. Most people are gonna consider some oral antibiotics and have the PET get a temperature at home.
Send the CBC to the oncologist and they'll recheck the PET. And if the neutrophils are really low and the pet is sick, then you probably want to put it in the hospital and give antibiotics and fluids. OK, it's really nice.
I think it's really nice to have those cutoffs and then obviously it's not just the number, it's the number plus what's happening with your patient. That's right. GI signs are probably the most common thing that we see and so we send home all our patients with Cerenia.
Many of them get Zofran as well that they have on hand at home, but they're really reluctant to give it. And so if they say they have it, give a subcu dose and send them home and tell them to give the medications like the oncologist said. And then what we should do for diarrhoea is really complicated.
We have for many years used metronidazole, but there are studies out there that say it doesn't really make a difference. Oncology patients are very worried about their pet eating. It, it is the most important thing in pet owner surveys.
So the minute the pet doesn't eat, they've got a rotisserie chicken from Costco. They've made bacon and eggs, and they're, they're getting out the liver worse. That is the worst thing they could do for that pet, and that pet will continue to have raging diarrhoea.
And then they get pancreatitis and then another thing, yeah, yeah, exactly. So probiotics and fibre are good, . Cannaevia is a chemotherapy diarrhoea medication.
It's pretty pricey. It works. It's not our first line and notice that it's can allevia CA which means it's conditionally approved.
So you have to use it for chemo, diarrhoea. I don't know if it will work in other diarrheas because it's conditional and we can't use it. So that is, That's something that if your practise has an oncologist and you're on emergency, you might want to find out how they like to use the cannaea.
Rx clay will definitely help these patients. The challenge is if they're not eating, getting it into them. And then loperamide, and we were talking the other day that maybe we should use more loperamide in being .
Can being cognizant of our antibiotic stewardship and not using metronidazole, but remember loperamide is an MDR, excreted drug, and so you gotta watch out for white feet, dogs. Many dogs on chemo will have had an MDR status tested because many of our chemotherapy drugs are also MDR drugs. So check the record for that before prescribing loperamide.
Awesome. Two things just to piggyback what Anne was saying. Any conditionally approved drug, if you use it in any other way than what it's conditionally approved for, that's a licenced loser.
Beware. And then also, this idea about when to use antibiotics for symptom. Treatment for diarrhoea, it's kind of over.
There's a consensus statement on rational use for antibiotics with, diarrhoea, and there's a whole NOA group in the UK and Europe where it's like antibiotic stewardship is a whole other level there compared to the United States. Bottom line is, unless your animal is septic, basically, you know, sick, even blood in the diarrhoea, which when Anne and I were interns, if there was a, animal that came in with blood and diarrhoea, that animal got hospitalised and IV antibiotics and IV fluids. That was just what you did.
If that animal feels great, that's blood in the diarrhoea is not even a cause for antibiotics in a healthy patient. So yes, we're the, and then one last thing about that real quick is, you know, with using metronidazole and Tylosin, one of the rationale, well, OK, great, maybe we don't need the antibiotic portion, but they have anti-inflammatory properties that might be helpful, and that has been questioned as well. So we're just assuming unless the animal has diarrhoea and is sick, we don't use antibiotics.
OK, onto your Unique but predictable things, and so, so every chemo, almost every chemo drug has some wonky thing that it does that's different than all others. So probably the most famous is doxorubicin, which has cardiotoxicity. It's not very common across all dogs.
Only about 4% that get doxo develop cardiotoxicity. So, your likelihood of seeing it is low, but if you see it, it's a bad problem because they don't respond well to therapy. Question, Dr.
Honhaus, are there breeds where that is more likely to occur in, or is it just across the board? No, so then the risk goes up to about 10% if you are looking at, breeds at risk for cardiomyopathy. So the Doberman and the Irish Wolfhound, those dogs have a higher risk of developing doxocardiotoxicity.
My last. Do that developed maybe doxocardiotoxicity was a dog with lymphoma and it was a Doberman. And so I don't know if it was the Doxo or the Doberman or the comma or the two.
But he lived a year and so I was like, wow. Yeah, he, he did OK with his lymphoma. CCNU can cause a hepatotoxicity and so what you guys in the ER are gonna see is a dog with a sky-high ALT, and that would be your clue that that's going on.
I don't think there's much you can do other than your usual liver treatment, but send the chemistry profile to the oncologist. We've already talked about cytoxic cystitis. You need to get a UA, get a urine, make sure the dog doesn't have bacterial cystitis, but there is not a lot of good treatments for cytoxan cystitis other than control the discomfort and wait it out.
