Ear lump revealed to be possibly malignant melanoma

[Liung]

More good news: the oncology surgeon doesn’t think they’ll need to take his entire ear. He’ll be missing a really awkward chunk of it, since they’ll have to remove some cartilage to make sure the skin can be pulled over, but he does actually get to keep the majority of his ear!

“But wasn’t the point of doing the cytology to know that if it was malignant, to take bigger margins, and considering its location therefore take the entire ear?”

Well apparently for malignant tumours they’d usually go up to 3 cm margins, but considering the location 3 cm wouldn’t be possible even if they removed the entire ear. There’s just not enough skin to take that much and then get the incision closed. So they think they can just do 1 cm margins, and if histopathology comes back saying they haven’t gotten it all, they will suggest radiation.

... so why did I do the cytology?? Literally the reason they gave for the cytology was because if it’s malignant it’ll need larger margins, and so if we do the surgery without cytology first and then find out they didn’t get it all, he’d have to go through a second surgery to get the rest.

But now despite results showing its malignant they’re telling me that they are just going to go ahead with 1cm margins. Okay, knowing it’s malignant meant knowing to screen for metastasis, but we could have also known it was malignant after the surgery when it came up as such during the histopathology???

Yes there’s the whole “if you’d gone ahead with the surgery and it had already metastasized he might not have survived”, but at the point they suggested the cytology to me, everyone was pretty sure it was no big deal, and they were also telling me that one of the drawbacks of cytology was that it can be pretty unreliable and give inconclusive results. Even the results we got only suggested malignancy based on a couple cells in the sample.

I dunno obviously just doing the surgery and having him not survive it due to metastatic tumours would have sucked, but I feel vaguely scammed that they didn’t determine ahead of time that the size of incision wouldn’t be affected by cytology results, when they told me that was the main reason to do the cytology. The fact that he could not survive the surgery due to metastasis wasn’t brought up until after the cytology results came back and they wanted to do screening.

I might have gone ahead with the cytology anyway on the basis that if results had come back as benign, they could take smaller margins, and that actually was the deciding factor for me to agree to the cytology: possibility of less trauma and recovery time. But THEY didn’t tell me that. I came up with it on my own and asked them if I was right.

I’m still highly satisfied with the quality of expertise and care Lahi receives at the OVC, but **** they are test-happy.

 

[Popsicles]

I can see why you’re frustrated, but at least you know they aren’t going to miss a thing and he is getting gold standard care! Hopefully the 1cm margins should be enough, especially since the lump hasn’t changed much in all the time he has hadn’t it it would suggest a slow rate of local infiltration, so fingers crossed for him!

 

[Playdoh52]

Liung I am a new rabbit owner and have recently learned about muscle wastage. Muscle wastage is when the animal is sick, poor health, has an infection, or bad diet and the muscles are burning off to make energy for the rabbit to move to the food bowl, water bowl, or other thing. I have 1 rabbit with sever muscle wastage( had a double ear infection he did treat though) and have not learned anything from my local large animal vet so I set into researching what muscle waste was and how to treat it. Seems like since you have a senior rabbit maybe you need to look up the nutritional needs for a senior rabbit?? I had to switch my 3 rabbits from farm store rabbit food pellets to Oxbow Senior Essential Rabbit Pellets with all the needed nutrients. I also went to a local farmer and got some fresh cut orchard grass, alfalfa, and meadow hay mixture to feed all 3 of my rabbits. They all have gained more weight by eating fresh mixture of hay, and hopefully the right pellets will build up my sick's rabbit weight soon. Just got them yesterday. Look at the forum Thin Rabbit with Double Ear Infection to see my links..or search youtube for sever muscular loss of rabbit, or muscle loss in rabbit and you will find my 3 update videos so people on the forum could see what she looked like. She's improving though

 

[cwebster]

Playdoh52, glad your bunnies are improving with the diet change! Liung, will be hoping for the best for Lahi, am very glad he will be keeping most of his ear!

 

[Playdoh52]

I am so happy your bunny will keep most of her ear! Hopefully my white foot will be able to use both of her back legs again fully, but we will see what happens in time. In the mean time I think she will end up being the most tame of the 3 rabbits since she has been sponge bath washed, held for feeding and watering( in the beginning) and lives in our kitchen...lol never thought I would have a rabbit inside let alone 2 more in my basement in a make sift pin

 

[Liung]

Dropping Lahi off for surgery tomorrow at 8am, super nervous for him.

