Bone Biopsy

[winnie]

I posted a few days ago that our galgo Beatrix is thought to have osteosarcoma in her pelvis. I forwarded x-rays to Dr. Couto who asked if we had a bone biopsy done. We did not. I have not heard further from Dr. Couto. He has neither confirmed nor ruled out osteosarcoma. The vet we saw said he was pretty convinced it was osteosarcoma. Our regular vet isn't as convinced. A vet who boards her horse at the same barn as mine also shared Beatrix's x-rays with an oncologist vet friend. Her impression was that it looks like an MLO (multilobular osteochondroma) and not an osteosarcoma based on the location. She feels that bone biopsy is extremely important in this case because she thinks if it is not an osteosarcoma then you will have a better outcome regardless.

 

So... has anyone had a bone biopsy done? I read this article and have concerns about the pain and risks. Is it worth knowing for certain what type of cancer we're dealing with? We plan on doing palliative care regardless. Due to the location in Beatrix's pelvis, amputation is not an option. Nor do we want to put her through other treatments if it just delays the inevitable.

 

https://pethelpful.com/dogs/Dog-Bone-Cancer-Biopsy-What-to-Expect-and-Associated-Costs

 

Copy of Beatrix's most recent x-rays.

 

 

Edited May 17, 2017 by winnie

[MP_the4pack]

While I do have an OS dog, it was a very ovbious wrist tumor. Classic. No biopsy.

 

Personally since she's a galga, and OS is not as common in them and it's in an odd location I lean towards doing the biopsy. Normally I won't. It would probably be the same amount of pain medication as for the palative care.

 

GOOD LUCK!!!

[krissy]

I don't really see anything glaring. What specifically within that circle were they concerned about? Early tumours can be difficult to identify conclusively. The issue is this x-ray is not straight, so you can see the symphysis (looks like a black fracture line almost) and then on the lateral wing there's a bit of "extra bone", except that because it's not straight it could just be a normal part of the pelvis peeking out from underneath. On top of that there's a towel or a trough creating lines running right through the area of interest. Will be interested to know what Dr. Couto thinks since he reviews way more of these. But if it were my dog I'd consider re-taking these x-rays to get them straight, get the towel out from underneath (I know, it sucks with those bony backs) - consider sedation if necessary to achieve that. Better to give a little bit of sedation if it's an option and get it done in a couple of quick shots then struggle and stress the dog having to retake again and again trying to get it right, or settle for less than ideal shots like this one.

[winnie]

I'd like to know what Dr. Couto thinks too. I have emailed him the x-rays, but after expressing initial interest in Beatrix's case, he has been unresponsive.

[NeylasMom]

If it is MLO would your treatment/care be different? Assuming an FNA isn't an option?

 

IMO if you're going to sedate to redo the x-rays, might as well get the biopsy while she's under. There is some risk to a biopsy - pain afterward (that should resolve), a very slight chance the bone would fracture (have no idea how the pelvis location affects that risk), small chance (I believe) you won't get a definitive answer, but when I considered it for Zuri I felt a little better about the risks than I had prior based on what the oncologist said. I don't think it's the worst thing to do, especially if knowing will help you or affect your treatment plan.

 

Krissy, I said the same thing about the x-rays not being straight. Nice to hear your more detailed explanation of what you're actually seeing. I actually thought the knee on the supposedly affected side looked fishy. It's much darker than the other knee near hte joint and traveling up into the leg. Is that a function of the angle as well?

Edited May 17, 2017 by NeylasMom

[winnie]

This is frustrating because we took Beatrix to a specialist vet. We were referred by our primary vet. He came highly recommend by two vet friends. We thought Beatrix may need TPLO surgery. Apparently he is an excellent surgeon, but his bedside manner was lacking. We were not adverse to having Beatrix sedated for x-rays. The staff there opted not too. He was also pretty definite that Beatrix has osteosarcoma and said there was nothing to be done. Now we've got others telling us that maybe it's not osteosarcoma, x-racks suck, need a bone biopsy, etc.

 

We don't have experience with other types of cancer to know if it will change our plans. We have been through osteosarcoma before and won't drag things out for our benefit when the end result is always death. However, now I've got people questioning if she even has osteosarcoma. I just want a clear diagnosis.

