February 20, 2019
Surgery plays a critical role in the management of cancer. One significant advantage of surgery is a chance at an immediate cure—after a single session. No other treatment modality can offer that.
Here are 10 rules that must be followed to ensure the best possible surgical outcome. Do the math: Surgery is only 10 percent of the entire story. What follows mainly pertains to skin masses, but it applies to any tumor, even intrathoracic or intra-abdominal.
Whenever a mass is discovered, it is important to take the time to prepare the client for the worst, while hoping for the best. Don’t sugarcoat things. Don’t make assumptions. Don’t claim to have microscopic vision. Don’t overpromise. Remember, for example, that a mast cell tumor is called “the great imitator” for a reason. It can feel like anything, including a lipoma.
Even though we typically say you can’t diagnose cancer by looking at blood work, it will occasionally show abnormalities, such as infection, hypercalcemia, or increased liver values.
Staging the patient (i.e. determining the extent of the disease) is a mandatory part of the preop workup. Before surgery is ever considered, perform three views of the thorax and/or abdominal radiographs or ultrasound. Occasionally, CT or MRI also may be recommended to investigate pulmonary metastasis or to understand the extent of a tumor in 3-D.
Although purists recommend taking biopsies of any tumor before surgery, others have a more practical approach. Benign or malignant, the tumor likely needs to be excised. And benign or malignant, the tumor should be excised in its entirety.
Skipping the biopsy saves time waiting for the results, as well as funds that might be better off going toward the actual surgery and postop care. However, if knowing whether a mass is malignant or not might change the practitioner’s approach, the invasiveness of the surgery, or the client’s desire to go to surgery, a biopsy should absolutely be performed first.
If you are going to take biopsies, it is critical to make sure the biopsy “tracts” can be excised along with the mass. The concern is the biopsy needle might “seed” tumor cells along its path as it exits the mass.
Believe singer Sade when she sings “Never as good as the first time.” The best chance at excising a mass with clean margins is the first time.
Before you attempt to remove a mass, be humble and ask yourself: “Am I truly capable of removing this tumor with clean margins the first time around? Will I be able to close the wound? Am I the best person to remove this mass? Am I about to do this patient (and this client) a favor by tackling this excision?”
If you answer “yes” to all four questions, proceed to the next section. If not, don’t get in over your head, or don’t be greedy—do the ethical thing by referring the patient to a board-certified surgeon.
Some tumors require special steps before surgery:
• Stabilize or rehydrate a metabolically unstable patient
• Administer saline diuresis in hypercalcemic patients
• Premedicate patients with a mast cell tumor with diphenhydramine and an antacid
• Do frequent glycemia checks and give supplemental dextrose IV to patients with pancreatic tumors, lymphoma, or muscle tumor, as they can become hypoglycemic
Make sure enough hair is clipped in every direction. It’s sometimes difficult to predict how long your skin incision will be. It might need to be lengthened during surgery to ensure you end up with clean margins. Of course, provide antibiotics and excellent analgesia.
Think about the approach before you even touch the skin. Look at your patient, the mass, and the surrounding organs or body parts. Take measurements. Decide how many centimeters in every direction you need to go. Make sure your incisions are parallel to the tension forces in the skin.
Just like a cosmetic surgeon in an extreme makeover show, use a purple surgery marker to plan the location and the extent of your incisions.
After you’ve manipulated and excised the tumor, change gloves to close the surgical site. And consider changing drapes and instruments.
Adequate analgesics should be used postoperatively, because some excisions can be quite invasive. Proper antibiotics also should be used, as the local tissues may now have reduced blood flow. The patient should wear an E-collar at all times to prevent self-trauma to the incision.
When applicable, follow-up chemotherapy and radiation therapy are usually postponed for two weeks after surgery to allow the incision to heal properly.
All masses should be sent to the lab for analysis. Again, be humble and acknowledge the fact you just don’t have microscopic vision.
There are three main reasons to send the mass to the lab:
• obtaining a diagnosis;
• confirming the margins are clean; and
• knowing its grade or how aggressive it is.
This information is critical to guide the client toward the next step.
Now is the time to have another discussion with your client. What did the pathologist find out? Did you get it all? How aggressive is the tumor? What is the next step? Be supportive and nurturing with your client, but don’t sugarcoat things and don’t overpromise.
It’s important to instruct the client to periodically inspect the surgical site. Encourage them to create reminders in their favorite calendar, physical or virtual. Depending on how aggressive the mass is, a monthly reminder might be enough. If the appearance or the “feel” of the surgical site changes, the client should be instructed to arrange a follow-up visit. In addition, regular appointments should be scheduled. Again, the frequency will depend on how aggressive the tumor is.
Clients have a critical role is assessing their pet’s quality of life.
A quality of life scale* by VPN guest columnist and cancer guru Alice Villalobos, DVM, FNAP, takes several important functions into consideration. A score is given to describe hurt, hunger, hydration, hygiene, happiness, mobility, and “more good days than bad.”
Dani McVety, DVM, cofounder of Lap of Love Veterinary Hospice, suggests using a quality of life scale** focusing on social functions, physical health, natural functions, and mental health. A number is attributed to each category to help clients assess objectively how their pet is progressing.
What matters here is the trend, rather than an absolute number. If the total score keeps getting worse and worse, it’s time for the client to seek help and have “the talk.”
Keep in mind euthanasia is not the only option these days. Hospice care is a reasonable and ethical alternative in some well-chosen cases. When that time comes, our responsibility is to step up and guide the client along the emotional path of grieving and decision-making.
Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified is a board-certified veterinary surgeon and author. His traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. You can visit his websites at www.DrPhilZeltzman.com and www.VeterinariansInParadise.com. Chris Longenecker, a certified veterinary technician in Reading, Pa., contributed to this article.
* The HHHHHMM Quality of Life Scale by Alice Villalobos
**Quality of Life Scale by Dani McVety, bit.ly/2RDs0sL
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