high grade sarcoma

Re: high grade sarcoma

Hannah Wynne Richards — Sat, 13 Sep 2014 10:30:48 GMT

This whole thread gives me cold shivers. Definitely one where I'd twist the owner's arms to get them to refer.

Wynne

Re: high grade sarcoma

Martin Atkinson — Fri, 12 Sep 2014 17:56:45 GMT

[quote user="Evelyn Barbour-Hill"] If I want to chisel something I want my workpiece immovably supported on something solid enough to provide the necessary equal and opposite reaction,[/quote] I use it more for nibbling away rather than smacking with a mallet! I was surprised but the maxilliary bone was relatively easy to chisel out.

I agree about using an osteotome and mallet to chisel off a femoral head/neck or a tibial crest it gives me the cold shivers!.

Re: high grade sarcoma

Evelyn Barbour-Hill — Fri, 12 Sep 2014 17:39:30 GMT

[quote user="Martin Atkinson"]osteotome[/quote]

Aargh I hate osteotomes. If I want to chisel something I want my workpiece immovably supported on something solid enough to provide the necessary equal and opposite reaction, unless I'm chiselling something like a railway sleeper big and heavy enough to be its own support, neither of which conditions is provided by most bits of dog on a table.

[quote user="Martin Atkinson"]From the OP's description it doesn't sound quite as dramatic as your surgery advocates[/quote]

Well maybe I've misunderstood but from that brief description it sounds every bit as serious as that.

Re: high grade sarcoma

Martin Atkinson — Fri, 12 Sep 2014 17:13:47 GMT

Wow Evelyn, after having said it was fairly straightforward you have made it sound rather scary!

From the OP's description it doesn't sound quite as dramatic as your surgery advocates but maybe I've misunderstood. Having removed a melanoma from a dogs mouth with a very similar description as this dog's tumour I found doing a partial maxillectomy and palatectomy (if they are real terms!) for the first time surprisingly easy with basic instruments and an osteotome (can't remember if I used the diamond disc or a saw as well) with surprisingly little haemorrhage and the gingival flap sutured nicely back !

Re: high grade sarcoma

Evelyn Barbour-Hill — Fri, 12 Sep 2014 01:29:20 GMT

[quote user="David Mills"]

[quote user="Evelyn Barbour-Hill"]'m not questioning your assessment at all, nor Gerry's advice, but I'd just like to say that one can remove a surprisingly large amount of a dog's head without compromising its welfare, and with surprisingly little cosmetic effect.[/quote]

Out of genuine interest as someone who would like to do more in cases such as these, how 'straightforward' would this be? Any potential disasters? And any tools beyond what a normal practice would have?

[/quote]

Phew.

Well, you have to be quite a good generally-skilled surgeon with a taste for combination of fine precise work with hefty gross bone cutting. You need something to cut bone precisely with, which means possibly all of diamond disc, surgical length HP round and tapered fissure burs, and bone-cutting FG or latch burs (Zekrya are great) all with your airdriven dental unit. Or if you're a spinal surgeon already you may have one of those fearsome air tools for which you can get reciprocating (or do I mean oscillating)saws.

One or two really decent periosteal elevators. A collection and selection of Hohmann retractors: they are just so useful for retracting, prodding, levering and generally manipulating. The finer ones are especially useful, also the one that looks like the Loch Ness monster. Some bone-holding forceps .

Review the anatomy and review it again. Have a skull handy to refer to as you go: I always do this.

Potential disasters? Hmm. Haemorrhage of course. In the case mentioned, you've got two arteries to think about: the infraorbital and the palatal. My firm preference is for dissecting out an artery and ligaturing it in advance, rather than cutting till I cut it and then clamping it. For the palatal, that means elevating the mucoperiosteum off the palate and finding the artery. For the infraorbital, there's a lot to be said for isolating the artery at the proximal side, i.e. inside the orbit, and clamping it there.

