What would you do? Young Labrador with a swelling

RE: What would you do? Young Labrador with a swelling

Anthony Dennison — Mon, 08 Jan 2024 12:17:56 GMT

I had a dog years ago that had a mass on it's thorax that would come and go, respond to antibiotics and then reappear a month or two later. Decided to biopsy it, had a hard bit at the bottom of the biopsy site

Pulled out a 4" skewer the dog had eaten that summer, had slowly been working it's way out of the body. Dog showed no respiratory signs at all.

RE: What would you do? Young Labrador with a swelling

Richard Carter — Thu, 21 Dec 2023 09:22:32 GMT

And talking of grass seeds- why do they never seem to rot?? After all in a wet environment with pus etc. I’ve found intact seeds months after the incident and we all know of cases where the seed travels over months through the thorax or up a limb to erupt behind a rib or shoulder…

Back to referring out of problem cases- there is an implication from insurance advertising that all the bells and whistles are available and the other are indiscreet specialists who, perhaps to justify their existence, will trash their gp colleagues to the client because someone didn’t sort or refer on the first presentation. Only the Sith deal in absolutes!

RE: What would you do? Young Labrador with a swelling

Neil Wheadon — Wed, 20 Dec 2023 23:41:15 GMT

[quote userid="8991" url="~/f/clinical-questions/30848/what-would-you-do-young-labrador-with-a-swelling/243254#243254"]The reason I posted this was my concern over the outsourcing of clinical reasoning that seems to be growing. A CT scan (regardless of how many slices) is after all just a lot of x-rays put together. It cannot replace clinical reasoning and it cannot obviously give a histological diagnosis. [/quote]

2 observations

Firstly

I was faced with a similar case 8 weeks ago. A 6 year old JRT that had an oozing fistula between the ribs and the ilium. It had been explored 6 weeks previously with nothing found. Financial concerns were expressed and it was with everything crossed as I managed to talk the client into having another look, estimating £800 with no guarentees.......

Secondly

I rather foolishly checked through the google reviews of a practice I work in on a very regular basis. Reviews are either 5 star or 1 star. The reviews were mostly very good, however the pattern in the 1 star reviews revolved around missed diagnosis. Several complained that cancer was missed.

Now consider the field we work in and I use this with clients. As vets we are approaching what hospitals can do to the majority of people. We can CT, MRI, Chemotherapy, ultrasound to a very high standard, something many of us have no access to in our place of work. GP vets are highly skilled, we have an incredibly wide range of skills from squeezing anal glands to removing a plastic toy from an ilium. However what it also brings is uncertainty as we also know that advanced techniques are available in specialist centres that will help us and the client, but at a cost. Any case aside a booster has this conundrum, do I treat, do I investigate, do I guess at a diagnosis, or do I refer? The latter has many advantages, not least the ability to reduce the complaint that you missed something. It also reduces the responsibility of the referring vet from getting to the cause and for that we are grateful to specialist centres. Consider our medical colleagues, they can use all these services with no costs involved to the client, or risk of reputational loss to themselves. We are indeed in a tricky position.

In this case, I can see why a CT scan was used, an attempt to find the location of the foreign body because that's what the majority of referral centres do very well. The thought at time of referral may have been 'that's the best way to find it' or even 'glad a specialist is dealing with this'

..... I found a 2cm grass seed, having fought my way through 3 cm of fibrous material. Another day, I may not, I was worried until the second I found it, that's the life of a GP vet. Every day we put our necks on the line, it's a funny old profession.

Neil

RE: What would you do? Young Labrador with a swelling

David Mills — Wed, 20 Dec 2023 19:04:45 GMT

P.s. I do have another similar one if anyone is bored over the xmas period

RE: What would you do? Young Labrador with a swelling

David Mills — Wed, 20 Dec 2023 19:03:35 GMT

So, after a lot of to'ing a fro'ing with meds, and a very worried owner thinking her lab had juvenile cancer...

Eventually re-operated on and a grass seed was found.

The reason I posted this was my concern over the outsourcing of clinical reasoning that seems to be growing. A CT scan (regardless of how many slices) is after all just a lot of x-rays put together. It cannot replace clinical reasoning and it cannot obviously give a histological diagnosis.

