Portal site metastasis after thoracoscopic resection of a cranial mediastinal mass in a dog Sarah G. J. Alwen, msc; William T, N. Culp, van; Anna Szivek, pv, Philipp D, Mayhew, pvmes; Christina D, Eckstrand, pvw Case Description—An {T-yearcld castrated male Vsla was evaluated for excision of a cranal mediastinal mass. Clinical Findings —Tho dog had a 1-month history of a cough that had recently inereased in frequency. On physical examination, the dog had a grade 2/6 left systolic heart murmur and multiple subcutaneous masses. A soft tissue mass was observed in the craniovental ‘aspect of the thorax on rad agraphs. Rasults of a CT scan revealed a wol-defined, 2.8 X3.2 X.9-em soft tissue mass in the cranial mediastinum, Treatment and Outcome—The dog underwent video-assisted thoracoscopic removal of the mediastinal mass and recovered routinely. Histologic examination of excised tissues revealed malignant thymoma. Approximately 6.8 months after surgery, the dog was evalue ated because of polyuria, polydipsia, decreased appetite, and vomiting. On physical exami- Nation, masses were fouind in both axilary regions. Resuts of serum biochemical analysis, indicated hypercalcemia. Thoracic ultrasonography revealed pulmonary metastases and 3 large mass n the right caudoventral region of the tnorax. The dog recewved supportive care and medical treatment for hypercalcemv, but clinical signs recurred, Euthanasia was elect- fed; necropsy and histologic examination revealed thymic carcinoma: Conclusions and Clinical Relevance—Descriptions of the development of portal site me- stasis in canine patients are rare. In this patient, portal site metastasis developad rapialy after thoracoscopic resaction of a malignant thymic mass and was associated with hyoer calcemia, As use of thoracoscopic procedures increases in veterinary medicine, it wil be important to monitor the development of major complications such as those in the pati Of this report. (J Am Vet Med Assor 2018;241:793-800) hl LL-yearold 21.6-kg (47.52-Ib) castrated male Vizsla was evaluated at the University of Califor- hnia-Davis Veterinary Medical Teaching Hospital for ex- cision of a cranial mediastinal mass. The dog had been evaluated at the same teaching hospital approximately 10 months prior to this examination, and a grade 2/6 heart murmur had been detected incidentally. Three: view thoracic radiographs were obtained at that time and revealed a radiographically normal eardiae silhou- ttte; a solitary nodular solt tissue opacity was observed in the cranial mediastinum on the right lateral thoracic radiograph: ‘One month after the murmur was detected, tho racic radiography was repeated, Evaluation of 3-view thoracic radiographs indicated no clinically relevant changes since the prior examination, with cardiovas- cular structures noted (o be within anticipated limits Results of a CBC and serum biochemical analysis were within the respective reference ranges. Abdominal ul- trasonography performed at that time revealed a round, From the Departments of Veterinary Sugial and Radiological Sc ces (Alen, Culp, Saitek, Mayhew) and Pathology. Microbiology Sd lnmsunology Eckstand, School of Veterinary Medicine, Unt. versity of California Davis, Davis, CA-95616, Dr Seveks present ares is Department of Clinical Scences, Collegeof Veterinary ‘Medicine. Misissppt Sate Unversity, Satie, MS 39738 Addiesscotespondence to Dr Culp (weulpBuedavised). ‘Aereviarion, VATS __Video-assisted thoracoscopic surgery ill-defined, 0.6 X 0.7-cm hypoechoic nodule in the spleen, The nodule did not deform the splenic capsule and was suspected to represent nodular hyperplasia Fine-needle aspiration of the splenic nodule was not pursued, No other abnormalities were found on ab- dominal ultrasonographic examination, Investigational ‘options for a future visit, inclading repeated thoracic radiography and CT, were discussed with the owner. The dog was reevaluated 5 months later. The owner reported that the dog was doing well at home, and no coughing had been noted at that time. On 3-view tho- racic radiographs, the cardiac silhouette was within an: ticipated limits, A 2.5X3.5-cm soft tissue mass was more clearly evident in the cranioventral region of the thorax fon the right lateral projection (Figure 1). The mass was not observed on the opposite lateral or ventrodorsal pro- jections, Two months later, an additional 3-view thoracic radiograph confirmed the presence of a 2.5 X3.5-cm soft tissue mass cranial to the cardiac silhouette with a mod: erate diffuse bronchointerstiial pattern and mild widen- {ng of the cranial mediastinum, The location of the mass precluded aspiration, and CT was recommended, TAM, VoI2A7 N70 Scents Ropons 798 SayEmit ey ‘The dog was reevaluated 1.5 months later because of a L-month history of a dry, hacking, nonproductive sporadic cough that was most notable when the dog ied to swallow; the cough had recently been increas: ing in frequency, No vomiting or regurgitation had been observed at home, and the results of physical ex- amination were unremarkable except for the previously detected heart murmur and multiple subcutaneous masses (lipomas). Results of hematologic and serum biochemical analysis were within respective reference ranges. The possibility of a CT examination and surgi- cal treatment options, including possible thoracoscopic removal of the thoracic mass, were discussed with the owner. The owner elected to proceed with CT and sur- gery 2 weeks later (approx 10 months after initial de- tection of the mediastinal mass), ‘The CT images revealed a well-defined sof tissue rass in the cranial mediastinum that measured 3.9 cm ventrodorsally, 32 cm lateromedially, and 2.8 cm cra- jue 1—Rignt lateral radiographic view of the thorax of an 5 Sysuraieastreted mal Viste tas was saluted for excision ot tani met astnal Pass, Novea the mass aro in the erenion rental espest ofthe thorek.® Right niocaudally. A mediastinal lymph node was visualized and appeared mildly enlarged. There was increased density and voluine loss at the periphery of dhe caudal aspect ofthe left cranial lung lobe, which was compat: ible with atelectasis, After administration of nonionic jodinated contrast medium there was mild heteroge- neous enhancement of the cranial mediastinal mass (Figure 2). The mass was located caudal tothe internal thoracic arteries and vental to the cranial vena cava however, these structures did not appeat to be invaded by the mass. No evidence of pulmonary metastasis was detected Tollowing the CT, the dog was prepared for VATS removal of the mass, Morphine sulfate (1-0 mg/g [0:45 mgfbl, $C) and atropine sulfate (0.02 mg/kg, {0.009 mgfbl, SC) were administered as premedications, and general anesthesia was induced with ketamine hydro Chloride (52 mg/kg [2.4 mg/lb|) and diazepam (0.47 ‘g/kg [0.21 mg/b)]. A Robert Shaw double-lumen en- dotracheal tuber was placed with endoscopic guidance to allow for I-lang ventilation, Anesthesia was main tained with isoflurane in oxygen, The dovble-lamen endotracheal tube became occluded with mucus and was replaced with a standard endotracheal tube ap proximately halfway through the procedure; from that point forward, the procedure was performed without Thing ventilation The patient was placed in dorsal recumbency. The far was clipped ventrally from the midabdominal area to the midcervical region and laterally to the level of the dorsal aspect of the thorax. The s with an aseptic technique, A L-cm Ina right paraxiphoid position, and a G-mm trocatless hreaded cannulas was introduced into the thorax. A 20-cm, 30° telescope! was then introduced through the anntla into the thorax. A T-cm incision was made at the level ofthe right fourth incercostal space inthe ven ital third of the thorax, and a second G-mm tocarless threaded canna was introduced, A third L-cm incision was made at the level of the left third intercostal space adjacent to the medi- astinal mass, and an 11.5-mm thoracic trocar cannula assembly" was introduced at ihs site Insulation was not required for visual access ‘The mass was located in the cranial mediastinum. and was displacing, but tightly adhered to, the internal thoracic arteries laterally, The mass was closely adhered to the cranial vena cava on the right lateral surface and to the pericat- dium caudally. Dorsally, the mass was adhered to the surrounding faty Us Sues. Dissection of the mass proceeded inva caudal-to-ctanial ditection until the mass could be grasped and mobilized from side to side Dissection