Cystic nasal mass in JRT

RE: Cystic nasal mass in JRT

Rob Davis — Sat, 22 Jul 2017 16:52:58 GMT

[quote user="Evelyn Barbour-Hill"]Certainly showing my age now, I find this sort of imaging quite deserving of the cliché "verging on the miraculous"[/quote]

I couldn't agree more (and I'm not even as old as you ). They are even cooler when you view them on the horos software and can rotate them in any direction, alter the algorithm to put in and take out the soft tissues, do virtual resections to remove bone/body wall and peer inside, even virtual endoscopy (though I've not quite worked out how to play with that yet...). The main problem I've found with CT is that it picks up all sorts of unrelated abnormalities and can be difficult to decide on their clinical significance!

RE: Cystic nasal mass in JRT

Evelyn Barbour-Hill — Sat, 22 Jul 2017 15:25:51 GMT

[quote user="Rob Davis"]The images below may help a little more.[/quote]

Certainly showing my age now, I find this sort of imaging quite deserving of the cliché "verging on the miraculous"

RE: Cystic nasal mass in JRT

Rob Davis — Sat, 22 Jul 2017 12:27:48 GMT

I re-recorded to CT movies at a slower frame rate, hopefully these are slightly easier to look at:

https://youtu.be/bEBqhzJzN7c

https://youtu.be/27Hq9V94a94

RE: Cystic nasal mass in JRT

Rob Davis — Sat, 22 Jul 2017 09:34:07 GMT

[quote user="Evelyn Barbour-Hill"]If it were a cyst, your approach could work though it would still be pretty radical surgery; the way the lesion crosses the midline so far really bothers me. and I would seriously consider extracting 105, 106, maybe 107 even, and all the upper incisors; and don't hesitate to extract 204 if it seems a good idea at the time.[/quote]

Yes, I would have to be prepared for the plan to change during the procedure....

[quote user="Evelyn Barbour-Hill"]If you did it, and it isn't a cyst after all, it's going to be a horrid disaster.[/quote]

If it turns out to be a solid mass then definitely decent biopsy rather than attempting resection would be my plan, however on contrast CT images there is no uptake of contrast within the mass, only a very fine rim around the edge which would appear to suggest that it is cystic (though obviously doesn't rule out an underlying neoplastic cause).

I haven't actually seen the dog myself so far, but have simply been asked for advice by a colleague, so I will suggest repeating biopsy via nose as the next step.

[quote user="Evelyn Barbour-Hill"]I don't know what everyone else thinks, but I find dynamic CT videos very hard to follow. I'd much rather have a series of still pictures. (Showing my age?)[/quote]

I agree, being able to scroll back and forwards through the images at one's own speed is far more useful, but I don't think it's possible to post the images this way on vetsurgeon. It would probably have been better if I had recorded it at a slower speed - I will try to do this next time. The images below may help a little more.

RE: Cystic nasal mass in JRT

Evelyn Barbour-Hill — Fri, 21 Jul 2017 20:02:14 GMT

I agree entirely with what Malcolm said but I also understand your dilemma. This may well be an expansile neoplasia rather than an aggressive cyst.

If it were a cyst, your approach could work though it would still be pretty radical surgery; the way the lesion crosses the midline so far really bothers me. and I would seriously consider extracting 105, 106, maybe 107 even, and all the upper incisors; and don't hesitate to extract 204 if it seems a good idea at the time.

If you did it, and it isn't a cyst after all, it's going to be a horrid disaster.

If you can't get a good grab biopsy via the nostrils, I might consider as it were starting your approach, i.e. extract the 104, and use this route to obtain a good biopsy of the inside of the apparent cyst. Of course the owner would have to agree that if this biopsy showed neoplasia, euthanasia should follow.

I don't know what everyone else thinks, but I find dynamic CT videos very hard to follow. I'd much rather have a series of still pictures. (Showing my age?)

RE: Cystic nasal mass in JRT

Rob Davis — Fri, 21 Jul 2017 17:29:55 GMT

Thank you, Malcolm, for your rapid and sensible response. This lesion has already been biopsied by a colleague and the biopsy report is as follows:

Description:
The two samples identified as from the right nose consisted of haired skin and underlying soft tissue. No obvious mass lesion could be identified despite evaluation of additional sections. However, apparent irregular fibrosis was present within the deeper located tissues (between muscle bundles.), but it is difficult to be certain.
The additional sections from the bone lesion on the right maxilla, which required decalcification prior to processing, showed repeated fragmentation on sectioning that hampered interpretation of abnormalities. The samples included interlacing mature bone spicules as well as variable quantities of connective tissue, apparently visible especially on the edges of the sample. Present on the one sample margin was an irregular layer of stratified squamous epithelium, but due to significant fragmentation, it was difficult to interpret as to the exact location and significance.

Diagnosis:
See comments
.
Comments:
Interpretation was very difficult despite evaluation of additional sections.
The portion of haired skin showed apparent deep-seated fibrosis. It is possible that these changes are not truly representative.
The samples from the maxilla included interlacing mature bone spicules with irregular fibrosis. The stratified squamous epithelium on the one margin may form part of the normal epithelium, but may also represent a lining of a cyst. Additionally, the probability that this represent portions of a cystic squamous cell carcinoma can also not be excluded.
Additional samples for histological evaluation from the bone lesion may be more informative.

I agree that a repeat biopsy would be ideal. My proposition was to treat this as a cyst, accepting that if there is an underlying neoplastic process then we are very unlikely to achieve a cure this way, and a more radical resection-type approach would be significantly life-altering. The approach I was envisaging should not significantly impair quality of life, but equally is only likely to be successful if this is a benign cystic structure. I am quite happy to take advice if this approach is deemed inadvisable!

RE: Cystic nasal mass in JRT

Malcolm Ness — Fri, 21 Jul 2017 17:16:33 GMT

There must be a significant chance that this is a non-survivable disease. I would want to know more diagnostically before embarking on an operation that is likely to be quality-of-life impairing with a low chance of overall benefit. I would be looking to collect a biopsy and that is most easily done by visualising the lesion using an otoscope lubricated and pushed into the nare - it should then be possible to take a grab biopsy which will hopefully be enough to decide whether rhinotomy and surgical removal/reduction of the lesion is wise.