So, hemangiosarcomas. Let me just check. All right. So in hemangiosarcomas, again, there is more than one type. We are going to focus on visceral hemangiosarcoma, there is a cutaneous form. Luckily it is not as aggressive. I'll talk about it briefly, but this is your classic hemangiosarcoma here. So this is the spleen over here. If you can see kind of where my pointer is on the left side. And then we have this humongous mass over here. You can see also that the amentum is adhesed over the top. That's actually because it's ruptured prior to this, a couple of times, and they tried to come in to patch it. You see that really commonly. These guys are really gross and nasty. So pathophysiology here are malignant, highly metastatic neoplasia of vascular endothelial cells. Age again, older. Okay. Not not surprising anymore. There's a strong genetic component. Yes, I'm showing my golden retrievers, but they're not actually golden retrievers, so it's okay. Doug is not even a little bit golden retriever, but golden retrievers do have a 1 in 5 chance of developing an HSA in their lifetime. That is a huge genetic predisposition. We know it's in the lines, but other large breeds as well. Labradors you know, kind of in that same group as far as retrievers. But we'll see it in any size dog. In fact, one of the hemoabdomens I saw in the last couple of days, No, two, were in like medium sized dogs and both with some doodle heritage, which doesn't help, but you'll see it in anybody. So presentation spleen is the most common sight and then the right auricular. It, it is a tumor of blood, blood vessel cells so it can be anywhere. So it's important to remember. But really, really, really most commonly we see spleen and then right atrium, we can have it as a primary site on liver or kidneys, but that is more likely to be a metastatic site. And again, this the cutaneous ones we'll get into, but they do occur. Very common to  metastasis, to metastasize for the lungs greater than 60% of metastasis are the lungs with this tumor. And again, initial clinical signs are nonspecific. They might be a little lethargic. They're inappetent, they're very mild initially. Sometimes that's mic, little micro bleeds that aren't enough to to be a problem. Sometimes that's tumor burden. I do feel like oftentimes the history is like, well, he was just slowing down. He's getting older. And, you know, the problem with that is that maybe we're not looking hard enough for for that other reason. So I see these all the time because how they often present is the acute collapse once they start to hemorrhage. So when we see that acute collapse, we see a dog that is pale, tachycardic, tachypnic, they might have a distended abdomen if we're talking about the spleen. They're weak. And if it's pericardial, then we're going to have the cardiac tamponade that gives us our muffled heart sounds. We're going to have the pulsus paradoxus. Okay. And these dogs do not look good coming in. 

So histopathology is the only definitive way to to fully diagnose these guys. There is no noninvasive test as of right now that are diagnostic. So this is a guess based on presentation until you have a surgical biopsy and that is obviously after a major an invasive. Cytology is rarely diagnostic and absolutely contraindicated if you have one of these on the spleen. Yes, can you stick a needle in it? Yep. Should you? Absolutely not. You risk seeding the abdomen, you risk causing hemorrhage and it's really unlikely to be diagnostic. Same with the effusions. If you want to sample the blood in the pericardial sac or the blood in the abdomen, it's not diagnostic either. There are some studies that look at apparent like a neoplastic effusion, having a lower glucose level, higher lactate levels. It's still not diagnostic and it's not specific enough. Blood work wise, you do again, always do full bloodwork. These guys will show you an anemia commonly. There's 75% chance you get at least some thrombocytopenia. They are really common. And then these guys are often coagulopathic. You absolutely want to check your PT and PTT. Greater than 50% of HSA cases are in DIC at presentation. So those are those are not great numbers to have. But all of this helps with owners making decisions, but also how stable of a patient you have to go to surgery because that's how you're going to get your your eventual diagnosis. X ray wise, you certainly want to evaluate for thoracic mets. Again, that is a really, really common site where you're going to have Mets. You never want to go to surgery without taking those x rays. But if you have a dog coming in with collapse and muffled heart sounds and you take this x ray and we can see this huge globoid heart, okay? And it is very, very rounded. We should immediately think pericardial. If you say, well, how do you tell that from like a really bad DCM, muffled heart sounds. You put your stethoscope on and you have to like cringe and listen and shift. And I can hear it a little bit. If this is a DCM dog, this heart is loud. It is right against the ribs because it is so big and you're probably hearing murmurs and arrhythmia. So so your stethoscope is going to help you out there. But ultimately, ultrasound is really our tool with these guys. And luckily most clinics now have some ultrasound and it doesn't have to be a very good one. You're just looking for fluid. So if you have this this dog here, you're going to put your ultrasound probe on and you're going to see that pericardial effusion. Or if you have a dog coming in with collapse and pale mucous membranes, ideally a distended abdomen, although not always, you're going to put your probe on, you're going to see this. So this was literally two days ago. I was kind of excited because, again, I didn't have a picture yet of it. And I saw this big splenic mass. So you can see my calipers measuring it there. It's seven centimeters ventral to dorsal. It's about the same the other way. This is a big mass. This is a very classic appearance of what I do think in this dog was hemangio. Obviously, we don't know that yet. Cavitated you can see where, let me get the laser pointer, where over here we have some cavitation. We have some up here. You could see it better in other areas. You can see how irregular it is. The margins are irregular. It's modeled this mixed echogenicity is modeled. So that is a really classic appearance on an ultrasound for these type of tumors. You also are doing an ultrasound to check for mets. If I see this, then we ideally get a full ultrasound because we're going to check the liver, we're going to check the kidney. We're going to look for other sites where it may have metastasized to. Of course, when they present as hemoabdomens, we don't always get that opportunity. This dog actually presented as a hit by car and this was an incidental finding, which is a real shame, but is a retriever breed. So unfortunately. 