was per- formed with a vessel-sealing device! and thoracoscopic rightangle forceps © The mass was manipulated by grasping the iced mutilenar reconstructed CT images of the shorex of ventral portion of the adherent fatty tis: ne same dog as n Figure 1. A sof egue atenuating © ‘ows evident in sagitl (Alana dorsal (8) sane views. ‘entodersaly, 2 ef lteromacel, and 2.8 cre cran acavdaly. sue with a Kelly hemostat.” As the mass was partially freed from the surrounding Jaa Scent Ropons AVIA, Vol 247 No, 7 October 1, 208tissue, a digit was introduced through the incision to perform more blunt dissection and better position the mass for complete dissection. Nearing the completion of dissection, the mass was found to be very ughtly ad- hered to ussties in the cranial mediastinum, and capsu- lar rupture occurred during dissection. When the mass was completely dissected {rom surrounding. tissues surgical gloves were changed and mass removal was perlormed by placing the mass in a specimen retrieval bag! and removing the bag through the left third inter costal space. A thoracostomy tube was percutaneously introduced into the thorax through the ninth inter- costal space. Thoracic lavage was not perlormed. The endoscopic cannulae were removed, and the incistons were closed routinely The patient was moved to an intensive care wnit for recovery and received supplemental oxygen. Hydro: morphone hydrochloride was administered (0.05 mg/ kg [0.023 mg/b], 1V, q4 to 6 has needed) for analge- sia. The patient was discharged [rom the hospital the following day. Results of histologic examination were consistent with malignant thymoma with prominence of epithelial and lymphoid components (Figure 3). Ma lignancy was determined on the basis of invasion of the surrounding capsule and adipose tissue by né epithelial cells Six months after surgery, the dog was evaluated because of a 3-day history of polyuria, polydipsia, de- creased appetite, and vomiting, On physical examina- tion, the dog had a high rectal temperature G9.0°C [103.9°FI; reference range, 37.9" to 39.9°C [100.2° to 103.8°F]). Further examination revealed 2 new sub utaneous masses that inclided frm, Lem masses attached to the body wall in both axillary regions. A CBC, serum biochemical analysis, and urinalysis were performed, Results of the CBC were within the refer- ence ranges, the serum biochemical analysis revealed hypercalcemia (total calcium concentration, 14.7 mg/ AL; reference range, 9-6 to 11.2 mg/dL), and specific gravity of the urine sample was 1016. Serum para igure 2—Photomieragrapn of a section of the cranial medias pal mass excisaa by means of VANS tor tho samo dog 35 Figure i. Amaed papaltion of cohesive ep thalaleels organ ed in clusters ane abeculge aumived wih sheets ang niorspersed olonies of mohocytes is present. Findngs wore consistant tha dlagnasis cf thymoma, HA sain, bat thyroid hormone and ionized calcium concentrations were measured for further evaluation of the hypercal: emia, Results indicated a low circulating parathyroid hormone concentration (0.30 pmol/L; reference range, 0.50 to 5.80 pmol/L) and confirmed hypercalcemia Gonized calcium concentration, 1.92 mmol/L; refer ence range, 1.25 to 1.45 mmol/L). These findings were likely auributable to 2 paraneoplastic effect, consider- ing that the dogs preoperative circulating total calcium concentration had been within the reference range Three-view thoracie radiography and abdominal and thoracic ultrasonography were performed. Ab- dominal ultrasonographic evaluation identified a large, heterogeneous, caudal thoracic mass that was visual- ized through the diaphragm (Figure 4). The previously identified splenic nodule appeared unchanged. Thorac ic ultrasonography confirmed a large caudal thoracic ‘ass that was centered in the right caudoventral region of the thorax but extended both eranially and to the left side, The left axillary lymph nodes were also matkedly enlarged and extended toward the cranial mediastt- num, Thoracic radiography revealed multiple, variably igure 4—Images ebtaired during abdominal (A) and thoracic ai ultrasonography of tne dag in Figure T dung evaluation be cause of clncal sighs of aolyuria, pobdipsia, decreased appetite, Sand vorling 6 manths ate resection