Tnovia can cause pulmonary fibrosis, quite rare. We have a recent case at AMC, palladia associated with pancreatitis and also a weird lameness. With Palladia, the most important thing is stop the drug.
So the people think the Palladia is saving the pet's life, but it's caused really bad pancreatitis. They don't want to stop the Palladia because the dog has cancer, but the pancreatitis is not going to get better till they stop the Palladia. So stop the Palladia, and I know it's really hard to convince the people to do that, but, but the oncologist will bless your little heart, for getting the people to stop the Palladium.
And then, then Christine, doxo, nitrogen mustard or mustrogen, Janovia, actinomycin D, and there's a recent report in the last couple weeks about kind of a slough from extravad carboplatin. So a dog comes in with a swollen leg. Usually the owner will know what leg the chemo was given in, and if that's the swollen one, start worrying about a drug slough.
Quick question, that, pulmonary fibrosis situation resolved with discontinuation of the drug or we don't know, or it's permanent? What's the story there with what will resolve the pulmonary fibrosis with Tanovia? No, I think it's, it's a downward spiral.
And the reason that we think we have one at AMC is because we have a necropsy on the dog, unfortunately. Oh boy. Another quick take a picture, this is a lovely little image that Anne found and just keeps like what these drugs can do in, in mind, we're gonna move on.
This one is interesting because I was always under the impression that if you develop this chemical cystitis on cyclophosphamide, you were, it was over, in terms of ever starting the drug again, but Anne has some subtleties around this which I think is super helpful. So, we, I, I would stop the Cytoxan for on the short term and the oncologist will figure out what you should give as a, what they're gonna give as a backup drug. However, if this pet comes out of remission, I am probably gonna try Cytoxan all over again in that dog.
And of course, oncologists pretty much all give a dose of Lasix with the Cytoxan. Not that it, it's an antidote, but what it does is it forces the owner to walk the dog more frequently while the irritating cytoxan metabolite is in the urine. And so what, what the cytoxan or what the Lasix does is just makes the dog pee out the offending chemical.
It doesn't treat anything, except I think it sort of treats the owner by forcing them to walk the dog. Yeah. But, but we can, for now, stop the Cytoxan.
And so you guys might see patients on oral Cytoxan that's being used in a metronomic or little teeny dose chemotherapy fashion, and that's when you can impact this patient by stopping the cyclophosphamide. Perfect. And then we, I think basically when it comes to extravasation, since we're not going to be giving chemo in most emergency settings, or we're going to be dealing with the consequences of it, and we've got the What to do on the right there in that table, but I think the main thing, I think your oncologist would be really grateful if whenever you needed to place a catheter or get a blood sample in the emergency room, if it was safe to use a large vein, use a large vein to spare the peripheral veins for the chemo that's going to be given.
Yeah, what do you say? Yes, and I think the other thing is that these chemo patients often have very fragile veins because they're on steroids and they're sick and they're losing weight. And so be sure to wrap those veins after venal puncture, so that that there's not a hematoma that formed and caused a lot of scarring in the vein.
OK, so we've been through, is it the chemo, is it, now we're gonna talk about is it the cancer when we've got a patient on chemo that's coming in sick and so we would just review our basic good clinical skills like Ann keeps reminding us to do, including our lab findings for signs of change that could be indicative of cancer being out of remission, potentially new lesions. Forming, another type of cancer forming. So let's just kind of work up the patient in standard fashion and, and these things I think are pretty intuitive.
Anne, is there anything here that you found particularly helpful and like, oops, this is, this makes me worry about the cancer coming back or I think the most important thing again is to pay attention to your physical exam because if those lymph nodes are bigger, and most oncologists. Actually measure lymph nodes. And so, you need to get out your callipers and compare your measurements to theirs to help you know if the lymph nodes are bigger.
Now, of course, if the oncologist says they were 1 centimetre and now you're feeling softballs, I don't think you need the, you don't need the callipers. You can see it from across the room, yeah. Yeah, they're likely to be measurements in the record.
And I think, so I think physical exam is important. I think the ER people are going to do a CBC chemistry and then if, if the PET is not doing well, you're probably gonna do some radiographs or an ultrasound, which will help you find the pulmonary mets or a recurrent abdominal mass or new nodules in the liver. So again, these are just normal tests that I see AMC's ER people doing when they are presented with a PET that's not well, but has cancer.
Yeah, and then I think we can wrap it up and Anna, you, you, you know, take us home here cause I think this was your, your slide and it's such a lovely calming approach to dealing with these sort of scary patients when we see them on emergency. So, we talked at the beginning of this about doing a physical exam, including a rectal, and that is gonna tell you a lot about your, your cancer patient in the ER. We're gonna look at that CBC and we talked about looking at the anaemia, the white cells, are they really high?
