Skin mass help

Re: Skin mass help

Kate Richardson — Wed, 10 Jun 2015 16:53:41 GMT

[quote user="Anthony Todd"]

[quote user="Kate Richardson"]The owner will only then feel awful that he put the dog through [/quote] et seq.

No I reckon the owner will still blame the vet and it will reinforce his prejudice!!

[/quote]

That is exactly what I was implying and Virginia put it perfectly. [quote user="Virginia Campbell"]Yes....and it will be forever lodged in the owners mind that, "He was OK till he had the anaesthetic, then he died" even if the death had nothing to do with the GA.....and convincing him to GA the next dog for ANYTHING is going to be even harder.[/quote]

Re: Skin mass help

Robin Grimmer — Wed, 10 Jun 2015 16:35:19 GMT

This thread is an excellent example of informed consent, and why it is so vital.

Re: Skin mass help

Anthony Todd — Wed, 10 Jun 2015 15:29:32 GMT

[quote user="Kate Richardson"]The owner will only then feel awful that he put the dog through [/quote] et seq.

No I reckon the owner will still blame the vet and it will reinforce his prejudice!!

Actually, seeing that my instant action has been squashed, and rightly so, I accept, and looking at the picture, local and a 6mm core biopsy punch should get you a nice sample of the whole mass, particularly if taken near the centre near the dark [haemorragic??] area.

A lot of the "tumour round the edge may just be reaction rather than tumour, possibly.

There looks like fair chance it will start to bleed like anything any minute now.....

Re: Skin mass help

Virginia Campbell — Wed, 10 Jun 2015 14:55:04 GMT

[quote user="Kate Richardson"]No point doing a full excision (unless it is for palliative reasons) only to find out it is highly aggressive or has high potential for metastasis and the dog dies 3 weeks later due to metastatic disease. The owner will only then feel awful that he put the dog through the procedure and he still lost him.[/quote]

Yes....and it will be forever lodged in the owners mind that, "He was OK till he had the anaesthetic, then he died" even if the death had nothing to do with the GA.....and convincing him to GA the next dog for ANYTHING is going to be even harder.

Re: Skin mass help

Tim Charlesworth — Wed, 10 Jun 2015 13:43:04 GMT

Completely agree that the mass needs to be biopsied first. Personally, I'd use a trucut needle but stay away from the preputial vessels. Glad to see most of the posters agree that you need a diagnosis before you can give a recommendation for treatment and associated prognosis! It may be some genuine fear about sedations/GA's based on a bad previous experience.

I also agree that these ones need a firm hand sometimes - I'd give them my recommendations and leave it up to them to decide what to do. If they refuse to give you permission to treat their dog appropriately then they will have to either leave their dog or move practice..

You could offer referral to a specialist unit with a dedicated anaesthetist (+ ST surgeon +/- oncology) - owners seem to sometimes accept things from specialists that they don't from their regular vets (maybe it's the cup of tea and comfy chair approach )

Re: Skin mass help

Anthony Dennison — Wed, 10 Jun 2015 12:49:10 GMT

Like Kate said - if it's nothing particularly nasty you could just do a debulk with minimal margins and get the dog looking more normal. Why go through a big surgery if it wasn't needed after all?

Re: Skin mass help

Anthony Todd — Wed, 10 Jun 2015 12:26:39 GMT

[quote user="Kate Richardson"] It doesn't look from the picture like it will be easy to excise with wide margins[/quote] et seq.

Yes, fair enough, can't disagree with the logic or Kate's opinion. No mention of LN involvement yet though??

Hope it goes better than it looks. Sounds as if the owner may delay things until it is too late anyway, Please keep us posted.

Re: Skin mass help

Kate Richardson — Wed, 10 Jun 2015 12:10:10 GMT

Absolutely agree w Anthony and Robin. It doesn't look from the picture like it will be easy to excise with wide margins and some reconstructive surgery may be necessary given the proximity to the penis and prepuce? so if the owner can be persuaded towards surgery, he needs to go in with his eyes open about what can be achieved and potential complications. No point doing a full excision (unless it is for palliative reasons) only to find out it is highly aggressive or has high potential for metastasis and the dog dies 3 weeks later due to metastatic disease. The owner will only then feel awful that he put the dog through the procedure and he still lost him. At least if he does decide against surgery he has made an informed choice. If it turns out to be a more friendly mass, and the surgery is likely to be curative, then gentle persuasion may help him and gain his confidence.

Re: Skin mass help

Anthony Todd — Wed, 10 Jun 2015 12:09:06 GMT

[quote user="Anthony Dennison"] I would always prefer to do an incisional biopsy first so it can be graded before removing the whole lump.[/quote]

I'll bear the turbo-post label, but ask why the mass can't be graded after wide removal?

You can then take as many biopsies as you want from exactly where you want.

Will "reactive fibroplasia" go away successfully and completely with treatment, let alone the more sinister diagnoses?