Edited May 17, 2017 by winnie

[NeylasMom]

I would probably shoot another email to Dr. Couto to make sure he got your x-rays. He's usually very quick to respond. See what he says first.

 

ETA: My two cents having gone through this a few times with the caveat that this was specific to greyhounds - imo specialists are generally very hesitant to diagnose cancer without some definitive proof, ie. the biopsy and the best you will usually get is "it's likely osteo, but it could also be this and this and this". If the specialist who did the x-rays, and who knows what he's looking at, felt strongly that it's osteosarcoma then my guess is it probably is. But without the definitive proof it's impossible to say and he could always be incorrect. Now if this was an orthopedist and not an oncologist, I would want an oncologist's input. Aside from Dr. Couto, is there an oncologist at the specialty clinic? If so, I would ask the ortho to consult with the oncologist, or even better if they have a radiation oncologist onsite have that person look at the x-rays and tell you what they think, whether you need better ones, etc. Having said all of that, if you really need to know, do the biopsy. Otherwise you won't have the definitive answer you seem to want.

Edited May 17, 2017 by NeylasMom

[winnie]

I would probably shoot another email to Dr. Couto to make sure he got your x-rays. He's usually very quick to respond. See what he says first.

Dr. Couto has the x-rays. I sent him another follow-up email last night. No response. I'm going to send both him and our primary vet an email later to ask their thoughts on a bone biopsy too.

 

I still very much appreciate any first hand accounts about bone biopsies in case we go that route.

[winnie]

Jen, just saw your ETA. The vet we saw on Friday who took the x-rays above is not an oncologist. We were there under the pretense it was a MCL/ACL injury. Oncology was not listed as one of his specialities (Dr. Morris bio - http://vrc-nova.com/surgery/meet-our-veterinarians/). They do not have an oncologist on staff from what I can tell

 

The vet who reviewed the x-rays as a favor to my vet friend at the barn is an oncologist (Dr. Stewart bio - http://www.vetreferralcenter.com/oncology.htm). She is not convinced it is osteosarcoma and is the one recommending the bone biopsy.

[NeylasMom]

Jen, just saw your ETA. The vet we saw on Friday who took the x-rays above is not an oncologist. We were there under the pretense it was a MCL/ACL injury. Oncology was not listed as one of his specialities (Dr. Morris bio - http://vrc-nova.com/surgery/meet-our-veterinarians/). They do not have an oncologist on staff from what I can tell

 

The vet who reviewed the x-rays as a favor to my vet friend at the barn is an oncologist (Dr. Stewart bio - http://www.vetreferralcenter.com/oncology.htm). She is not convinced it is osteosarcoma and is the one recommending the bone biopsy.

Gotcha. I honestly don't know if that makes me think it's osteo more or less. Frankly it was always our ortho guy who said this is probably what this is, while the oncologist wanted the "proof", but because she's a galgo I think it's a good idea to keep an open mind. See what Dr. Couto says and then if you still think there's a good chance it isn't osteo, I would set up a consult with an oncologist and be prepared to do the x-rays or biopsy that day if needed. There's a really great oncology team at Friendship AH in DC - it's a haul for you, but they're amazing. The one downside is in DC animals must be sedated for x-rays so I always had VOSM do the x-rays and send them. Let me know if you want more info - there's a doctor in particular I would recommend if you can get in with her.

[winnie]

Yeah, the vet we saw on Friday was pretty definitive despite not have oncology listed as one of his specialties. He was also not helpful in suggesting treatment options - guess vet surgeons have as good of a bedside manner as human ones.

 

I'm getting ready to e-mail Dr. Couto and our primary vet again (now that I'm not in a meeting on an iPhone). If we do pursue this further, I will see Dr. Stewart who is the oncologist that reviewed the x-rays for my vet friend - Springfield, VA isn't far from us. My vet friend said that Dr. Gordon there is friends with Dr. Couto and has an interest in greyhound cancers too.

[krissy]

Krissy, I said the same thing about the x-rays not being straight. Nice to hear your more detailed explanation of what you're actually seeing. I actually thought the knee on the supposedly affected side looked fishy. It's much darker than the other knee near hte joint and traveling up into the leg. Is that a function of the angle as well?

