By Dr. Becker
Today, I'm filming at my practice, Natural Pet. I decided to include my newsletter readers in how I go about determining when to remove lumps and bumps on a pet. As it turns out, my dog Violet needs to have two masses removed, so I'm going to walk through the process of determining how, why, when and what to do about lumps and bumps when you find them on your pet.
I say "when" you find a lump or bump, because if your furry companion is blessed to live long enough, it's not a question of whether your dog or cat will develop a skin tag, sebaceous cyst, wart, tumor, or fatty mass called a lipoma – it's a matter of when. This is because as pets age, just like humans, their skin doesn't remain beautiful and flawless. Most humans even at midlife are dealing with skin tags, discoloration, and lumps or bumps that are benign in most cases.
It's important, as the terrain of your pet's body changes, to have new lumps and bumps evaluated by your veterinarian. My first recommendation -- as you're doing your routine at-home wellness checks of your pet and you find something that feels different on the skin – is to part the fur and take a closer look with a light source like a flashlight. It's important to identify things that have been there awhile and things that are new – or things you aren't sure were there last week but are there now. It could be something as simple as an insect bite or a scab, or it could be something you can't identify.
Animals can develop sebaceous cysts or pimples very quickly -- even overnight or during the day while you're at work. It's rare that these lumps or bumps require emergency action. Occasionally, a mass like an abscess or boil may require urgent care. If your pet is really uncomfortable and you know the mass is growing or changing, you'll want to make an appointment with your vet, preferably within 24 hours. But rarely is it necessary to visit an emergency animal hospital or make an emergency appointment with your vet because of a lump or bump.
A Lump or Bump That Is Rapidly Growing or Changing Should Be Evaluated by Your Veterinarian, and Sooner Rather Than Later
What I advise my Natural Pet clients to do when they find a lump or bump is to monitor it. If the mass is growing or changing quickly, it's best to see a veterinarian sooner rather than later. If you notice there is, for example, a discoloration on the skin or what looks like a skin tag, and it doesn't get bigger or change over the course of days, weeks or months, then just mention the area to your veterinarian at your pet's next wellness exam. But again, if the area is changing rapidly, you do need to have your pet seen by your vet as soon as possible.
In my dog Violet's case, I noticed she had two very small pea-sized lumps on her body. They were firm, and I could move them around under the skin. I knew they were new lumps, and I decided to monitor them. Over a period of time, both lumps grew larger and firmer, so I did exactly what I advise my clients to do, which was to evaluate them.
I performed what is called a fine needle aspirate. It involves inserting a needle into the lumps, extracting cells, and typically, sending samples to a pathologist for evaluation and a preliminary diagnosis.
In Violet's case, I stained the slides myself and looked at them in-house with my microscope. I didn't like what I saw. The cells had a high mitotic division rate, meaning they were replicating quickly. I sent the slides out for a second opinion. The pathologist thought there could be spindle cells, which can indicate a tumor -- cancer. He suggested the lumps be surgically removed, and today is the day.
My Two Rules of Thumb for How to Treat Growths on a Pet
This is a slightly different approach than what I learned in veterinary school, where students are taught that if a pet owner brings up a lump, bump, skin tag or mass, you should suggest removing it because the vet makes money and the client goes away happy.
Following that instruction means lots of pets will be undergoing anesthesia on a regular basis. For many lumps and bumps, removal is totally unnecessary because the masses are benign and there's nothing to worry about as long as they don't impinge on the pet's quality of life or longevity. As long as the mass isn't cancer and doesn't impede the animal's movement or quality of life, there's no reason other than aesthetics to lop the thing off. In my opinion, the risk of anesthesia and surgery far outweighs the benefit of having a lump-free pet.
My two rules of thumb are:
- If the fine needle aspirate shows there's something dangerous brewing, like cancer, then surgically removing the mass will give the pet the best chance to be cancer-free. So you need to go to surgery.
- If the fine needle aspirate shows the lump is benign, which means there are no abnormal cells and nothing to worry about, then leave things alone.
Of course, I always mark down exactly where the mass is, the size, the date, and the results of the fine needle aspirate on the animal's body chart. Then I measure the mass and check for changes each time I see the pet at future appointments.
