1. When Enough is Enough: Ultrasound-Guided Ascent Into Heaven Ashley C. Barfield April 4, 2007

2. Winston Counterman 14-year-old miniature Schnauzer Several months of weight loss Vomiting 2-3 times a day for 3 days Decreased energy Small amount of diarrhea for 3 days Recent diet change

3. Labwork Abnormalities CBC Mild leukocytosis Moderate anemia Severe thrombocytopenia Chemistry BUN = 50 ALKP = 272 AMYL = 1287 TGL = 214 ALB = 1.9

4. Radiographic Abnormality RDVM noted decreased serosal detail consistent with abdominal effusion

5. The Good Stuff Large heterogenous splenic mass and multiple heterogenous nodules

6. Large heterogenous hepatic mass and multiple nodules Liver…It’s So Good

7. Kidney: Not just for breakfast anymore Bilaterally decreased corticomedullary definition, multiple heterogenous nodules, multiple cysts, one hypoechoic nodule

8. And the Badness Grossly enlarged and heterogenous right medial iliac lymph node

9. The Sauce Large amount of echogenic peritoneal fluid, consistent with hemorrhage (accompanied by a normal pancreas); aspiration yielded fluid hemorrhagic in appearance

10. Interpretation “These findings are consistent with metastatic neoplasia.” -- Tony Pease DVM MS

11. How to Save Winston? Aspirates of liver, spleen, kidney, lymph node Thoracic radiographs (additional met check) Transfusion and surgical resection of bleeding mass Surgical resection/debulking of other masses Chemotherapy and radiation therapy based on histopath results Serial imaging to monitor progress during therapy Winston’s owner elected humane euthanasia to prevent further suffering.

12. Pumpkin Rogers 12 year-old spayed DSH 6-month history of chronic weight loss Watery diarrhea of unknown duration No change in appetite or energy level No PU/PD or vomiting FELV/FIV negative indoor cat

13. Labwork Abnormalities CBC Mild normochromic, normocytic anemia Thrombocytopenia Hypoproteinemia Stress leukogram (elevated SEGS & monos, decreased lymphs) Chemistry Hypoalbuminemia Hypoglobulinemia Mildly elevated ALT Mildly elevated ALKP

14. Labwork Abnormalities Urinalysis 1+ proteinuria 4+ bilirubinuria T4 = 0.53 (1-4)

15. Again, the Good Stuff Mildly thickened small and large intestinal walls

16. Bowel walls also fluid-filled Top differentials: Neoplasia Inflammatory bowel disease

17. Hyperechoic kidneys with decreased corticomedullary distinction

18. Hypoechoic liver

19. Peritoneal fluid & possible pancreatic edema

20. IBD or Lymphoma? Full-thickness or endoscopic intestinal biopsies Mesenteric lymph node aspirates Liver and kidney aspirates

21. What if it’s the big K? Met check/staging Thoracic rads Peripheral lymph node aspirates Serial imaging during therapy Prognosis 6 months to >2 years severity of disease (histopathologic grade and tumor phenotype) response to chemotherapy

22. Pumpkin’s Situation Loss of 50% of body mass in 6 months Potential involvement of liver and kidneys Owners elected no further diagnostics Owners elected pred and ice cream therapy Pumpkin died at home the next day