 

The good leg is only shooting through a single leg. If you look at the unaffected leg, it is whiter above the joint because it is laying over top of the thigh muscles of the leg underneath, so you are now effectively shooting through the thickness of 2 legs and you're not going to get the same exposure.

[NeylasMom]

Laura, if the Dr. Gordon you're talking about is the radiation oncologist who did Zuri's radiation (can't imagine it's not), I adore him.

 

 

The good leg is only shooting through a single leg. If you look at the unaffected leg, it is whiter above the joint because it is laying over top of the thigh muscles of the leg underneath, so you are now effectively shooting through the thickness of 2 legs and you're not going to get the same exposure.

Ah, cool, thanks.

[robinw]

Loca was diagnosed with osteo by a radiologist who specialized in canine cancer. I sent the X-rays to Dr. Couto who disagreed, stating that they showed normal bone superimposed on lung tissue (if I remember correctly).

 

I do know of several galgos who died of osteo, so it does happen. Hopefully that's not the case with Beatrix.

 

Can you call Dr. Couto?

[tbhounds]

I don't really see anything glaring. What specifically within that circle were they concerned about? Early tumours can be difficult to identify conclusively. The issue is this x-ray is not straight, so you can see the symphysis (looks like a black fracture line almost) and then on the lateral wing there's a bit of "extra bone", except that because it's not straight it could just be a normal part of the pelvis peeking out from underneath. On top of that there's a towel or a trough creating lines running right through the area of interest. Will be interested to know what Dr. Couto thinks since he reviews way more of these. But if it were my dog I'd consider re-taking these x-rays to get them straight, get the towel out from underneath (I know, it sucks with those bony backs) - consider sedation if necessary to achieve that. Better to give a little bit of sedation if it's an option and get it done in a couple of quick shots then struggle and stress the dog having to retake again and again trying to get it right, or settle for less than ideal shots like this one.

Could agree more. The only other thing I would suggest is go straight to a ct scan. You will receive better images and will have a radiologist read the scan. You could also potentially get an aspirate at the same time. Of course-honestly if you are only going to treat palliatively maybe just treat as you are and repeat rads (pelvis and chest) a month or two from now (checking for further lytic lesions and mets).

[winnie]

We're treating palliatively assuming it is osteosarcoma. We walked this path before and we know how it ends. We're inclined to let Beatrix go in the very near future rather than wait. Now doubts have been put in my head that it may or may not be something else. It's a complete rollar coaster of emotions. I just want a definitive diagnosis.

[greysmom]

My suggestion would be to have an oncology radiologist read the rads instead of all the vets. Radiologists specialize in reading xrays and are often able to be clearer about what they are seeing. Vets, despite all the extra years, don't read xrays for a living (no offense intended to any vet here!).

 

Maybe see if you can just talk to an oncologist about the different cancers it *could* be and see what sorts of treatment options are available for each. If they are basically all the same, will it really matter what it is??? Just my 2 cents.

[winnie]

I followed-up with Dr. Couto again yesterday and received this response this morning. So, rather than the bone biopsy, I think we'll take his advice and look into having a CT scan done first since that certainly seems less invasive. Based on my quick internet research, it appears to be roughly the same cost. We do not have pet insurance, but I'd like a definitive diagnosis even if it does not change our treatment plans.

 

Hi Laura; I am in Span lecturing at a Congress with other oncology colleagues and I just shared Beatrixs radiographs with them; we are concerned about a pelvic mass, but because she has so much poop in the colon, it is difficult to outline it (and for me, personally, to feel confident about the diagnosis). Do you know if they palpated any abnormalities in rectal exam? If she were my dog, I would strongly consider doing a CT scan to further define the problem. Please let me know and hope the girls is well,

Guillermo

[NeylasMom]

While its not technically invasive, it does require anesthesia and it takes time to get the images so she would be under anesthesia for a lot longer than she would for the biopsy. I can't remember how long Zuri was under for his, but at least an hour plus some extra time while they went back and forth giving me info so I could decide whether to have them do the biopsy while he was under. They are also very expensive (think MRI expensive). Our bill from that day was $2885, which I think was just the consult, CT scan & anesthesia and maybe some blood work.