The fact that they told me initially that malignant would mean larger margins, and that now they’re telling me that they don’t think they can take 5cm margins and are just going to settle for 1cm margins... oh my god I’m so worried this isn’t going to work. They mentioned that if histopathology comes back to say that they didn’t get it all, they’ll talk to me about chemotherapy, but it’s generally very expensive and would require him coming to the OVC multiple times a week.

“And also... rabbits have highly delicate digestive systems that likely don’t react well to chemo?”

“Well yes, that too.”

They also said they’d offer a melanoma vaccine, though that would also be extremely expensive.

Okay I am completely anti-anti-vax, vaccines are among the most amazing things created ever! But...

Vaccines are preventatives. They give the body something to practice fighting so that if it encounters the real thing, there are already antibodies to it. How on earth would a vaccine help as a treatment??

Moreover, while I know some cancers can be caused by viruses, they are not viruses themselves. If Lahi caught the virus and it prompted the development of the melanoma... again, what on earth is the vaccine going to do to fight the cancer? Antibodies aren’t going to do **** against cancerous cells, that’s why cancer sucks so much. The body can’t typically differentiate deviant cells from normal cells.

Even if giving a vaccine after the virus has been contracted helps fight it... Lahi developed this lump in 2014. I’m not entirely clear if this means that he had the virus in 2014 and it’s always been a melanoma that developed malignancy this year, or it was a normal lump until he contracted the virus this year and it developed the lump into a malignant melanoma???

But if it’s the former, then a vaccine certainly isn’t going to do anything. Pretty sure he’d have all the antibodies he could have after four years with the thing.

Maybe I’m wrong, oncology certainly isn’t my specialty and my medical education is that of a veterinary assistant, but nothing I know about vaccines and how they work meshes with somehow doing something significant if it turns out the surgery isn’t successful.

The other thing they said is that they might want to remove his associated lymph node during the surgery, which, gahhhh. It’s so hard to look any of this stuff up, it’s either aimed at patients with no medical background and completely void of any helpful detail, or so thick with medical jargon and assumptions of a thorough knowledge of the subject that I can’t make heads or tails of it even with a basic medical education. We touched on lymph nodes during my program, but only really to talk about some of the things that can go wrong with them. I really haven’t any idea what the pros and cons of removing his lymph node are, and honestly I was surprised to hear that there is one associated with the ear. If you’d asked me prior to this I would have uncertainly guessed that there’s a lymph node in your armpit, and under your jaw. And also that manually manipulation to check for swollen lymph nodes is an important part of a physical exam.

I trust the OVC to know what they’re doing, they are literally the best of the best but at the same time it’s making me so anxious that I don’t have any idea what’s going on right now and have to trust them blindly. Just the fact that whenever they do a physical exam, they take him away to the back and don’t do it in front of me so I can watch them makes me anxious. It’s a teaching hospital, so obvs they do that because the DVM is narrating and demonstrating what they’re doing to a class of vet students... but dammit I want to be there listening to that too!

I really miss college where I had professors to patiently explain this stuff. More than a couple times I went up to my Surgical Ops prof all “so a medical thing happened and I don’t quite understand all the biological systems involved, can you explain them?” That was the best.

Also vaguely wondering if I’m going to need to get him a cone so he doesn’t try to touch his ear. He can get at his ears with both front legs to groom them and back legs to scratch them so it’s probably important. I remember someone telling me about cones they made for their sugar gliders, so it’s definitely possible.

Nose boops and bunny kisses to everyone!

 

[Popsicles]

Really good luck to Lahi, I’ll be thinking of him!
RE: vaccines - I don’t know the details of the melanoma vaccine but I do know there are vaccines that can work as treatments as well as preventatives. Off the top of my head I can’t think of the example we were taught (haven’t started my revision yet!) but it’s definitely a thing. So it’s very possible that this melanoma vaccine does the same thing, if the studies show that it works!
I was going to ask you whether they had taken the lymph node too - it is very good practice and you definitely want them to do it - there are several lymph nodes throughout the body, and each part of the body drains into the closest lymph node. By removing and testing the lymph node they will get a good idea of whether the tumour is beginning to metastasise as the lymph node is the first place it will spread to.
As for a cone, speak to your vet, but if you do get one it will need to be a soft one so he can still get to his caecotropes and groom properly. I would be reluctant to put a cone on a rabbit unless he is really bothering with the wound, but it really is a case by case discussion.
On a side note, if you ever need any help with “medical jargon” or anything needs explaining feel free to give me a message and I’ll see what I can do! I’m not far off graduating as a vet so my knowledge of technical terms should be pretty much all there by now haha.
Best of luck and keep us posted!