There are of course some odd aspects to this case (e.g. why was histo never performed, why was CT done first) but it is a real-life case. Also it is not knocking CT or the report - they simply describe what they see and give the most likely differentials. BUT I see it as somewhat of a sit up and take note kind of case. CT is often recommended for tracking FBs. In this case, the CT report led the clinicians down a very different path. I think it is important to recognise the limitations of any diagnostic test, even advanced imaging, and how that dovetails with case management.

And this brings me back to outsourcing. In this case the CT report was wrong. Outsourcing therefore can be dangerous and is not always the safety/defensive medicine net it can appear. What if the owner had run out of money for this case? It does make you think.

RE: What would you do? Young Labrador with a swelling

Clive Ansell — Wed, 20 Dec 2023 09:04:29 GMT

That would be my train of thought too; young Labrador with a possible entry hole in mouth, it's a FB until proven otherwise.

RE: What would you do? Young Labrador with a swelling

Richard Carter — Wed, 20 Dec 2023 08:58:45 GMT

Or it’s a 2 year old Labrador- it’s got a f/b in there…

RE: What would you do? Young Labrador with a swelling

Clive Ansell — Wed, 20 Dec 2023 08:57:20 GMT

[quote userid="9515" url="~/f/clinical-questions/30848/what-would-you-do-young-labrador-with-a-swelling/243243#243243"]What slice CT scanner? ie. what was the resolution of the images to determine very small things?[/quote]

I know very litle about CT scanning, but what would be the smallest thing you could see to identify it accurately?

A remaining FB; grass seed, bone or stick fragment, could be smaller than a rice grain.

Someone else, Alasdair I think, suggest ultrasonography. Again with a good machine and operator (not me!), what would be the smallest fragment you could detect?

RE: What would you do? Young Labrador with a swelling

Sarah Keir — Tue, 19 Dec 2023 07:49:33 GMT

[quote userid="8991" url="~/f/clinical-questions/30848/what-would-you-do-young-labrador-with-a-swelling"]Was put through the CT scanner[/quote]

What slice CT scanner? ie. what was the resolution of the images to determine very small things?

RE: What would you do? Young Labrador with a swelling

Neil Wheadon — Tue, 19 Dec 2023 00:04:14 GMT

[quote userid="8991" url="~/f/clinical-questions/30848/what-would-you-do-young-labrador-with-a-swelling/243221#243221"]Small hole communicating with the mouth.[/quote]

OK, slightly confused (sorry)

Swelling to the outside, but you say communicating to mouth, so is this a tract or a fistula, or 2 exits, the one you created and another?

There's foreign material at the bottom of this somewhere? If it is these are tough to find, any amounts of imaging isn't a treatment, you either need to wait, hold your nerve and wait for it to blow out or have another look surgically following that new tract. I'd do the latter.

Picture?

Neil

RE: What would you do? Young Labrador with a swelling

Alistair Graham-Evans — Thu, 14 Dec 2023 20:06:46 GMT

Surgery yesterday on similar case - 3 months duration.

Young French Bulldog with recurring submandibular abscess - no penetration in ear or mouth identified. Shrank it down with Clav prior to surgery.

Some of these become chronic fibrotic tracts - excised and origin was small area of fibrosis dorsal to pharynx. Tracked just caudal to base of ear canal and facial nerve. Parotid salivary duct went through it and had to remove the gland. Lymph nodes all normal size.

Expect and hope for resolution now.

RE: What would you do? Young Labrador with a swelling

Clive Ansell — Thu, 14 Dec 2023 18:17:23 GMT

I would be suspicious of a stick injury with remaining material, tracking grass seed, fragment of bone, or other foreign body; further sugical exploration, (or another CT scan ) ?

I had case earler this year where we though a dog had a malar abscess, turned out to be a penetrating injury from a sharp piece of chicken bone.

RE: What would you do? Young Labrador with a swelling

David Mills — Thu, 14 Dec 2023 14:13:14 GMT

So next step the swelling was explored.

Small hole communicating with the mouth.

Lanced and drained thick bloody possibly sl purulent material. Drain sutured in place. Meds restarted.

Cytology from procedure showed neuts, no bacteria, some fibroblasts and dysplastic epithelial cells.

Resolved then recurred in slightly more lateral location 2w later.

Next steps?