The only reason other than cancer that I recommend surgery for lumps or bumps is if the patient's quality of life is compromised. For example, skin tags that grow on the margins of a dog's or cat's eyes are entirely benign, but because they are on the eyelid, as the pet blinks it can cause corneal irritation and pain. In a situation like that, even though the mass is not cancerous, I do recommend surgical removal because it's causing the animal discomfort.
Another example is warts on dogs. They can be very itchy, and a dog can spend the entire day licking and chewing the area. The pet parent returns home from work to find a big, open, bloody wound on the dog. The wart itself is benign and harmless, but the patient's quality of life is suffering because of the itching and self-wounding. In such a situation, most veterinarians would recommend removing the wart, as would I.
Why Every Lump or Bump Should Be Evaluated Using a Fine Needle Aspirate Procedure
In Violet's situation, because her fine needle aspirate came back with questionable cells, we're going to proceed with surgery to remove those lumps. I'll excise them (cut them out) and send them to the pathologist for determination of what the cells are. If the cells are worrisome, I'll follow up the surgery with an appropriate integrative protocol. If it turns out the lumps have a high cellular replication rate but are benign, I won't need to follow up other than with a mild detoxification protocol to help her body rid itself of the anesthesia drugs she'll be given.
The importance of the fine needle aspirate procedure can't be overstated. Veterinarians aren't psychic. Once in awhile a client will say, "My vet felt this mass and said it needs to come off." The problem with this approach is we don't know what's going on inside that mass unless we extract some cells from it and evaluate them. So I always recommend doing a fine needle aspirate.
Another reason for a fine need aspirate is there are some types of tumors that need to be excised very widely. For example, mast cell tumors need to be surgically removed in most cases, and they need to be excised with a very wide margin (removing the tumor plus surrounding tissue). When a vet does no more than feel a mass and advise it should be removed, if it happens to be a mast cell tumor and he or she does a very small cosmetic cut to remove only the mass, fingers of tumor cells can be left behind to slip down into deeper tissue. That's why I always get a confirming diagnosis with a fine needle aspirate – so I know what surgical margins to take based on the type of tumor I'm dealing with. This is an extremely important aspect of tumor removal.
Still another reason for a fine needle aspirate is that some tumors require the expertise of a soft tissue surgeon. I'm not a soft tissue surgeon. My practice is 90 percent internal medicine and I also treat a lot of exotic pets. If Violet's fine needle aspirate showed a deep-seated cancer, I would have asked the soft tissue surgeon I work with to complete the surgery because that's his area of expertise. But in this case, I feel very comfortable excising Violet's lumps myself.
This is a good question to ask your veterinarian – does your pet's lump or bump removal require the expertise of a special type of surgeon? For example, if Violet or another of my pets had a bony tumor, I would ask the orthopedic surgeon I work with to step in, because bone surgery is not within my area of expertise. Your vet should not be offended by such questions. Questions like, "Do you feel comfortable doing the surgery?" … "How many have you done?" … "Would you feel better if I went to a soft tissue surgeon or an orthopedic surgeon for the procedure?" … "If my pet has to spend the night, who will be here to take care of her?" -- these are all questions you should feel free to ask your veterinarian, even if you've been a client of the practice for years. Protocols change and evolve. You should feel very confident that your vet is comfortable performing a procedure on your pet.
It's Important for Pet Owners to Be Informed About Anesthesia, Pain Management and Recovery Procedures Used by Their Veterinarian
At my practice, we have a form, "What's Different About Anesthesia at Natural Pet?" It goes over some of the basic questions about surgeries requiring general anesthesia, like "What are we going to do for pain management?" In my opinion, if your pet is about to be cut with a scalpel, he requires pain management. Period. Some vets believe pain will help "keep a pet quiet" and resting while he heals. This is simply not true. What we know about pain is that it inhibits wound healing.
In my opinion, there is no reason and no excuse not to administer excellent pain management. If you're nervous about having your pet on pain medications, I can assure you your dog or cat will heal better, with fewer complications, if you accept a pain management protocol for your furry family member. The type of pain management -- the dose, the category of drug, the addition of natural supplements – will be based on the procedure(s) your pet undergoes, her age, any concurrent medical conditions, and what type of medicine your vet practices (for example, traditional Western, holistic or alternative, or integrative). But pain management must be addressed in my opinion.
