Cat with abdominal mass - opinion on x-ray please

Re: Cat with abdominal mass - opinion on x-ray please

Anthony Todd — Fri, 14 Feb 2014 19:21:37 GMT

duplicate deleted

Re: Cat with abdominal mass - opinion on x-ray please

Anthony Todd — Fri, 14 Feb 2014 19:20:43 GMT

PS. A friend has just been to a consultant urologist in Harley St.

Equivocal consultation and examination £185.00 [ "drink lots of water", hyoscine and dichlofenac for the pain and relaxation ]

Recommended an ultrasound, took no more than 15 mins, ["yes there are signs of hydonephrosis from the back pressure, no it won't show the stone, you should have a CT and something scan to show it"]

Ultrasound £376.00

Re: Cat with abdominal mass - opinion on x-ray please

Anthony Todd — Fri, 14 Feb 2014 18:44:18 GMT

[quote user="Neil Wheadon"] maybe £600 of surgery [/quote]

So how much has been spent so far, what's happening and how has it helped the cat?

Re: Cat with abdominal mass - opinion on x-ray please

Anthony Todd — Fri, 14 Feb 2014 15:13:33 GMT

[quote user="Neil Wheadon"]Imagine the scenario, older cat, maybe £600 of surgery and it would involve an enterectomy, possibility of peritonitis and prolonged recovery.[/quote]

Why? It would surely depend on what you saw [re enterectomy] and the histology of the removed mass.

Where does all the peritonitis and prolonged recovery come from?

Cats usually used to recover quickly and uneventfully.

Of course tumour spread starts microscopically. unless it's the primary and you're lucky.

Re: Cat with abdominal mass - opinion on x-ray please

Neil Wheadon — Fri, 14 Feb 2014 11:18:53 GMT

The article also said that spread was often microscopic, so macroscopic inspection by an ex lap may not tell you a lot.

Imagine the scenario, older cat, maybe £600 of surgery and it would involve an enterectomy, possibility of peritonitis and prolonged recovery. You tell the owner that you saw no spread. A month later another growth. Would you put your cat through that?

Neil

Re: Cat with abdominal mass - opinion on x-ray please

Anthony Todd — Fri, 14 Feb 2014 01:26:09 GMT

[quote user="Neil Wheadon"]There's a couple of review articles in the Journal of Feline Medicine 2012 talking about alimentary lymphoma that backs up the biopsy verses the laparotomy-remove and cured?[/quote]

But did these survival rates have the "primary" removed, [and in this one there isn't even agreement, yet, that it is lymphoma.] ?

For heavens sake, gimme a break, I'm not saying an ex-lap and removal of the mass is a cure! I'm saying it gives a positive diagnosis for sure [or should, definitely, with multiple samples].

Are you assuring me that every FNA is diagnostic?

With an ex-lap the chance to look for secondaries and anything else, assuming it isn't a lymphoma, is available which isn't with a FNA.

And there's this from AJCP in humans:

http://ajcp.ascpjournals.org/content/135/4/516.long

Diagnostic accuracy of lymphoma diagnosis using CNB and/or FNA have largely been reported for deep-sited lymph nodes, mostly by European groups, and the rate of diagnostic accuracy varies between 70% and 98%, depending on the type of care facility performing these procedures. Limitations are mostly related to the lack of sufficient tissue for diagnosis.^2–4,7,9

Note the last sentence [and casting no aspersions at all as to the accuracy in the case discussed]

[quote user="Neil Wheadon"]As many will have spread to surrounding tissues I wouldn't even consider ex lap and remove on these cases[/quote]

How will you know that?

My ex-lap should give you a good idea of spread and you can take histo, if in doubt, from multiple sites if you like,

Not sure if the treatment would be worth a max. of 29 months but I don't know the details, although pred seems to feature which is fine.

Re: Cat with abdominal mass - opinion on x-ray please

Neil Wheadon — Fri, 14 Feb 2014 00:33:01 GMT

There's a couple of review articles in the Journal of Feline Medicine 2012 talking about alimentary lymphoma that backs up the biopsy verses the laparotomy-remove and cured?