ofthe cranial mediastinal is evdentin sre moran adjacent to the er is inceated lastevskh. BOM rasonogyaahy, tne mass isvcentered in the fal region of the thor ‘Caudal Rand fT "Thorax. Ine scale on ile of the mage TRVIAR, Vol 27 No 70 Scents Ropons 798 SayEmit ey sized, soft tissue pulmonary nodules consistent with pulmonary metastasis, On the left lateral projection, the largest of the masses appeared to displace the ven: ‘wal margin of the lung dorsally. Given the pattern of the metastatic lesions, these findings suggested tumor cell seeding at thoracoscopic portal sites in both axillary regions and at the paraxiphoid location, With limited capacity for evaluation, however, it was not possible to distinguish a definitive metastatic process at that time. Fine-needle aspizates of the axillary lymph nodes were obtained; cytologic results were consistent with epithelial cells highly suggestive of metastatic carci- noma, No nodal cells were identified, suggesting that the lymph node was effaced, The owner was advised to discontinue a previously prescribed carprofen treat ‘ment that the dog had been receiving for suspected os teoarthritis and to administer prednisone (1.0 mg/kg, PO, q 24h) 2 to 3 days after discontinuing the NSAID. Further medical management recommendations im- cluded administration of lactated Ringer solution mL/kg [21 mL/b], SC, q 24 h) and administration of tramadol hydrochloride (2.5 mg/kg [1.1 mg/lbl, PO, q8 to 12 has needed) for analgesia, ‘5_Photagraphs obtained at crapsy of the deg in Figure I ‘BVariably sized, mulifocal poorly itcumscree vow cular masses are present throughout the cnorace losing, we, rm nodular masses ate present in the sj rrediastinurn. D—The pleura overlying ‘ne thoracic wall land lung lobes cantaina whe, tim, loBuleed "9 bosryerd masses, Fanging in sie ‘ram O.d 20 eon in ammeter Major merements of heveoalpal rence Ipanele A and 0) and rule panels B ana Ch ind Four days later, the dog was admitted to the hos- pital for pamidronate treatment after this was offered as an option to creat the hypercalcemia. Results off serum biochemical analysis indicated mildly. pro- agressive hypercalcemia (total calcium concentration, 15.6 mg/dL.) with no azotemia. The dog received an IV infusion of pamidronate (2.2 mg/kg [1.0 mg/l] in L Lof saline [0.9% NaCl] solution over 2 hours), The dog was discharged from the hospital that afternoon, and the owner was instructed to continue prednisone and subcutaneous fluid administration One week after pamidronate eatment, the dog was returned for reexamination, The owner reported the dog’s appetite and energy level had improved sub- stantially, and no vomiting had been observed, Results of serum biochemical analysis indicated that the pa tient was normocalcemic (total calcium concent tion, 10.9 mg/L). Continued prednisone treatment and subcutaneous fluid administration and reevalua- tion of the dog’ circulating calcium concentration in L week were recommended. ‘At the follow-up visit 1 week later, the owner re- ported that the dog had a normal appetite with no 796 Scent Ropors AVIA, Vol 247 No, 7 October 1, 208vomiting and a mildly decreased energy level. Serum biochemical analysis revealed mild hypercalcemia (to- tal calcium concentration, 11.5 mg/dl). The owner was advised to continue prednisone administration and subcutaneous fluid administration and to return the dog for measurement of circulating calcium concentra- tion in L week, At the next weekly visit, the owner reported that the patients appetite and energy level were decreased, compared with the previous weeks observations, Blood was collected for hematologic and serum biochemi- cal analysis. Results of the CBC were within reference ranges, and the biochemical tests revealed moderate hypercalcemia (total calcium concentration, 13.8 mg/ dL). The owner elected euthanasia at that time, On nec ropsy; firm, white, multilobulated masses (4 to 5 cm in diameter) were identified in the subcutaneous tissue of the left axilla and the right parasternal region. Both masses were firmly adhered to the body wall, and on cout surfaces, the centers were dark red. Directly oppos- ing these areas within the thoracic cavity were similar appearing firm masses surrounded by botryoid clusters