Looking at the picture, does anyone think it will not need complete removal sooner better than later.

Re: Skin mass help

Robin Grimmer — Wed, 10 Jun 2015 11:54:22 GMT

You beat me to it Anthony D, and very eloquently put :)

Re: Skin mass help

Anthony Dennison — Wed, 10 Jun 2015 11:27:43 GMT

[quote user="Anthony Todd"]

[quote user="Anthony Dennison"]

I would agree with the idea of an incisional biopsy under local. Could even use a Tru-Cut needle for something like that I should think. If the histo reports come back as suitably scary then that should persuade him.

[/quote]

Would there be any biopsy result which would justify anything else apart from total excision [apart from eventual euthanasia...] ?

The owner is reluctant to allow anything, let alone 2 bites at the cherry.

[/quote]

The owner is unwilling to put the dog through a GA, but not unwilling to treat. Cytology has shown spindle cells but that's all the information given. A Tru-Cut (or punch, though this wouldn't be particularly deep) biopsy can be done under local, avoiding any sedation or GA, and histopathology can be done. The structure of the tumour and cellular arrangement that can be determined from a tissue biopsy will give a much better idea of what's going on - whether it is a reactive fibroplasia (not as worried about removing it) up to a grade III undifferentiated soft tissue sarcoma (needs removal with wide margins, local radiotherapy and chemotherapy due to the 40% risk of metastasis).

If any tumour cytology comes back with spindle cells and could potentially be a soft tissue sarcoma, I would always prefer to do an incisional biopsy first so it can be graded before removing the whole lump.

Re: Skin mass help

Anthony Todd — Wed, 10 Jun 2015 09:26:16 GMT

[quote user="Anthony Dennison"]

[/quote]

Would there be any biopsy result which would justify anything else apart from total excision [apart from eventual euthanasia...] ?

The owner is reluctant to allow anything, let alone 2 bites at the cherry.

Re: Skin mass help

Anthony Dennison — Wed, 10 Jun 2015 08:59:20 GMT

Re: Skin mass help

Martin Atkinson — Tue, 09 Jun 2015 17:56:21 GMT

Oh dear me. If half the cases on here today were mine I would have no clients left because this is another one I would be blunt with and say, 'Do as I suggest (i.e. accept a GA and do the job properly) or take a hike'. Honestly life is too short for this crap from clients.

Re: Skin mass help

Kate Richardson — Tue, 09 Jun 2015 17:52:32 GMT

Is it a fairly amenable dog? Could you take an incisonal biopsy or punch biopsy with him conscious using local anaesthesia/nerve blocks? If histopathology can give a diagnosis, and if it is a nasty, then this may persuade him that further action is the better option. And plenty of time talking through his concerns with regards to a GA- as someone else mentioned has either he or another pet had a bad experience? Sometimes time and patience can win these people over, but obviously you cannot completely eliminate all risk, but it mind help to talk about pre anaesthetic screening and talk through the procedure and monitoring in more detail (if you haven't already obviously)

Re: Skin mass help

Robin Grimmer — Tue, 09 Jun 2015 17:44:42 GMT

It needs a incisional biopsy first. It could be a soft tissue sarcoma and may need wide excision. I wouldn't mess about with sedation and local. You have to say there's a small risk with a GA, but a much bigger risk with leaving it and the longer you leave it the bigger it will get etc, the more chance of it metastasising. There's little point referring to a dermatologist, if you're going to refer anywhere then refer to an oncologist.

Re: Skin mass help

Joyce Whitehead — Tue, 09 Jun 2015 17:19:09 GMT

Yes I'd agree, I can't think of anything dying under routine sedation (touching wood now!) and that I would remove it in an instance if he were mine. You can't help some people though. No ideas as to what it is though?

Re: Skin mass help

Hannah Wynne Richards — Tue, 09 Jun 2015 17:16:19 GMT

Frustrating - but all you can do is advise - forcefully.

Wynne

Re: Skin mass help

Michael Woodhouse — Tue, 09 Jun 2015 17:12:58 GMT

There is a bigger risk to the dog leaving that alone............

Has anyone, ever, seen a fatality with sedation?

I've seen lots of dogs die from cancer...........

(you can't help some people)

Re: Skin mass help

Joyce Whitehead — Tue, 09 Jun 2015 17:09:21 GMT

I've suggested the sedation and local (he's a lovely quiet lab), but he won't have that either as there is a slight risk with any sedation or anaesthetic and he isn't prepared to even take that small risk.

Re: Skin mass help

Michael Woodhouse — Tue, 09 Jun 2015 17:05:14 GMT

How about sedation and removal under local if he refuses a GA? I saw practice at a PDSA Petaid vets and they did a surprising amount of surgery under dom/torb and local. I've done similar if they adamantly refuse a GA.

Have you asked them why so against anaesthesia? Have they had a bad experience?

That needs to come off IMO.....