Differing diagnoses on histopath

Re: Differing diagnoses on histopath

Thomas Johnson — Fri, 17 Apr 2015 15:42:42 GMT

Do you know if the referral practice reviewed the biopsies themselves before proceeding with surgery? If we refer oncology cases we will often be asked by the referral practice to give the lab permission to send the slides to the referral practice.

Re: Differing diagnoses on histopath

Anthony Todd — Fri, 17 Apr 2015 13:53:01 GMT

A vet friend of mine had a tumour removed from his spine, it was starting to press on the spinal cord.

When it came to the diagnosis, as to benign or malignant, he and the histopathologist sat opposite each other and counted, very carefully!, mitotic cells within each field using a dual headed mike....

Sometimes, he was told, it's not an exact science.....

Re: Differing diagnoses on histopath

Tim Charlesworth — Fri, 17 Apr 2015 13:28:34 GMT

SCC is really very different from acanthomatous ameloblastoma and that's not a confusion that I've come across before. To fully understand where the confusion has come from, you'd have to get the full reports (and not just the bottom line) from both labs and wade through the microscopic description. Pathologists are under a lot of pressure to always give a diagnosis as most vets "expect" a certain diagnosis from histopath and so there is sometimes reluctance for pathologists to say "we don't have enough tissue to be certain..". I suspect that the original biopsy was relatively superficial and that this in conjunction with the gross appearance was misread as SCC although it is not impossible for the dog to have had both.

Either way the owner should be happy that her dog has been "fixed"...

The worst pathology report I remember was a gastroscopic biopsy from an ulcerated stomach in a 10 month old dog that came back as adenocarcinoma. I phoned the lab and said "that's unusual for a 10 m.o." and they apologised, said that they thought the dog was 10 years old and revised the diagnosis to IBD! We changed our lab..

I agree with MM re referral centre "etiquette" - full history/results should be available to any vet involved in the care of the patient.

Re: Differing diagnoses on histopath

J G Wray — Fri, 17 Apr 2015 11:02:50 GMT

[quote user="Mike Martin"]JGW - Can I pick up on your point about a referral centre not discussing a case with you. I have come across this before. I think this is wrong. Whoever the vet is in care of an animal, then the referral centre must share their records with that vet.[/quote]

Well, you'd think so wouldn'tcha? Common sense was not necessarily uppermost in my thing and RCVS guidelines and manipulations shouldn't be the order of the day, but my "situation", if you're a pathologist is a service provision and opinion, without treatment which when angels are dancing on pinheads might be differentiated from a referral as you do, at least in a pathologist's mind.

Re: Differing diagnoses on histopath

Martin Atkinson — Fri, 17 Apr 2015 09:43:44 GMT

I don't know if I'm missing the point here but as much as Catherine wishes to help her client surely the responsibility is with the referring practice to request copies of histology/clinical history from the referral practice and the labs they both used and she has no jurisdiction over what has happened between two other practices. If the patient has now come back to her, all she can do then is request the history back from the second practice that performed the original surgery and made the referral as one would for any case of supersession of care.

Re: Differing diagnoses on histopath

Mark Hedberg — Fri, 17 Apr 2015 09:31:15 GMT

[quote user="Mike Martin"]

I really do not understand why some referral practices 'think' they can withhold clinical records for any vet caring for that animal?

[/quote]

Because they're thinking like stage magicians - show how the trick is done, and it loses the magic. Alternatively, it's the selfish concern of 'if i show them what i did, next time they'll do it themselves and won't refer!'

Re: Differing diagnoses on histopath

Mike Martin — Fri, 17 Apr 2015 09:24:43 GMT

Another link....

5. Communication between professional colleagues

Updated 6 March 2015

5.3 Veterinary surgeons and veterinary nurses should liaise with colleagues where more than one veterinary surgeon has responsibility for the care of a group of animals. Relevant clinical information should be provided promptly to colleagues taking over responsibility for a case and proper documentation should be provided for all referral or re-directed cases. Cases should be referred responsibly.

