Margins second time around

Re: Margins second time around

Michael Woodhouse — Mon, 08 Oct 2012 23:46:47 GMT

Good lass

(edit - I assume you are female...........)

Re: Margins second time around

Busybee — Mon, 08 Oct 2012 20:25:40 GMT

Oooo I like a good discussion!

Saw the dog back today. Discussed all with owner. Original scar is barely visible now and dog doing very well. The owner is aware of the risk of it returning and the (low) risk of malignant spread. I don't think I'd be comfortable re-operating now.for the reasons I gave above, and said so to the owner. We made an informed decision based on the evidence available, the pros and cons involved, and decided to leave alone for now but to closely monitor the site, adjacent lymph node and for signs of metastatic spread.

Re: Margins second time around

Rajat — Mon, 08 Oct 2012 19:05:58 GMT

I second Malcolm's comments (not that they need it) and do the opposite for Michael's comments (whatever the opposite of seconding is, first- ing?!!)

Agreed they are usually benign, but why take a chance when repeat surgery is not that invasive i..e not requiring amputation etc?

I've seen melanomas like this 'monitored'- by the time they have grown back mets are present and it is too late for anything and everyone is a bit sorry for their previous decisions!

But I guess, at the end, it is the owners call eh.

Re: Margins second time around

Malcolm Ness — Mon, 08 Oct 2012 08:40:39 GMT

The comments about likely nastiness of the tumour in earlier posts are true as a rule of thumb but they are certainly not absolute.

I would go back at this stage and excise the wound with a margin of about 1cm, full skin thickness plus deep soft tissues. Closure of defect on the muzzle is straightforward though you might want to consider a rotation flap or similar. From the dog's point of view, the surgery is superficial and the convalescence will be short and unthreatening.

Leaving things alone at this stage might well result in a good outcome but equally, you might be missing the opportunity for a permanent cure.

If the mass was worth removing in the first place then it is worth removing properly now.

Re: Margins second time around

Utlendigur — Sun, 07 Oct 2012 22:37:37 GMT

[quote user="Stephen Courtney"]I also knew a couple of dogs that had malignant melanomas and managed to live another 18-24 months and die of something unrelated, so even if they are malignant, they are not always an immediate crisis.[/quote]

I had an odd case - black labrador cross with tumour on toe. I advised amputating toe as I suspected melanoma (and it was on the foot!) but the owner asked us to biopsy first. Fast track histo confirmed melanoma with poor/guarded prognosis. Amputated toe within a day or two but the dog came back a few weeks later with a huge pre-scapular lymph node - FNA confirmed metastasis. Dog went home for a few weeks TLC before pts - and reappeared months later with mild gastroenteritis and normal LNs. As far as I know (and hope - they were really nice clients) she is still ok.

[quote user="Stephen Courtney"]If it isn't in the eye, in the mouth or on a foot then it probably isn't malignant[/quote]

Provided you are talking about dogs, as far as I remember, cats are different as usual

What about asking an oncologist. Just wondering whether radiotherapy might be an option??

Re: Margins second time around

Stephen Courtney — Sun, 07 Oct 2012 22:01:41 GMT

If it isn't in the eye, in the mouth or on a foot then it probably isn't malignant, and the biopsy said it wasn't malignant, so leave it be.

Melanomas in canines are not the same beast that occurs in humans, and subjecting the dog to a further and possibly disfiguring surgery with a high risk of complications ( inferred from the original post) just because of an anthropomorphically visceral reaction to the name, is probably an over reaction.

From my experience with several malignant melanomas i referred, repeat surgery has been a waste of time. The worst one was an oral amelantoic melanoma that had 2 extra surgeries, started the vaccine, and died of CHF from cardiac mets after a truly awful time under the knife.

I also knew a couple of dogs that had malignant melanomas and managed to live another 18-24 months and die of something unrelated, so even if they are malignant, they are not always an immediate crisis.

Re: Margins second time around

james herriot lied — Sun, 07 Oct 2012 21:23:47 GMT

I think what Michael's saying is that for stuff like this, he doesn't send them off straight away, but keeps them in a pot in case of any recurrence - then sends them to the lab to see how the land lies. It has its pros and cons, I guess.

As pots are free, I always bung lumps in them even if I can't persuade the owner to go for histopath, as a back-up plan (and document the history clearly as to why histopath isn't being performed)

In this situation, a low mitotic index should settle some anxieties, but if you're that worried, why not do an excisional biopsy of the wound and send that back in; if there are no cells left, monitor for six months and breathe a sigh of relief. I'm not sure I'd go that far at this stage, but it's an option. Don't, whatever you do, bother with FNAs.

As the lump is a melanoma - a common bogey word in human medicine, have you had a chat with client about any personal experiences, which might make them nervous even in the presence of an apparently benign mass? Understanding the client's motivation could help set up a sensible plan based on monitoring rather than repeated surgery in the absence of symptoms.

Re: Margins second time around

Michael Woodhouse — Sun, 07 Oct 2012 21:13:49 GMT

[quote user="Busybee"] It hasn't recurred already![/quote]

Yes - that is why I am saying do nothing and see what happens.

Re: Margins second time around

Busybee — Sun, 07 Oct 2012 21:09:27 GMT

Sorry, should have made clear - it was a suspected wart when I first saw it, then removed it and sent it away to the lab and on the lab report it came back as a melanoma. It hasn't recurred already!

Re: Margins second time around

Michael Woodhouse — Sun, 07 Oct 2012 21:06:17 GMT

This is why I normally keep the lump in a pot and send it off if anything recurs.

I would do nothing at this stage and wait and see if anything recurs. You may well be putting the dog through a completely unnecessary operation. If there is any sign of it coming back then operate.

I know this suggestion will make the purist surgeons squirm, but these pedunculated masses on places like muzzles, lower legs etc I grasp with rat toothed forceps or allis tissue forceps and pull mass away from the skln. Just cut through with stout curved scissors. That way you get a decent margin, but leave enough skin to close easily in a tricky location.