 

CT scans are great diagnostic tools. If you're comfortable with the anesthesia and cost definitely consider doing it, but also consider getting the biopsy while they're doing it if they still aren't certain eyeballing the images. You don't want to have to put her under a second time for just that.

[winnie]

Thank you for the feedback on costs, Jen. That is certainly a lot more than my internet research estimates, but I'm guessing those didn't come from the DC Metro area. It's just frustrating not having a definitive diagnosis. Right now, only Dr. Morris is convinced it is osteosarcoma and this is not his area of expertise. We went to see him for a surgical consult for a possible soft tissue injury. I have at least three other vets who are not convinced that is what we are dealing with due to the location and that she is a galgo (not saying osteosarcoma can't happen in galgos, but it is less common). I'm not comfortable making an end of life decision without knowing what we're dealing with. The investment is worth my peace of mind even if the outcome is the same.

[NeylasMom]

Imo more info is almost always better if the risks are reasonable. One thing I will add, Zuri was really woozy after the scan and he really struggled when they brought him out. It makes me angry to this day because in retrospect he needed more recovery time before I took him and they never should have brought him onto the linoleum , but all if that aside, getting around is going to be a little tougher and they will have to manipulate her into potentially uncomfortable positions to get the images so be prepared for her to be more painful for a bit after. Zuri's was likely exacerbated by him slipping on the floor but he was worse for about a week. I had ordered him a Help Em Up harness, but of course it arrived after we got home that day.

 

And on second thought, he had a Zoledronate treatment that day, which would account for about $350 of the costs. And I remember now he did have bloodwork first, but you'll likely need that anyway.

[winnie]

Beatrix had her senior exam, including a full blood panel, about six weeks ago - right before this all started. So, hoping we don't have to repeat it.

[racindog]

A specialist told me re: my greyhound Ivy's possible osteo diagnosis that while there were risks (which he explained to me) in the biopsy it was in his opinion extremely important. He told me that there were other conditions (which he gave me example of) that can appear to be osteo but are not. He said the only way to be sure was to do a biopsy. He said that the overwhelming number of times there is no harm resulting from a biopsy. I took his advice and proceeded with one and while it confirmed the osteo diagnosis she had no ill effects whatever from the procedure. ESPECIALLY in Beatrix's case if it was me I would demand a biopsy- the peculiar location of the alleged osteo, her being a galga etc. Too many issues to take a chance with-to me I would have to know for sure before I could agree to put her through ANYTHING else. IMO she should tolerate the procedure quite well and who knows? The results might indicate something totally different. The whole thing depends on Dr. Cuoto though. Nobody knows better than him what to do imo-except for you-since you are her Mom. I agree whole heartedly with you: "I'm not comfortable making an end of life decision without knowing what we're dealing with. The investment is worth my peace of mind even if the outcome is the same."

[tbhounds]

While its not technically invasive, it does require anesthesia and it takes time to get the images so she would be under anesthesia for a lot longer than she would for the biopsy. I can't remember how long Zuri was under for his, but at least an hour plus some extra time while they went back and forth giving me info so I could decide whether to have them do the biopsy while he was under. They are also very expensive (think MRI expensive). Our bill from that day was $2885, which I think was just the consult, CT scan & anesthesia and maybe some blood work.

 

CT scans are great diagnostic tools. If you're comfortable with the anesthesia and cost definitely consider doing it, but also consider getting the biopsy while they're doing it if they still aren't certain eyeballing the images. You don't want to have to put her under a second time for just that.

Ct scans take about 5 minutes and most radiologist read the scan the same day (ours within hours) ;-)

Edited-the clinic I work for charges $1,250-that's all inclusive (consult, scan and report)-no other hidden charges but biopsy would cost an additional charge (biopsy, histo, coag..)

Edited May 18, 2017 by tbhounds

[NeylasMom]

I suppose it depends on what you're scanning. Zuri's took significantly longer than that, but we may have scanned a lot more of his body than some need to. Obviously cost would increase with that as well.

 

Great to hear that it may not be as much of an ordeal for Beatrix. Maybe Laura will do better on costs too. The consult alone for us was $255.

Edited May 18, 2017 by NeylasMom