Another thing you should ask your vet is what type of anesthesia will be used. Hopefully, your vet is using up-to-date inhalant anesthesia. At Natural Pet, we use an inhalant anesthesia called sevoflurane. Isoflurane is another commonly used inhalant anesthesia. It's important that your vet is using one of those two inhalant drugs.
You can also ask about pre-op medications. We recommend a drug called butorphanol, which is what I'll be using with Violet today. The great thing about butorphanol is that it helps reduce the amount of inhalant anesthetic a patient requires during surgery. It will help to keep Violet's drug dose low. But we also know that butorphanol blocks some pain fibers. What we know about giving pain meds prior to surgical procedures is they help reduce the amount of intense pain a patient may experience by blocking pain fibers before the procedure even begins. That's smart medicine, in my opinion.
At Natural Pet, we have certified anesthetic equipment, which means an independent company visits annually to check all of our equipment to make sure everything is working exactly as it should.
Asking your veterinarian about recovery is also very important. Don't let anyone tell you that anesthesia is routine and nothing to worry about. Anesthesia is anything but routine, because what it does is keep a patient hovering between unconsciousness and death. That's a fine line, and one that must be closely and carefully monitored. Mistakes can be fatal.
A pet's recovery from surgery is also critically important. Maintaining body temperature before, during and after a procedure is important. When I perform any procedure, I have a technician that remains with the patient the entire time and does not leave the animal's side during the recovery process.
Anesthesia monitoring during the procedure is another important area you'll want to ask about. Are they monitoring temperature, pulse, respiration and oxygen levels? Your vet should be able to answer "Yes" to each of those questions. I have clients who learned to ask these questions of their regular vets, and elected not to use certain practices based on responses like, "Well, we don't really have monitoring equipment. We just look at the color of the tongue." That's a huge red flag. I would never recommend putting a pet under anesthesia at a practice that doesn't have up-to-date anesthetic monitoring equipment. Checking the color of an animal's tongue as the only method of anesthetic monitoring is unacceptable.
Another thing to understand is there's no cookie-cutter anesthetic protocol for all pets. If an animal has kidney disease, liver disease, cardiac disease, is older, or has a chronic medical condition, the anesthetic protocol should be adjusted to accommodate the individual needs of the patient.
Preparing for Your Pet's Surgery
Violet is a very healthy dog. She's almost nine and has no medical issues. Her pre-op bloodwork is perfect. That's another point I want to make. Don't let any veterinarian anesthetize your pet without checking vital organ function (via bloodwork). I never anesthetize an animal without checking organ function, because I need to be absolutely certain the organs of detoxification are capable of doing their job.
Probably the biggest risk associated with anesthesia is when the body is incapable of processing the anesthesia drugs. That's when unexpected deaths occur. By checking vital organ function, we can evaluate the potential for kidney or liver dysfunction and forego the procedure if the risk is too great. Insuring organ function is normal is an important aspect of using anesthesia safely.
On the day of surgery, your vet will ask you to fast your pet. That means no food or water for a specified number of hours prior to the procedure. How long your pet must be fasted generally depends on the drugs your vet plans to use.
Violet had dinner last night, and she had water up until midnight, but she has not consumed any food this morning. If your pet sneaks food or you forget and give her food or water, tell your veterinarian, because the GI tract needs to be empty and rested. If an animal consumes food or water too close to undergoing anesthesia, the chances of vomiting and aspirating are much greater, and the situation can become life-threatening. So if your pet sneaks something or you forget and feed or water him after the deadline, be honest with your veterinarian the morning of your pet's procedure.
So here's our patient, Violet, who happens to be my own dog. She has two lumps that developed suddenly. I noticed them when they were pea-sized, but now they're about the size of a quarter. They are growing rapidly, they contain spindle cells that could indicate cancer, and so they're coming off based on my #1 criteria: something dangerous could be brewing in those lumps. Of course, Violet doesn't even know she has lumps. She has no idea why she's here today. The lumps don't bother her, but they bother me because the fine needle aspirate told me there are some weird cells involved.
Some people worry that if the fine needle aspirate comes back benign initially, who is to say the lumps will still be benign in two or three years? That's a great question, and what I suggest to clients is if the fine needle aspirate comes back benign, just relax. There's no need to worry unless the mass grows or changes. If that lump stays the same, we can be confident nothing is happening to the cells inside the lump, and there's truly nothing to be concerned about.