Are they really low? Don't forget that the automated analyzers might tell you it's a monocytosis, be suspicious about that. I don't think there are very many cancer patients that don't benefit from fluids.
I would say there are two that might not. One is the patient who's got heart disease, be cautious with fluids, and then the patient with heart disease and anaemia. Those things go into heart failure in just a heartbeat.
It's very easy to volume overload the anaemic patient with leaky valves or hypertrophic cardiomyopathy. Be very liberal with your anti-nausea medications. And then if all these reasonable everyday things that you do in the ER all the time don't help the patient, ramp up and think and do some more things.
You know, it, it might not be the treatment or the cancer that's causing this pet to be sick, but just take a deep breath and practise good ER medicine and I think you're going to help these patients immensely. I will say one, I will say one thing, that is just like, that's what you do. Everything Doctor Honos just said, do that.
And remember when it comes to fluids, remember cats usually just get half of what dogs get in terms of tolerating fluids, right? And, and also cats and dogs can hide up to 5% dehydration on you. So, if you're dealing with a patient and physical exam findings don't reveal like decreased skin elasticity or tachy mucous membranes or any of the physical findings we look at to identify and determine the degree of dehydration, that can all be normal and there can still be up to 5%.
And this is why I think Ann's statement that almost any patient who presents this way could benefit from fluids, even if they're not overtly dehydrated, at least correct up to 5% dehydration, and a lot of times they'll perk up, those cats will start eating because dehydration is like the number one appetite killer in a cat. OK. And then finally, we're gonna get, we've gotta get these guys to Doctor Honhaus.
So Ann, how do we do that? So keep in mind that the pet owners want to be referred to a specialist, but they also want to work with their regular veterinarian who, who they see as their partner and advocate. And, and so, all, everybody needs to be in the loop.
They also want to know their options presented up front. They want, want you to say, OK, we can send you back to your regular vet, but I think your pet has cancer. We could send you to a specialist, and I think they're gonna recommend this, that or the other thing, and, and just have an honest conversation with them.
They want to know what you think is wrong with their pet. They. People whose pets have cancer don't want to be judged for their decisions.
And so I try always to present a menu of options to the pet owner and say, here are things that I think are reasonable options in your pet. Tell me how I can help you understand each option so that we pick the right decision for your pet. And then the other thing they don't want is they don't want us as veterinarians to assume anything about their financial situation.
So present the $20,000 option and the $20 option because they want everything presented upfront, and if they choose the $20 option, they don't want to be judged for that. And, and I think just being a kind human being will help smooth these referrals over tremendously. That is so helpful and I, and my MO when I was dealing with these cases or any of the Berg from RSC was to do exactly what Dr.
Honhaus said. They got the Cadillac version. This is the best we can offer.
This is middle of the road, and this is what we can do to stabilise and get you comfortable and maybe refer. And then I would just let them decide, and I don't know what your guys' experience has been, but mine was that it was rare, but by far the majority picked the top end. Whether I saw that coming or not, I was, I was often surprised, hence, don't judge.
But also, what I think judging can do is like make you offer less because you're not sure that they can afford it, but I think everybody wants the options and I think you might be surprised at how often they go for, exactly what you recommend. So I think, and I think this is, this is key takeaways for ER vets. So Bill, I'll leave this for you because you are the ER vet and I am not an ER vet at all.
So basically, I don't think we need to go over these in, in line by line fashion, but I think it should be clear by now. They come in, they get treated like any other emergency, which is just start with your physical, get your 4 quick assessment tests, round out the lab work, get your imaging, do as much as you. Need to do to get an idea about where you're headed with the diagnosis, and then therapeutically, when it's bad, they get oxygen, they get an IV catheter, they may not need fluids.
You'll decide that looking at their perfusion status and hydration status, and then a tonne of monitoring, because these patients can be dynamic, and their condition can change from minute to minute. So they get placed in an area where you can see them, watch them. Are the respiration, is the respiratory rate changing?
Is something changing, temperature changing. So, the key is eyes on them, frequent hands on them, and, and really thorough monitoring, and then the diagnostics you need to support their physiology until you get an answer, which might not be possible early on in the emergency, but that doesn't mean you can't help them. So, Wow, Ann, thank you so much.
I learned a tonne. Really appreciate your wisdom and your practicality, and thanks to you all, thank you all for coming, Ann. We'll let you close it out.
Great, and I hope that this helps you not be so nervous when a cancer patient comes into your ER because you can do it. You can do it. All right, guys, have a great night.
Thank you. You too. Bye.