Don't be afraid to remove some of the wall of the orbit. Don't try to be clever and preserve a bit of bone or an odd tooth (This from experience!) Make your bone incision lines as simple, sweeping and rounded as you can. Plan, plan, plan.

Start off as a preliminary by extracting teeth at the extremities of your bone cut line (in the case described however the caudal extremity would be caudal to the last tooth). Don't make your surgical cut through teeth.

You are going to cut nerves. This will not matter. A bit of desensitisation or the paralysis of a few little muscles will not matter (contrast to head surgery in the horse!).

Even when you have made all your bone cuts and made them quite deep enough, the final removal is going to be a matter of gentle levering until your chunk finally yields with a horrible crack..

The nasal conchae can bleed like mad, but cold saline and gentle pressure will stop that. You could put an untied ligature on the carotid artery in advance, for use in emergency. At least be sure you know how to ligature the carotid artery in a hurry.

Have a nurse handy with big syringes of saline. Copious irrigation is always a good thing.

Have a proper throat pack (not swabs) in place, just as you would for a dental procedure. Have suction handy in case of need.

Be patient in the removal. This will avoid breaking the skull where you didn't mean to break it. Be painstaking in the repair. This is not an operation to do within time constraints. It would be perfectly acceptable to stop for a quick drink of orange juice after the removal stage before donning fresh gloves and mask for the repair. Add fresh drapes at the same time.

I like to incorporate BioSis in the repair, when I can get it. I can't get big sheets any more, but there seem to be substitutes available from the USA. In fact, I'd be glad to hear from anyone in the same situation who has a suggestion for a substitute.

That's all I can think of for now.

Re: high grade sarcoma

David Mills — Thu, 11 Sep 2014 23:36:20 GMT

Re: high grade sarcoma

Evelyn Barbour-Hill — Thu, 11 Sep 2014 15:57:16 GMT

[quote user="nelu rudareanu"].On mouth examination found aproxx 3 cm long ulcerated and friable mass starting at 4th premolar and ended at last mollar upper right maxilla not able to remove with wide margins.[/quote]

I'm not questioning your assessment at all, nor Gerry's advice, but I'd just like to say that one can remove a surprisingly large amount of a dog's head without compromising its welfare, and with surprisingly little cosmetic effect.

Re: high grade sarcoma

Bob Russell — Thu, 11 Sep 2014 12:03:30 GMT

Speak to VRCC. At a talk given by one of their radiologists (radiotherapist?) it was suggested they can get surprisingly good results.

Re: high grade sarcoma

Malcolm Ness — Thu, 11 Sep 2014 10:59:31 GMT

[quote user="Gerry Polton"] a conciliatory course of tablets,[/quote]

A great expression Gerry. Can I steal it?

Re: high grade sarcoma

nelu rudareanu — Thu, 11 Sep 2014 10:01:52 GMT

Thanks Gerry

Re: high grade sarcoma

Gerry Polton — Thu, 11 Sep 2014 08:15:51 GMT

Hi Nelu

It is possible, but unlikely, that surgery alone could cure this. I suspect if I were to see the case, my advice would be likely to be CT to define anatomic extent of disease, followed by the combination of surgery and radiation therapy to manage the primary tumour. Metastasis is possible. We would have to discuss how we manage that risk (to treat or not to treat; to not even start because of the risk, etc).

Life expectancy is a tough one to estimate. At best this could be cured. At worst, with no further therapy, this dog could have been euthanised within the next two months.

If the owner is considering any sort of radical therapy, by which I mean something more than a conciliatory course of tablets, the first priority now has to be an accurate definition of how extensive this disease process is, both the primary and the possible secondary tumours.

Best wishes

Gerry

Re: high grade sarcoma

Hannah Wynne Richards — Wed, 10 Sep 2014 18:11:56 GMT

I'm not an oncologist, but my understanding is that this one carries a rotten prognosis.

Sorry

Wynne