Lumps should be regularly monitored, however. If the mass changes in size or appearance, it needs to be re-aspirated even if previous diagnoses were benign. The thing with cancer is that the cells always replicate. They're always growing. They can be slow growing or very aggressive, but regardless, they replicate faster than normal cells. If a lump on your pet has never changed size, the chances of cancer are slim to none, because the size hasn't changed. If on the other hand you have a pea-sized lump that suddenly quadruples in size, it's time to do another fine needle aspirate.
Now, even though I don't advocate anesthesia to remove benign lumps and bumps, I do ask clients whose pets need a surgical procedure if there's anything else they want me to take care of while the animal is under. Violet has some skin tags and a few warts – as I mentioned, she's almost nine. I'm going to leave all those alone. But if for example she had bad teeth (she doesn't) – if she needed a dental procedure – now would be a good time to do it. Put her under anesthesia once and get everything taken care of.
Violet does have a rather large skin tag, and it's growing. It creeps some of my family out, but not me. I told them we should refer to her dingleberry as her "beauty mark." They're not buying it. Anyway, here's her skin tag – hopefully you can see it. It's large and growing, but totally benign. There's no medical reason to remove it. But because it will take me all of 30 seconds to remove it while she's already under anesthesia, and because some of my family members think it's gross, I'll take it off.
If Violet's only issue were her giant skin tag, I would never recommend anesthesia just to remove it. It's totally unnecessary. But because she'll be out anyway for removal of the two masses, I'll add one small cosmetic procedure and snip off the skin tag. I'll also be trimming her nails. She doesn't like nail trims, so I'm going to do it while she's out. So if you have a pet that doesn't like nail trims, like Violet, ask your vet to do a pedicure while your dog or cat is under anesthesia for another procedure.
Violet Receives Her Pre-op Medication
So now I'm going to give Violet her pre-op medication. My vet tech, Ashley, will hold Violet while I do the injection. This medication is to reduce the amount of anesthesia necessary. It will take about 20 minutes for the drug to relax her, so we're just going to hang out with her while she gets sleepy.
I'm also going to apply some essential oils. This one is called Peace & Calming, and I'm applying it to the tips of Violet's ears and on her spine. She's actually quite nervous right now, so using essential oils will help support a calm experience for her as the butorphanol starts to relax her.
Now that Violet is beginning to relax and we have her on the surgery table, I'm going to put a catheter in her front leg. The reason it's important to have a catheter is that if there are complications (which we don't expect, but it's important to prepare for them) and I need to administer medication – let's say her heart rate drops and I need to give her some drugs to get her heart rate back up – I need to have a really easy, already established point of entry for those medications. So I'm going to pop a catheter in. As you can see, the butorphanol is working. She's starting to really relax now.
Violet is on a heated surgery table, which is very important. Your vet may not have a heated surgery table, but he or she should use some type of heated blanket to maintain your pet's body temperature. Violet is maintaining her own body temp right now because she's not yet unconscious, but once she is, she'll appreciate that extra heat.
Okay, the catheter is in. Pre-op meds are on board. We are now going to induce Violet under anesthesia, which means I'm going to inject the drug propofol into her IV. This will take her rapidly from a conscious state to an unconscious state. Once she's unconscious, I'm going to put a tube down her trachea and tie it to the roof of her mouth. We're going to fill the cuff of the tube with air (which will form a seal in her trachea). This is to make sure, of course, that we're keeping her trachea, larynx and glottis open in the back of the throat so we can administer gas inhalant anesthesia and 100 percent oxygen to her lungs and keep any debris, mucus and fluid in her mouth out of her trachea.
Putting Violet Under Anesthesia
I'm giving Violet the propofol slowly now as she takes some nice, deep breaths. Her eyes are getting heavy. She's fully unconscious by the time I finish injecting the propofol.
Ashley's going to check her jaw tone now (this is how we assess if she's ready to put the trach tube in) so we're propping her up so I can see down her throat. And Ashley will hold her mouth open while I move her tongue out of the way and feed the tube down the back of her throat and into her trachea. I'm going to tie it to the roof of her mouth, and we're going to get her started on 100% oxygen and inhalant gas anesthesia by attaching her tracheal tube to the oxygen and anesthesia tube.
