Freesia’s fate

Skin tabs and beyond.

When I first met Freesia she was a 12-pound bundle of adorable, wiggly puppy. Over the years she grew into a typical Island Labrador, with typical Island medical issues. The occasional bout of fleas. Seasonal allergies. Skin problems. Sporadic ear infections. Annoying, but not worrisome. Then, at 7 years old, a pedunculated mass grew on her chest.  Pedunculated is a great word. Derived from the Latin for “foot stalk,” it means the mass attaches to the body by a narrow tissue band like a flower stalk. Pedunculated skin masses are often benign, but Freesia’s was in an awkward spot, dangling down and rubbing the floor when she laid down. Over time the surface began to ulcerate and bleed. “It’s probably just from the friction,” I told her owners, “but when a mass ulcerates, we worry more about malignancy.” We all agreed that even if benign, the growth was messy and cumbersome and should be removed.

Surgery went smoothly. The biopsy report came back with a diagnosis of “fibroepithelial polyp, ulcerated.” In parentheses, the pathologist added (skin tag). Aha. The comments went on. “The sample features a polypoid proliferation of dermal collagen and mildly hyperplastic epithelium consistent with a benign hyperplastic fibroepithelial polyp …  these may occur as a proliferative response to trauma or resolving furunculosis. … Prominent ulceration and associated inflammation [are] likely secondary to local trauma. No evidence of malignancy.”

That’s a lot of scientific jargon just to say that, as we had hoped, Freesia simply had grown a big honking skin tag that had rubbed raw on the rug. Phew. No cancer. Freesia was good to go. Two months later her annual physical exam found her in excellent health, although a little overweight. Then, four months later, in early December, Freesia came in again. The family had been away for two weeks on vacation. Freesia had been well-cared for in their absence, but on their return, just didn’t seem herself. At first, her owners thought perhaps it was an emotional reaction to their being gone, or maybe she had strained or sprained something. They tried keeping her quiet and letting her rest, but soon Freesia began to exhibit pain. “She’s moaning, especially at night,” her mom said. Freesia’s appetite was still good, but, well, Labradors do love to eat.

I looked her over. She wasn’t limping. She resisted my manipulating her neck side to side, but that didn’t seem to actually hurt. I palpated each limb, feeling for heat or swelling. I moved each joint checking for crunchiness (called crepitus), pain, abnormal laxity, or any altered range of motion. I systematically pressed each vertebra down her back. Everything checked out normally. “She’s having trouble getting up onto the bed,” her owner added, “and hesitates getting in and out of the car.”

I wasn’t worried. That history in a middle-aged, overweight Labrador?  Pretty common. Probably back or joint pain. Maybe a pulled muscle, or intervertebral disc disease, or degenerative joint disease (i.e., arthritis). Blood work ruled out Lyme disease or metabolic abnormalities. Since she was walking and eating normally, and I couldn’t find anything on exam, I doubted it was serious, and prescribed 10 days of anti-inflammatory pain medication, restricted exercise, weight loss,  and “tincture of time.”

Freesia felt much better on her pain medication, but very soon after finishing the 10-day course began limping on her left hind leg. I dispensed additional medication and suggested more rest. “If she’s not significantly better in two weeks, we should take radiographs,” I said, warning the owners that many musculoskeletal problems don’t show up on plain x-rays. Conditions like intervertebral disc disease often require MRI for definitive diagnosis. “But radiographs are our next step,” I concluded, “to rule out things like hip dysplasia.” (Yes, dogs can have dysplasia for years without showing signs, only developing symptoms later with age.) But Freesia couldn’t wait two weeks. Within days her lameness was worse, and the pain meds had stopped working adequately. We proceeded immediately with x-rays of her hips, knees, and spine.

For hip films, we place dogs on their backs, stretch the hind legs out parallel to each other, rotating the femurs inward. This may require anesthesia for good positioning, but Freesia was cooperative. I put the film on the viewing screen. Her hips and knees looked fine. But wait. What was that? Farther up the pelvis on the portion called the ilium, the bone looked funny.  Freesia was a big dog, so the whole pelvis wasn’t on this picture. “I need another film,” I said, my heart sinking. This was not what I had expected.

On the new film, Freesia’s left ilium was clearly abnormal — the bone mottled where it should have been solid, fuzzy and irregular where it should have been smooth. There was a remote chance this was osteomyelitis, i.e., a bone infection, but far more likely, it was cancer. “How would she get an infection there?” her owners asked. That’s the question, isn’t it? Unless Freesia had recently traveled to the southwest, fungal infection was virtually impossible. Bacterial infection was also extremely unlikely. “The only way to get a definitive diagnosis would be bone biopsy and culture,” I sighed. “But the odds are overwhelming that it’s cancer.” For some reason, all I could think of was that old fatalistic saying, “Sometimes you eat the bear, and sometimes the bear eats you.”

We consulted a specialist, who agreed this was almost certainly cancer. With the location and extent of the lesion, the prognosis was poor. At best, we were talking amputation, followed by chemotherapy or radiation. Freesia’s family opted to spare her such invasive procedures. We focused instead on palliative care, hoping to keep her comfortable, but it wasn’t long before the pain became too much and we had to say goodbye. Sweet Freesia. I had hoped those radiographs would just find something like arthritis in her hip or back; something she could live with to a ripe old age. But that was not to be. Sometimes you eat the bear …