OU'O1- to OS-cmediameter nodules, Similar masses (11 to 6 cm im diameter) were multifocally present on the thoracic aspect of the diaphragm (Figure 5), the parietal and visceral pleura, and the mediastinum Histopathologic examination revealed that the masses exclusively comprised clusters and sheets of disorga- nized epithelial cells supported by a prominent fibrous matrix (Figure 6). Given the overall lack of lymphoid components characteristic ofa thymoma, a diagnosis of thymic carcinoma with carcinomatosis was made. Tu- ror cells were immunoreactive for cytokeratin by im- munohistochemical analysis, consistent with epithelial cell origin. cussion ‘Since its advent, VATS has replaced conventional tech- ‘niques in the investigation and treatment of many thoracic conditions in humans, including malignant disease ‘Common indications for VATS include mass lesions of the mediastinum, pleura, ngs, and lymph nodes; pleural effu- sion of unknown origin, chylothorax; pericardial effusion with or without mass lesions; spontaneous pneumothorax; and persistent right aortic arch? In veterinary medicine, ‘more commonly perlormed thoracoscopic procedures in clude lung lobectomy, pericardial window procedure, sub- total pericardiectomy, gation of patent ductus arteriosus, thoracic duct ligation, and treatment of pyothorax"” In human and canine patients, reported advan- tages of VATS over open thoracotomy include a lesser degree of postoperative pain, faster recovery of pul- rmonaty function, lower postoperative circulating con centrations of interleukin-6, and shorter general and intensive care hospital stays." However, long-term complications such as portal site metastases can o¢- cur following minimally invasive surgical procedures in humans, portal site metastases have been reported after thoracoscopic®? and laparoscopic“ resection of various malignant tumors, The true incidence of por- tal site metastasis in humans is unknown. Stemming primarily from research conducted in the late 1990s, reports generally indicate portal site metastasis rates of < 494.40" Whether the incidence of metastasis is ‘more common in minimally invasive versus open pro- cedures is also unclear’ Results of 1 study" revealed that tumor manipulation was the most accurate in- dlicator of the likelihood of tumor spread in rats that underwent laparoscopic or open procedures. It is pos- sible that minimally ivasive procedures involving ex- tensive tumor resection may require greater tumor ma- nipulation, compared with that needed for excision by open procedures. ‘To our knowiedge, portal site metastasis in adog has. only been reported once in the veterinary literature in that dog, portal site metastasis was identified 3 weeks after diagnostic thoracoscopy and evaluation of biopsy specimens of the pleura, mediastinum, and pericardium revealed invasive mesothelioma and pericardial fibrosis In humans, tumor seeding at portal sites has been iden- tified as eatly as a few days alter surgery, with a typical ‘ume frame of 14 to 15 months after surgery for detection of such metastases.*"~? Similar to the report by Brisson et a” diagnosis of portal site tumor seeding in the dog of the present report was made earlier (6.5 months after surgery). The etiology of portal site tumor seeding is not well understood, but iis likely multifactorial. [vis postu- lated that the pathophysiology involves the implantation of malignant cells in the surgical wound through direct ‘wound implantation, contamination of ‘instruments, aerosolization of tumor ces, a so-called chimney effect (where tumor cells congregate at incision sites alter be- ing aerosolized during the procedure), local and system- ic effects of the pneumoperitoneum created with carbon dioxide (in procedures that require insufflation), exces- sive manipulation of the tumor, hematogenous spread, fr some combination of these.” Im the dog of this report, a vessel-sealing device and digital manipulation were used to dissect the cranial mediastinal mass away from surrounding tissues. The VATS method provides limited 2-D visual access with limited tactile manipulation at the surgical site. Consid- cring that surgical technique has been correlated with JAM VoI2A7 No. 7 October 7, 2015 Scientific Reports 