Stating the Blindingly-Obvious

I was gonna title this "cancer sucks", but changed my mind for two reasons:

1. This is may not be the only post in the coming weeks/months that would want that title.
2. It's a statement of the blindingly-obvious (and, thusly, not terribly original)

Vet contacted me, today, about Lady. The initial test-results were not confirmative of insulinoma. He said this wasn't surprising because, while her blood sugar levels were quite low, they weren't in the range typically necessary for a blood-draw to be definitive for insulinoma. Worse, just because the sonogram showed a obvious, consolidated tumor in her liver, that no tumors were visible in her pancreas isn't definitive of primary hepatic cancer. It's notionally possible that she could have pancreatic tumors that are too small to see on sonogram - even if they were the primary source of the cancer in her liver. It's a concern because primary hepatic cancer is rare in dogs. So, while she could be lucky - inasmuch as having life-threatening cancer in the liver can be - and have primary cancer of the liver, the odds are against that.

This left me with a couple options:

• Do the oncology consult (scheduled for the morning of July 15th) without doing more to eliminate the likelihood of insulinoma
• Drop her off at the vet, tomorrow, for some additional testing

Since it would be horrible to subject her to liver surgery if one could know that it was both unnecessary and make her spend her remaining weeks recovering from major abdominal surgery, I'm opting for the additional testing. Unfortunately, those tests can still produce a non-definitive diagnosis: like many tests, they're ok for confirming a positive diagnosis (that she has insulinoma) but not for confirming a negative diagnosis (that she absolutely doesn't have insulinoma). For potential longevity sake, I obviously hope for lack of a positive diagnosis from the tests. 

Unfortunately, the tests aren't without risk. They have to fast her to see if her blood sugar drops enough to get a definitive positive test result. Fasting her to that point puts her at risk for seizures and worse. Primary thing going for her is that she'll notionally be being closely-enough observed during the fasting that (if she does have insulinoma) that she would be caught low enough to test yet not so low that she suffers neurological impairment (that would necessitate an even earlier departure than pancreatic cancer, by itself, would have caused).

Still even if the fasting-blood-tests don't prove confirmative of pancreatic cancer, proceeding with surgery isn't a slam-dunk. They could open her up, do the liver resection, send off the excised tissue for biopsy and still find that it wasn't primary hepatic cancer. Meaning, that I potentially put her through abdominal surgery for nothing and put her in pain for a non-trivial chunk of her remaining time with us.

I imagine, if tomorrow's tests are non-confirmative, one of the things that we'll discuss at the oncology consultation is further pre-surgical testing. And whether they could be conducted as part of a larger, contingent procedure. That might be something like, "do an MRI (or something) and, if that comes back clean, only then move on to the resection."

Problem is, dogs, unlike humans, can't really be given an MRI without general anaesthetic. That means either doing one, long sedation for the MRI and then surgery (if the MRI were clean). The longer anything is under general anaesthetic, the riskier things become. Notionally, could do separate procedures, but that has its own risks: 1) two applications of anaesthetic in a short period of time is risky; 2) liver cancer is aggressive enough that the delay between discreet procedures likely results in the growth of the existing tumor and/or possibly allow time for it to metastasize even if it has yet to do so. And, risks to Lady aside, there's also the financial impact: doing the additional testing also markedly increases the costs of an already expensive procedure.

My primary concern is that I do the most good for the least amount of harm. And, if I can't do her any good, I'd like to at least not do her any further harm than whatever bomb ticking in her abdomen is want to do.

There's just not a lot of good choices, here.