Re: Differing diagnoses on histopath

Mike Martin — Fri, 17 Apr 2015 09:17:18 GMT

Here's the relevant RCVS link...

Mutual clients

5.8 Where different veterinary surgeons are treating the same animal, or group of animals, each should keep the other informed of any relevant clinical information, so as to avoid any danger that might arise from conflicting advice, or adverse reactions arising from unsuitable combinations of medicines.

Re: Differing diagnoses on histopath

Hannah Wynne Richards — Fri, 17 Apr 2015 09:10:01 GMT

I would insist on a copy of the original histopath, and then be open with the owners, and show both. What they do after that is up to them. You will have demonstrated that your advice was given in good faith.

Wynne

Re: Differing diagnoses on histopath

Mike Martin — Fri, 17 Apr 2015 09:05:36 GMT

Hi Catherine, I think from how you have explained this, you have taken a very balanced and professional viewpoint. Anything involving humans will often have variations in opinion (pathologist, vets, specialists), as have the pathologists in your case. It would be interesting to have the first pathologist's review the histo-block and ask their opinion anyway. Its also worth checking they do have 'pathology' post-grad letters after their name too.

JGW - Can I pick up on your point about a referral centre not discussing a case with you. I have come across this before. I think this is wrong. Whoever the vet is in care of an animal, then the referral centre must share their records with that vet. Just the same as when a client changes their primary vet to another, the new vet is entitled to request the clinical records and the first vet is obligated provide it - by RCVS guidelines, simple courtesy, and care and welfare for the animal.

My feeling is, I'm always willing to share our clinical records for a vet caring for the animal (that is jointly under my care) - its really important for the animal. I really do not understand why some referral practices 'think' they can withhold clinical records for any vet caring for that animal?

Re: Differing diagnoses on histopath

Suzanne Kelly — Thu, 16 Apr 2015 23:46:09 GMT

Acanthomatous ameloblastomas may be benign, but they are nasty as hell and IMO the surgery was the correct course of treatment. In this case benign does not mean harmless, far from it. Explain to the owner that these act like very malignant tumours and really should be treated aggressively.

http://onlinelibrary.wiley.com/doi/10.1111/j.1476-5829.2010.00208.x/pdf is a good article on the subject, the dentists/oncologists may have more to say in the morning. You've done the right thing and the owners should come to terms with that in time.

Re: Differing diagnoses on histopath

Martin Atkinson — Thu, 16 Apr 2015 19:15:49 GMT

I don't think that you can ever rely on histology from one small biopsy. Under any circumstances it is one person's opinion against another and anything is open to interpretation. Given that a much more representative sample would be gained from the resected bit of mandilble this obviously has to be the more reliable result. Also it can't be discounted that there was more than one condition going on and both results wre right.

I would continue to reflect on the fact that the treatment would probably been the same and not dwell on the possibility of someone's mistake. In all honesty I thought this post was going to lead to someone blaming you for missing the carcinoma when you did the dental but although it didn't I would still be wary of making too many waves.

That said I have had an incident with our lab where they mixed up the histo results of two samples they had on the same day. They tried to bluff it before accepting their mistake which was obvious as they were tow totally different conditions in two different species!

Re: Differing diagnoses on histopath

J G Wray — Thu, 16 Apr 2015 18:43:06 GMT

As I read this, the histopath was requested by another practice. In other words the histopath lab's customer is the other practice, not you. I had a similar issue with a client where a well known organisation near Newmarket took the view they had no obligation to discuss the case with me, since I was not the one they had the professional and commercial relationship with. They also took the view that the owner of the dog, the owner of the source material was also at least two places removed from them and even with their consent they weren't willing to discuss the case.

RCVS were consulted and were as much use as usual.

We resolved the matter by getting the owner to point out that the biopsy - not the opinion - was still their property and they'd like their property to be sent to another lab..... unless the original lab consented to discuss the case. That worked.

See how you get on.