A Team Effort

Dr. Kuzminski describes tumor
Dr. Kate Kuzminski describes Blackie's tumor to her family.
Photo by Shea Long

February 22, 2016
by Kate Kuzminski, DVM, HSVMA-RAVS Field Medical Director

Every trip we meet a patient we know we will remember forever. Sometimes it is because they were fabulously lovable, or their guardian was particularly caring. Other times it is because of the impact we made on each other’s lives. Blackie, a terrier from the San Carlos Apache Reservation in Arizona, is our most recent memory.

Blackie came to our clinic last November to be spayed. She had been vaccinated at the summer’s wellness clinic and was thought to have a transmissible venereal tumor, or TVT. A TVT is a contagious form of cancer that is spread through contact. While rarely seen in affluent urban areas, it is not uncommon in communities that lack accessible veterinary care and spay/neuter services.

One of Blackie’s special qualities was that she did not like to be handled. Tail tucked between her legs, she became a shark if we brushed up against her or approached from behind. While a full examination of her tumor would have to wait until she was under anesthetic for her spay, we were able to get a preliminary look as she sat waiting for surgery.

Blackie’s TVT looked to be about 4-6 inches in diameter. Blood and pus drained from at least a dozen visible open tracts. It was ulcerated, necrotic, and looked incredibly painful—no wonder she didn’t want us near her hind end! The tumor was far more advanced than the dozens of others we have successfully treated through spay/neuter and chemotherapy at previous RAVS clinics.

Close-up of Blackie's TVT
Blackie's TVT was 4-6 inches in diameter (view larger image).
Photo by Shea Long

An impromptu consultation with our RAVS veterinary team allowed us to reflect on the severity of the situation, our experiences with TVT regression, and how we define appropriate welfare. Without appropriate follow-up care, Blackie would continue to suffer. As a group that provides mobile field medicine, it is paramount that we make decisions about care that are fair to our patients and their families. Leaving a patient in pain or with needs that are unattainable for our clients is not an option.

To her family, Blackie seemed "fine." While they knew she was bleeding, they didn’t realize the damage the cancer was doing. They had, in fact, never actually seen the tumor. We discussed the realities of the situation in depth and evaluated what we all were willing to do for Blackie. We even introduced euthanasia as one of the potential options. After significant discussion, we finally arrived at a plan.

As a team, we committed to evaluating Blackie’s tumor while under general anesthesia. If appropriate, we would spay her and give her the first dose of vincristine chemotherapy. We would keep her at the clinic for the following four days in order to monitor her treatment response and manage her pain. We knew we might see the tumor begin to regress in just 48 hours. If things went well, we would discharge her to her family for continued care. If no improvement, we would discuss quality of life issues further. As partners in this process, her family committed to follow-up vincristine therapy at a regional veterinarian and intense daily monitoring. We discussed welfare, severity of disease, pain management and each of our roles in partnering to ensure Blackie’s best interests were served.

We started Blackie on broad-spectrum antibiotics and sent her to surgery. Once under anesthesia, we found that her TVT was far worse than expected. The tumor had infiltrated her vaginal vestibule as far as we could palpate. Urine drained from many of the ulcerative open tracts instead of her vulva. Blackie’s ability to urinate normally was questionable. We wondered if it was possible for her urethra to become scarred and obstructed as her tumor shrunk. Would we start down this road of care only to end up with a dog that can’t urinate? We chose to commit to our original plan, knowing that daily monitoring was going to be critical.

What is TVT?

Canine transmissible venereal tumors (TVTs) are round cell tumors spread by contact and are usually transmitted during sexual and social activities such as coitus and sniffing. They are often seen on the genitalia of young, intact dogs allowed to roam, but can also be transplanted to the face and nose. TVTs are friable, bloody tumors that can be pedunculated, plaque-like, or deeply infiltrative. A bloody preputial or vulvar discharge is often the initial presenting complaint. A TVT can range in size from a small plaque or nodule (5 mm) to a larger mass (>10 cm). While rare, a TVT can be so invasive that it interferes with normal urination. Metastasis is uncommon. Diagnosis is based on clinical signs and cytology. Chemotherapy is the treatment of choice. Most dogs with TVTs will have complete remission after 4-6 weekly injections of vincristine.

Being able to describe Blackie’s condition through pictures and drawings was instrumental to the client’s understanding of the situation. Their acceptance of Blackie’s condition shifted significantly during our interactions and they became willing partners. As a result, we delivered our piece. Her family committed to theirs. In the end, the regional veterinarian joined the team by not only providing follow-up care and updates, but provided critical services at a cost that was within the client’s means. Win!

Three months have passed since we first met Blackie. Within 48 hours of her initial vincristine injection, we saw tumor regression and her draining tracts dried. She received four vincristine treatments. Her temperament improved immediately following the start of her care. Dr. Lisa Shriver, RAVS’ Outreach Veterinarian in San Carlos, has kept in close contact with Blackie’s family during this journey. At their last update, Blackie’s spirits were good, she was urinating normally, and she was finally holding her tail up again! The tumor is gone. Her family is thrilled.

Blackie’s case exemplifies the essence of what RAVS does for our communities and patients. Through client education and community collaboration we facilitated critical care for a patient and reduced the spread of a contagious disease within a community. We drastically improved the life of an incredible dog and helped a family in need. While it did take some time and creativity to develop a successful plan, all it truly took was a solid commitment to help an animal in need. Who can’t do that?

 
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