There are basically 3 types and these need differentiating on biopsy, so you know which one you are dealing with.

With Intermediate/high grade alimentary lymphoma. Remission 38-87%, of these they survive 7-10 months

With Low grade alimentary lymphoma, Remission 56-96%, of these they survive 19-29 months

With Large granular lymphocyte lymphoma. Remission 5%, of these survive 17 days

As many will have spread to surrounding tissues I wouldn't even consider ex lap and remove on these cases

Neil

Re: Cat with abdominal mass - opinion on x-ray please

Anthony Todd — Fri, 14 Feb 2014 00:19:05 GMT

[quote user="Laurence Webb"]What's wrong with a FNA? can be done in 30 seconds with a probable diagnosis. The cost is a fraction of a laparotomy, and significantly less invasive. The cat should be home in, say 12 minutes, eating and normal.[/quote]

Sure, agree with your description of a FBA, but you're not going to remove that large "lymphoma" ? [assuming it's not something else, and there seems to be some debate about that]

I'd be very surprised if any human doctor would not remove such an obvious lump; it just might be the primary. I think I'd want it out.

[quote user="Laurence Webb"]The dog went home half an hour later showing no more than a shaved abdomen as a result of its investigation. Had it been a more relaxed dog it wouldn't have even been sedated.[/quote]

Fair enough, not doubting that but see above re removal of the mass.

[quote user="Laurence Webb"] I ultrasounded it and found a non-resectable liver mass. The dog went home half an hour later showing no more than a shaved abdomen as a result of its investigation. [/quote]

A large anterior abdominal mass in the region of the liver, conveniently not really comparable to a mobile mass the size of a kidney but, in that case, I would suggest a non-invasive procedure but admit that, as was the way, probably have a quick ex-lap and make sure it wasn't the spleen, which would be a different situation, and fixable there and then.

Prepared to agree on the FNA in this one though.

[quote user="Laurence Webb"]laparotomy may also be a unnecessarily traumatic[/quote]

No more than an "extended" cat spay in my experience and, as I said, all the info is available.[of course depending on what else was discovered.]

Still love to compare the total fee using the same fee scale.

Re: Cat with abdominal mass - opinion on x-ray please

Laurence Webb — Thu, 13 Feb 2014 22:38:33 GMT

[quote user="Anthony Todd"]

I'm sorry, here I go again, but an ex-lap on a cat with an easily found mass that is "not particularly sick" would be done in 30 mins with the possibility of removal of the mass, 100% accuracy in the histo., a probable diagnosis, and with a quick look around, a pretty accurate prognosis.

The cat has already gone through plenty and so far, apparently not much has been defined, and I won't even mention the cost.

The cat should be home in, say, 12 hours, eating and normal.

[/quote]

What's wrong with a FNA? can be done in 30 seconds with a probable diagnosis. The cost is a fraction of a laparotomy, and significantly less invasive. The cat should be home in, say 12 minutes, eating and normal.

Given that the most likely diagnosis is lymphoma you would have used the most invasive option to diagnose a condition that is treated medically anyway. Surgery is still an option if it is non-diagnostic or aspirates indicate it is the appropriate action anyway.

[quote user="Anthony Todd"]Not sure about FNAs of the kidney though, which it sounds as if it maybe.[/quote] I wouldn't choose to do that blind, that's why ultrasound is preferable. Ultrasound guided aspirates of the kidney cortex are pretty safe and will probably diagnose lymphoma.

[quote user="Anthony Todd"]And you're probably going to do a laparotomy, inevitably, anyway which will give you all the info. you ever would have needed on day one, in fact, if it had been a morning consult, by 12.0am. [/quote] If it's lymphoma why would you end up doing a laparotomy, unless there was an obstruction or perforated intestine (in which case surgery is purely palliative anyway)

[quote user="Anthony Todd"]Home at 6pm, check daily and report on histo within a week.[/quote] Aspirates, home by lunchtime, cytology results within 24hours and start on chemo that evening if you really wanted.