 

[cwebster]

Am wishing the best for Lahi and for you. Hope they get all the melanoma. I know how frustrating medical jargon can be...and i dont like it either when our vet takes our pets to a back room to do anything (drawing blood, getting a swab, whatever). I hope things wotk out well for Lahi...both of you deserve happy binky times now.

 

[Liung]

So Lahi had his surgery around noon today. A couple hours later they called me with the update: the surgery had gone well and he was just getting settled into an incubator for warmth while he woke up.

The bad news: they were unable to take the 1cm margins they wanted to, because there was a major artery in the ear that was in the way. They took what they could, but this is mildly concerning when the 1cm margins were already a concession to the location down from 5cm

They were unable to find the lymph node they had wanted to remove, and decided against going digging for it. This is concerning because apparently they’d felt a lymph node under his jaw during palpation last time, and being able to feel it at all likely means it was swollen.

The good news: Lahi made it through the surgery Safe and Sound and now at this point there’s no point borrowing trouble until results come back from that histopathology.

But **** got my hopes up hearing about the potential for that lymph node to really firmly tell if we got it in time. And now I’m worried that if it’s already swollen he potentially should have had to have it removed anyway?

He’s staying at the hospital overnight for pain monitoring, so that they can give him the Good Drugs. Once they’re sure he’s eating and pooping again on his own, they’ll be sending him home with me in the morning.

Extra bonus news: small possibility of upcoming pictures of tiny bunny in a Cone of Shame! A soft cone, so he isn’t uncomfortable, but gotta make sure he doesn’t scratch at the incision for the first few days.

@Popsicles thank you SO MUCH for explaining lymph nodes and such, it helped a lot.

I asked the vet about the vaccine and chemo/rad and other options but that was vaguely infuriating, IMO the melanoma vaccine she described to me doesn’t actually sound like it should be called a vaccine at all!! I’ll type that up in the morning cuz right now I’m crashing hard, didn’t really sleep last night out of stress

 

[cwebster]

Glad to hear Lahi is coming home tomorrow and made it through the surgery. A swollen lymph node can have lots ofcauses not just cancer. I have a swollen node they said is large because it is next to an artery. Hope they got the melanoma and that you and Lahi have a great long happy time together now.

 

[Liung]

Lahi is home and doing well. Let him out of the carrier to hop into the litter box on his own and the first thing he did was stuff some hay in his face, followed by quite an extended period of eating cecotrophs, then running up the ramp to eat a few bites of food and then fell straight asleep.

He’s shaken his head a couple times but otherwise hasn’t been bothering his incision at all. I did stop and pick up a Kong xs soft cone on my way to the OVC and showed it to the DVM, but considering how far down the incision goes she recommended against using the cone unless he starts really scratching. That’s more likely to happen around the 3 day mark when the healing starts to itch.




It looks like a pretty normal ear for now, but the DVM said that the missing chunk should become more obvious once the swelling goes down.

They’ve given me oral Sulfamethoxazole/Trimethoprim for antibiotics (Popsicles, is there a less mouthy name for this? She called it something much shorter, STP or some acronym but I’ve already forgotten), and then for painkillers oral Meloxicam and injectable Buprenorphine. I am so glad now that I already have training on SQ injections, I’d be terrified otherwise.

There’s also a suggestion in the discharge instructions to apply a cold compress 5 minutes twice a day, but I feel like putting pressure on a fresh incision is a pretty bad idea for today. Maybe tomorrow.

They also sent me home with some critical care since he wasn’t eating enough, but he seems to be eating now so perhaps it won’t be necessary. I’m going to do it anyway since getting more food than he needs certainly isn’t going to hurt him right now. Skinny little boy.

As to my consternation over the vaccine!

So when I was dropping him off I took the chance to ask the DVM to explain the vaccine. And I was recording the appointment because I knew there would be lots of stuff I wouldn’t be able to remember, so this is word for word:

“My understanding of vaccines is entirely that they are a preventative,” I said, “how does it help treat something that’s already there?”

“It creates an immune reaction to the cancer tissue, is the easy way to describe it. So it kinda forces the body to fight the cancer tissue.”

“But... isn’t the whole reason why cancer is such a problem that the body can’t differentiate...?”

“Yeah, so it’s trying to create that immune response, if that makes sense, create an immune reaction to it.”

“Okay, so it’s not actually a vaccine in the sense of cancer that’s been sparked by a virus.”