797Ema es contamination rates,’ itis possible that a VATS approach right contribute to imprecise definition of tumor mar- gins or unnecessary tumor handling and therefore an increase in the risk of tumor disruption and dissemina- tion ® Yamashita et al! showed that the proportion of patients with stage I non-small cell lung cancer that developed detectable carcmoembryonic antigen mRNA (a measure of micrometastatic cells) im the circulation during tumor resection by VATS (16/18) was signif cantly greater than that of similar patients who under went lobectomy via open thoracotomy (18/35). Those investigators* postulated that these cells (expressing carcinoembryonic antigen mRNA) might increase the risk of subsequent thoracic and hematogenous tumor spread, and that tumor cell shedding may be exacer- bated by manipulation of che tumor for placement in an extraction bag, accidental grasping of the tumor direct: Jy, or forceful manipulation of internal structures for better visibility. Interestingly, biopsy specimens in the case described by Brisson et ab® were removed through cannulas without the use of specimen bags, indicating that minimal tumor manipulation may be sufficient to cause portal site metastasis, In the dog of the present report, a collection bag was used to remove the mass as a means of preventing contact with the tissues of the body wall. However, owing to the presence of multiple adhesions between the mass and surrounding tissue, Clean resection of the mass was challenging. As a result of the adhesions, the tip of a vessel-scaling device was passed through the assist incision positioned at the left third intercostal space, and the surgeon used the same site for digital access to the mass, Extensive manipula: tion of the mass during removal resulted in disruption of the tumor capsule, possibly facilitating the spread of tumor cells, The recurrent and metastatic nodules in the dog of this report were morphologically different from the originally resected tumor. Itis unknown whether a neo: plastic wansformation occurred or ifthe original tumor may have also contained components of thymic carci- noma, The initial mass was found (o contain a mix of epithelial and lymphoid cell populations, whereas the recurrent and metastatic foci were exclusively epithe- lial with a prominent schirrous response and areas of necrosis, similar to carcinomas of many other organs Prognosis on the basis of tumor cell population (lym. phocyte rich, mixed, or epithelial cell predominant) hhas not been extensively investigated in. veterinary medicine; however, there is some evidence that patients with Iymphocyte-rich tumors have a more favorable prognosis.” Despite the cellular components identified, the histologic evidence of capsular and adipose tissue invasion im the originally resected mass conferred a guarded prognosis, Thymic carcinoma is a rate malig- rnancy sn humans and dogs and is generally identified at a locally advanced stage with an aggressive histologic appearance. *=* In human medicine, increasing concern regarding the efficacy of minimally invasive approaches to thymic tumor resection has been raised.» Recent research indicates that the single most important prognostic factor in (eating thymoras and human patients is complete resection Although VATS provides distinct benefits, it also may limit sur- gical exposure, perhaps resulting in incomplete tumor resection, In the dog of this report, although insufflation was not used and the mass was primarily manipulated through the incision at the left third intercostal space, metastasis developed at all portal site incisions as well as throughout the thorax after surgery These results suggest that metastasis cannot be solely explained as a result of gas effects or direct contamination. It is pos sible that, because of the degree of manipulation re- quired, tumor implantation may have occurred through secondary contamination {rom tumor cell-bearing in- struments coming into contact with portal site inci- sions during the attempt to retract the mass from the surrounding tissues Local changes in immune system functional ity associated with minimally invasive surgery tech: niques may also promote tumor metastasis. Although most reports discuss immune