[quote user="Anthony Todd"][awaits the expected anonymous red-stars, mention of "gold standard", state-of -the- art, referral, ultrasound, etc.][/quote] I'll tell you about a dog I saw yesterday - it had a big tender abdomen but was too tense to palpate. Under sedation it was obvious it had a huge cranial abdominal mass, probably liver (boo) or spleen (hooray, we can chop that out and throw it away). You would have opened the dog up. I ultrasounded it and found a non-resectable liver mass. The dog went home half an hour later showing no more than a shaved abdomen as a result of its investigation. Had it been a more relaxed dog it wouldn't have even been sedated.

I do agree that it is easy to perform unnecessary procedures and investigations if you don't carefully think about what each will add to your case. Just be aware that laparotomy may also be a unnecessarily traumatic and expensive option if you never consider any alternatives.

Re: Cat with abdominal mass - opinion on x-ray please

Emma Middleton — Thu, 13 Feb 2014 21:03:28 GMT

Yes I'm repeating the bloods because they have an asterisk next to them, this means the lasercyte algorithm can't measure correctly and the result is invalid. Not that it's really relevant but I didn't charge for the in house haematology for this reason.

Re: Cat with abdominal mass - opinion on x-ray please

Emma Middleton — Thu, 13 Feb 2014 20:58:55 GMT

Hi Anthony,

I'd be inclined to agree with you but I'm not sure I explained the owner's decision very well. What I meant was that she didn't want to go for surgery now or later on, but was happy for us to go ahead with the xrays and bloods in the hope that we might find something easily treatable. Then having found the mass I managed to persuade her that doing an fna is minimally invasive but could give us vital information and potentially enable us to start specific treatment. I'm not saying it's the exact route I'd choose to take, but it's certainly not unreasonable given the owner's feelings. She didn't want to ex-lap him in case he was worse following surgery than he is at the moment.

Re: Cat with abdominal mass - opinion on x-ray please

Anthony Todd — Thu, 13 Feb 2014 20:53:08 GMT

PS: and you're repeating the bloods!! cos you don't believe them...

Let us know what the bill is so far, and whether the cat is better yet.

Re: Cat with abdominal mass - opinion on x-ray please

Anthony Todd — Thu, 13 Feb 2014 20:49:56 GMT

[quote user="Laurence Webb"]I see the benefits of aspirates over laparotomy as being cheap, quick and low invasiveness. If you find a lymphoma then you can discuss chemo/palliation. Of course they may not be diagnostic and you can't resect anything resectable but laparotomy can still be done when you get the results back a couple of days later.[/quote]

Not sure about FNAs of the kidney though, which it sounds as if it maybe.

And you're probably going to do a laparotomy, inevitably, anyway which will give you all the info. you ever would have needed on day one, in fact, if it had been a morning consult, by 12.0am.

Home at 6pm, check daily and report on histo within a week.

An ex-lap, on a reasonably well cat, is just a big mid-line cat-spay, except that the "mass" [or kidney] is easier to find than some ovaries....

Re: Cat with abdominal mass - opinion on x-ray please

Anthony Todd — Thu, 13 Feb 2014 20:41:11 GMT

[quote user="Emma Middleton"]Owner has already said this morning she would not like exploratory surgery as she doesn't want to put him through too much given that he is not particularly sick at present.[/quote]

The cat has already gone through plenty and so far, apparently not much has been defined, and I won't even mention the cost.

The cat should be home in, say, 12 hours, eating and normal.

If you wait until the cat is "particularly sick" it'll be too late.

[awaits the expected anonymous red-stars, mention of "gold standard", state-of -the- art, referral, ultrasound, etc.]