We actually got this x ray which made us look a little bit harder. You generally do not get to see the mass like this because when they present as a hemoabdomen, you just you have no contrast, right? You have a white out because of the fluid in the abdomen. But, you know, if you are doing checks on this older dog who was slowing down, you might see this on your x ray and then you need to look a little bit harder. And one thing to keep in mind is don't overinterpret an ultrasound. The spleen can have regenerative changes and that sort of thing. Like try not to overinterpret it, but big model tumor in a retriever breed is pretty concerning. Once we have a hemo abdomen, then those numbers change and I'll get into that in a second. 

So treatment wise, basically for the splenic ones, that is going to be surgery, okay, splenectomy. So again, we can see, hold on I  keep doing that, that we have spleen over here. It doesn't even look entirely normal to me. I bet there is some tumor through the spleen here. We can see these little raised edges, but that that is the spleen. And then this whole big dude over here is the tumor. And that probably looks a lot like the ultrasound I showed you. So that needs to come out. We obviously need to stabilize these guys first. They're in hemorrhagic shock, they're in DIC. They need blood products, either whole blood or combination of PACs and plasma for the pericardial ones. We're doing pericardiocentesis, followed up by a subtotal pericardectomy and if possible, a right auricular ablation. That is not a surgery that anybody but a surgeon is going to do. It is not easy. And the prognosis, unfortunately, even with these big interventions, is still poor. We can follow them with chemotherapy, doxiv, vincristine, Cyclophosphamide, other therapies are out there. I think at this point everybody's heard of Yunnan baiyao, there are studies on it now that does show it can prolong survival times, reducing chances of bleeding. Thalidomide has been looked at. There's a mushroom out there called I'M Yunity that's supposed to even have potentially better survival times than some of the chemotherapy we see. But overall, the therapy for this tumor is still limited. We don't get great responses and it is just so aggressive and metastatic. So essentially, even major surgery like this, this is considered a palliative treatment. 

So prognosis again, very, very poor. Surgery alone has a 2 to 3 months survival. Without surgery, when these guys presented the hemoabdomen, there isn't a survival time. I mean, once in a while I've put them on Yunnan Baiyao and bought them a couple of days. But they're, you know, it's not good once they rupture. There's also a very high perioperative mortality, which is another thing to warn your owners about is these dogs don't always make it off the table. Either we go in and we found metastases we were not expecting and we make the decision not to wake them up or because they're in DIC, they're at really high risk of throwing clots, of bleeding post operatively. They have arrhythmias from these splenic tumors as well as the cardiac ones. So really not great surgical candidates all round. When we add chemotherapy after we  make it through surgery, we still only get a six month survival time. So really unfortunate when we treat these guys. And then HSA most common cause of pericardial effusion in the dog. So yes, there's other causes, including lymphoma, but it is the most common cause, a pericardial effusion. And then neoplasia itself is the most common cause of non traumatic hemoabdomen. So you have to take the hit by cars off the list but in non traumatic hemoabdomen, and it is the most common cause and up to 88% once you have the hemoabdomen are going to be HSA. So if you diagnosis splenectomy before hemoabdomen, those numbers are different. 88% is actually the highest I've ever seen. There's a bunch of different studies out there. I usually tell my owners of non retriever breeds around 80%. So assume you're going to have an HSA when you go to surgery and then sometimes, I am managing this so poorly, sometimes you have this and you don't go to surgery. These are Mets literally everywhere. I could probably put up 100 arrows. Again, cutaneous real quick is different. Surgical removal if it is a low grade stage one cutaneous, HSA can actually be curative. So keep that in mind. It is a little bit different, but is really pretty uncommon.