“Correct. So it’s not an infectious cause, it’s basically trying to stimulate the body’s immune reaction. The literature in dogs, it’s mainly used in dogs with melanoma, we don’t see it as commonly in cats, is very variable. Here we offer it for other species but we don’t know how much the benefit is. It’s a pretty pricey vaccine, it’s about $400 per treatment, and they need I think at least 4, and we don’t particularly know how much it would improve the outcome. It’s not to say we can’t do it, it’s very safe, it’s just whether or not it will be more beneficial.”

“Well, if the way you’re talking about it is like an immune agitator, that almost sounds like you’re inducing an autoimmune response, in the sense of just sending the immune system into overdrive. So wouldn’t there be some pretty serious possible complications in that?”

“They don’t really report serious complications in other species. And I’ve never used it in a rabbit, personally, so it would be a first time for us doing that, but side effects are pretty rare.”

Okay so MAYBE I’M WRONG but I’m pretty sure that that is completely outside the definition of a vaccine. A vaccine has a defunct virus in it. I do know that often the contents of a vaccine include an immune agitator to ensure that the body properly recognizes the defunct virus as an enemy (I know this because this is why it’s dangerous for people with autoimmune disorders to get vaccines, the immune agitator sends their immune systems completely off the rails and it starts destroying anything that remotely resembles an enemy)

But an immune agitator by itself... is just an immune agitator?? Not a vaccine????

And that still doesn’t explain how this gets around the problem of cancer cells being indistinguishable from normal cells to the body’s immune system. I do not understand in the slightest.

Anyway then she explained the chemo and radiation to me. I was saying that having seen first hand someone go through cancer treatment, I’m pretty against subjecting him to that level of suffering that may not even work.

She said that essentially the veterinary community agrees with that sentiment, it’s not fair to put a feeling creature that can neither consent nor understand why they are being put through so much misery through full-blown chemo and radiation. Veterinary chemo and radiation is much milder than the human version, because the goal is less to put the cancer into remission and more to manage the spread and maintain quality of life.

But it would be exorbitantly expensive and he would have to come into the OVC multiple times a week for treatment. That’s less of a problem for me since I live just 10 minutes away, but for others who are coming to the OVC Cancer Centre from across the province, that’s obviously a major consideration.

Ughh right now I’ve decided not to borrow trouble and wait until the histopathology results come back. It’s still very concerning that they were unable to get the lymph node, since they mentioned that it would be able to indicate very well whether or not the melanoma had gone metastatic, and the fact that they could feel it at all was concerning to them.

PS I lowkey wanna ask for a copy of Lahi’s xrays so I can, I dunno, frame it or something and show off. I already have his tooth in a jar, now I want a picture of his ickle bones.

 

[cwebster]

Liung, glad Lahi is home. Trimothoprim-sulfa-methoxazole is Bactrim.
https://www.everydayhealth.com/drugs/bactrim

 

[Popsicles]

Yeah Bactrim is one name for it, or the abbreviation you are probably looking for is TMP-SMX.
I'm really glad it sounds like Lahi is recovering well - particularly that he has a good appetite! Sounds like a very chilled out dude.

So, vaccines. Vaccines aren't always bits of virus, we can produce vaccines against any antigen. Antigens are the proteins expressed on the surface of cells, be that viruses, bacteria, or our own body cells. The combination of different antigens is what makes each cell recognise each other. For example, every "self cell" will have the specific antigen warning immune cells not to attack, which is how the immune cells know to attack anything that enters the body without that antigen, but not attack the actual cells making up the body. Each different cell type will also produce specific antigens. Melanocytes will have different surface antigens to other cells, and when those melanocytes undergo the mutation that causes them to become cancerous, those cancerous cells will have yet again distinct antigens. These mutations occur fairly regularly, and the immune cells usually know to kill any cells that display signs of being cancerous. It is when these cancerous cells go under the radar, for whatever reason, that we get actual tumours form, as the immune cells don't know they should be killing those cells. This is where the vaccine comes in. The vaccine is made using the antigens specific to cancerous melanocytes, combined with other immune-stimulating components, that tells the immune system to kill any cells with those antigens. Basically the vaccine gives a kick-start to the immune system to destroy any cancerous cells in the body, that were previously being ignored. I reeeeaaallly hope that made sense, I can explain further if you need!

I can also confirm that chemo doesn't affect animals nearly as much as we let it affect humans, so if that is a route you need to go down, the vets wont let him suffer in any way as a result of treatment. Really good luck with the results, I've got my fingers crossed for a complete removal with good margins!