function in the context of laparoscopic portal site seeding, effects of thoraco- scopic procedures are likely similar®""9 Research evaluating the effects of intraperitoneal endotoxin ad: ministration on abdominal implantation of adenocar. cinoma cells and portal site metastasis in rats indicated a lower propensity of tumor seeding in the presence of endotoxins. These effects were presumed attributable to endotoxin stimulation of cytokines such as tumor necrosis factors, which are essential mediators in the activation of lymphocytes that may have a role in kill: ing tumor cells." “Although exact mechanisms for portal site metasta sis are unknown, itis likely that employment of several principles can help decrease their incidence. Following strict oncological techniques as for open surgery, imclud= ing careful handling of the specimen, adequate surgeon raming and experience, and proper patient selection, may contribute to prevention of portal site metastasis Ina large, prospective study” involving 533 human pa: tents who underwent laparoscopic procedures because of various intra-abdominal malignancies, the incidence fof portal site metastasis in patients with advanced dis- ease at the time of laparoscopy (3/71 446) patients) was significantly greater than that for patients without advanced disease at that time (1/462 [0.2%I). Surgical ‘modifications such as excision of portal sites following procedures involving malignancies have been recom- mended.® A disadvantage of adopting this strategy in- cludes negation of the principles of minimally invasive surgery. Given the likely multifactorial etiology of portal site seeding, the possible advantages of portal site exci- sion may not be sufficient to warrant exploration, Hypercalcemia, as found in the dog of this report, is a common finding in humans and dogs with malig” nant neoplasia” Although to the authors’ knowledge hypercalcemia associated with thymic carcinoma in dogs has not been described in the literature, a recent seudy" reported hypercalcemia in 40 of 116 (4%) dogs with thymoma, Often, paraneoplastic syndromes parallel the underlying malignancy, and it is common: place to find that successful treatment of the tumor will lead to elimination of the paraneoplastic condition, rly, recurrence of paraneoplastic syndromes can 798 Scent Ropors AVIA, Vol 247 No, 7 October 1, 208often indicate recurrence of the tumor, preceding de- tection of the tumor itself" The most common cause of hypercalcemia in dogs is neoplasia," and it is most typically associated with lymphoma.‘ Given that hy- percalcemia can be a potential medical emergency in severe instances, determining the underlying cause and instituting the appropriate treatment is paramount. In the case described here, mild to moderate hypercalce- ria warranted supportive care with the administration of corticosteroids, uid therapy, and pamidronate. The owner ultimately elected for euthanasia because of the patients compromised quality of life ‘Findings in this patient, as well as the previous description of portal site metastasis in a dog," indi- cate that this possible result should be conveyed to the owner as a potential, albeit rare, risk associated with interventional oncological thoracoscopy. Itis important to note that in cases of advanced oncological disease, the effect of portal site metastasis subsequent to tumor biopsy is unknown and may not drastically alfect the ultimate rapid progression of the disease. The ability to quickly and accurately diagnose the nature of the dis- ease for implementation of treatments such as chemo- therapy may therefore warrant the procedure, despite the possible risk of portal site metastasis (which is an- ticipated to be low). rove 570, Bracco Diagnostics Ine, Paneeion, NJ B. Robert Shaw endobronchial tbe, Telelex Meal, Durham, Ne. “Ternamian endotp cannula, Karl Stor Veterinary Endoscopy Goles, Cab 4. Hopkins Karl Storz Veterinary Endoscopy, Goleta, Cal © Thoracopot, Covidien Ine, ManaGild, Mass FLgaware Covidien Inc, Manel, Mass Kat tors Veterinary Endoscopy, Goleta, Cai A. Karl Store Veterinary Endoscopy Endo Catch, Covidien Ine, Manebeld, Mass References 1 Stammberger U,Steinacher C, linger 5, eal. 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