At the same time, I'm going to put a smaller tube down her esophagus, which is going to monitor her temperature, pulse, and respiration. And then we're going to hook a clip on her tongue, which will monitor the oxygen-carrying capacity of her bloodstream. The beeping noise -- we've come to love that beeping. It tells us the patient has a nice strong heart rate. Ashley will lubricate Violet's eyes so that her corneas don't dry out. And I'm going to start some fluids, some lactated ringers, which is an electrolyte fluid solution, to help keep her blood pressure up and her body hydrated during the procedure.
Now, this is Violet's dingleberry (her giant skin tag), which I'll be removing as a cosmetic procedure because it's unsightly and bothersome to my family. We would never perform anesthesia just to remove a benign skin tag. But because she's out we'll take advantage of it. This is one scary mass we're going to remove right here, and this is the second scary mass we're going to remove. Ashley's going to clip the hair and clean these areas to get the skin prepped for surgery.
Removing Violet's Masses and Skin Tag
Okay, Violet has been clipped and cleaned. All three sites have been prepped. Ashley will re-prep as we go along. I'm just going to remove the first lump. I will carefully cut it off, and put it in the specimen container.
Okay, the first one's done. I'll hand off the mass to Ashley, who will pop it into a formalin jar, and we'll submit it for pathology.
Now, I'm just putting in a last stitch here in the first incision, and we'll move along to the second tumor.
Okay, we're done. We've removed the second mass. The second mass was slightly larger, so I cut it in half to allow the formalin to infiltrate the mass. I'm going to pass this one off as well to my lovely assistant. All we have left is Violet's benign skin tag, which will come off incredibly easily with just a little lick of the scalpel.
Right now, I have a hemostat on there to help occlude any blood supply to the tumor or the skin tag. I'm going to easily and gently remove that little dingle just like that. And that will make my entire family much happier because it's gone. Tada!
Now, we're going to start waking Violet up. Ashley's going to turn the gas off and we'll let the oxygen flow continue until she regains consciousness. We'll leave her tracheal tube in until she's able to swallow. Now we'll do a little cleanup of her incisions, I'll get out of my surgical apparel, and Ashley will perform a pedicure.
Violet's Recovery from Anesthesia
Violet's procedures are done. All of her masses came off fine. She was totally stable during anesthesia. We've turned the anesthesia off and she's breathing 100 percent oxygen. She will start blinking and swallowing soon. Once she regains those reflexes, we'll take the 100% oxygen away, and breathing room air will actually help facilitate her waking up process.
Ashley's going to hang out with Violet, check her vitals, and monitor her temperature. She has a hot water heating pad on her to help maintain her body temperature. Ashley will check her body temperature every three or four minutes until she's awake.
Now, Violet has been off the surgery table for about 15 minutes. The tracheal tube came out. She's breathing room air on her own. She's recovering fine. She's peaceful. She's got great pain meds on board. Temperature's fine and stable. She'll probably get up and try walking in a few minutes. She'll go home in a few hours. It's important when your dog or cat is recovering from anesthesia that she is alert, awake, and able to walk before going home.
You should feel free to ask your veterinarian any questions you have about the procedure. Your vet won't have answers about the masses right away, because they must be sent to a pathologist who will examine them microscopically. In about three to five days, I expect the pathologist to provide a report on Violet's masses, at which time I can make an appropriate treatment plan.
Keep in mind that anesthesia shuts down the GI tract. So Violet won't poop for at least a day, maybe two. Tomorrow, she's going to take it easy. It's important that she doesn't lick her incision. We'll either put an E-collar on her, or a t-shirt to make sure she's leaving her incisions alone. I want her to take it easy for the next few days, not have a lot of exercise and just allow her body to recover from the anesthetic.
I will be giving her milk thistle, which will help her liver detoxify from the medications and the anesthesia. Probably by tomorrow afternoon, she'll be wondering why we're making her rest!
Hopefully, this video will help you make more informed decisions about the lumps and bumps on your pet that you choose to remove, how you choose to remove them, and a treatment protocol that makes you feel good about the anesthesia involved in this type of procedure.