Re: Cat with abdominal mass - opinion on x-ray please

Emma Middleton — Thu, 13 Feb 2014 12:28:03 GMT

Thanks Laurence. I explained the good success rates with chemo if indeed it is lymphoma and owner decided it was worth doing an FNA. So I did this ultrasound guided and it does look like intestine and possibly some lymph node enlargement too. Hopefully the FNA will be diagnostic!

Thanks again, both of you

Re: Cat with abdominal mass - opinion on x-ray please

Laurence Webb — Thu, 13 Feb 2014 11:53:23 GMT

Even if the owner were happy for an ex-lap I'd normally go for FNA as Martin advised .

Ideally I'd ultrasound it first. Ultrasound will give you an idea what the structure is and what it is attached to (ie intestinal, a lymph node or just an abnormally positioned kidney) and also help you to aim a needle into different parts for aspirates. If you've got Doppler I find that useful to see where big blood vessels are so you can avoid them too. If you don't have (or the oner doesn't want) ultrasound then I've done many blind aspirates without problem but there are of course risks of sticking a needle into the unknown.

I see the benefits of aspirates over laparotomy as being cheap, quick and low invasiveness. If you find a lymphoma then you can discuss chemo/palliation. Of course they may not be diagnostic and you can't resect anything resectable but laparotomy can still be done when you get the results back a couple of days later.

Re: Cat with abdominal mass - opinion on x-ray please

Emma Middleton — Thu, 13 Feb 2014 11:18:19 GMT

Thanks Martin. Yes when I saw the rads I also thought kidney but feels more like intestine when palpated and is not dorsal enough. I'm going to give them a ring now and try and get an FNA as the cat is still sedated and seems a shame not to do it when it could dramatically change the outcome... Cat is insured so if it was lymphoma, then at least we could give chemo a good shot given the success rates.

Re: Cat with abdominal mass - opinion on x-ray please

Martin Atkinson — Thu, 13 Feb 2014 11:11:58 GMT

Looks like it might be the right kidney on X-ray but then you say it is pretty mobile. In a cat this age its highly likely to be intestinal lymphoma. I'm a dynovet and don't have ultrasound and would go for ex.lap. but if I did I would scan it. If it was possible to get an diagnostic ultrasound guided FNA even if the owner won't let you ex lap, chemotherapy is then an option. I have a cat with intestinal lymphoma on COP at the moment doing very well and given you only need a very small amount of the vial of vincristine each time it is pretty cheap. That said not all respond well to chemo but now is the time to explore the possibility before it becomes obstructed and totally sarcopenic.

Re: Cat with abdominal mass - opinion on x-ray please

Emma Middleton — Thu, 13 Feb 2014 11:00:45 GMT

Here's the full haematology report - although I don't trust it given the probable
platelet clumps and am going to send another sample and smear to the lab after speaking to the owner.

WBC    * 16.76  x10^9/L 5.5-19.5  
LYM    * 3.54   x10^9/L 0.4-6.8   
MONO   * 1.66   x10^9/L 0.15-1.7  
NEU    * 10.65  x10^9/L 2.5-12.5  
EOS    * 0.81   x10^9/L 0.1-0.79   ***HIGH***
BASO   * 0.11   x10^9/L 
%LYM   * 21.1   %       
%MONO  * 9.9    %       
%NEU   * 63.5   %       
%EOS   * 4.8    %       
%BASO  * 0.6    %       
HCT    = 29.5   %       30-45      ***LOW ***
RBC    = 6.84   x10^12/ 5-10      
HGB    = 9.4    g/dL    9-15.1    
RETIC  * 63.3   K/uL    3-50       ***HIGH***
%RETIC * 0.9    %       
MCV    = 43.1   fL      41-58     
RDW    = 18.7   %       17.3-22   
MCHC   = 31.8   g/dL    29-37.5   
MCH    = 13.7   pg      12-20     
PLT    > 162    K/uL    175-600    ***LOW ***
MPV    = 10.5   fL      
PCT    = 0.17   %       
PDW    = 27     %       
WBC Abnormal Distribution

PLT Aggregates Detected