RE: What would you do? Young Labrador with a swelling

Clive Ansell — Tue, 12 Dec 2023 09:04:00 GMT

[quote userid="19228" url="~/f/clinical-questions/30848/what-would-you-do-young-labrador-with-a-swelling/243205#243205"]if possible with chest x-ray . [/quote][quote userid="2131" url="~/f/clinical-questions/30848/what-would-you-do-young-labrador-with-a-swelling/243202#243202"]Radiograph teeth.[/quote]

These may have already have been imaged with the CT scan?

Where I have referred similar cases, usually on a tumour hunt, they include full head and neck, and usually scan the chest for metastases too.

RE: What would you do? Young Labrador with a swelling

cairncross — Tue, 12 Dec 2023 06:12:30 GMT

Stick a needle in it if I was confident on palpation, presumably mouth and throat already EUS during CT would like a good look under tongue , continue meds if that's owners only option incision if possible with chest x-ray .

RE: What would you do? Young Labrador with a swelling

Evelyn Barbour-Hill — Mon, 11 Dec 2023 20:25:24 GMT

[quote userid="8991" url="~/f/clinical-questions/30848/what-would-you-do-young-labrador-with-a-swelling"]What would you do next?[/quote]

Examine the interior of the oral cavity and throat properly.

Radiograph teeth.

You did ask what I would do!

RE: What would you do? Young Labrador with a swelling

Gillian Mostyn — Mon, 11 Dec 2023 15:56:52 GMT

[quote userid="5012" url="~/f/clinical-questions/30848/what-would-you-do-young-labrador-with-a-swelling/243193#243193"]

In order

1) Conscious if possible, needle sample; serum? pus? cells?.

2) Euga: oral pathology? trauma? stick injury? If not diagnostic then full biopsy

Would want to rule out the obvious prior to advanced imaging.

[/quote]

I'd also do this

RE: What would you do? Young Labrador with a swelling

Anthony Dennison — Mon, 11 Dec 2023 12:07:31 GMT

I would FNA, then dependent on those results do an incisional or excisional biopsy. We do have a CT scanner and may consider this but only after discussion with the owner, it's a possible route to go down rather than the only option.

RE: What would you do? Young Labrador with a swelling

Alasdair Hotston Moore — Mon, 11 Dec 2023 10:04:56 GMT

Nice scenario. Even after the Ct I’d go to US. If there’s a cavity I’d think about guided aspirate. If it’s solid I’d do a Trucut, likely conscious. If I’m suspicious of a visible FB, pick up a knife.
if all these are declined, trial broad spectrum antibacterials

RE: What would you do? Young Labrador with a swelling

Alasdair Hotston Moore — Mon, 11 Dec 2023 10:01:32 GMT

Or indeed an US. Love a CT myself but many argue a good US would be better here

[quote userid="6386" url="~/f/clinical-questions/30848/what-would-you-do-young-labrador-with-a-swelling/243182#243182"]Can I ask why an FNA wasn't performed before a CT scan?[/quote]

RE: What would you do? Young Labrador with a swelling

Clive Ansell — Mon, 11 Dec 2023 09:59:06 GMT

Back to basics!

I guess the main differentials are going to be neoplasia, abscessation or foreign body?

In order

1) Conscious if possible, needle sample; serum? pus? cells?.

2) Euga: oral pathology? trauma? stick injury? If not diagnostic then full biopsy

Would want to rule out the obvious prior to advanced imaging.

RE: What would you do? Young Labrador with a swelling

Joyce Whitehead — Mon, 11 Dec 2023 09:48:43 GMT

I would agree with above, FNA first, and if non diagnostic I’d be inclined to get a trucut or similar biopsy. I’m assuming CT didn’t show any fluid pockets? I must say my first thought would have been FB rather than tumour.

RE: What would you do? Young Labrador with a swelling

Lucy Fleming — Mon, 11 Dec 2023 09:14:36 GMT

Poke it with a needle!

RE: What would you do? Young Labrador with a swelling

Kate Richardson — Sun, 10 Dec 2023 21:30:05 GMT

seems a bit random to jump to CT first!!! Kind of assumed it wasn't your case as can't imagine you doing CT first, do you even have access to it> Anyway, my answer would be do an FNA or biopsy!!!

RE: What would you do? Young Labrador with a swelling

David Mills — Sun, 10 Dec 2023 21:27:26 GMT

[quote userid="6386" url="~/f/clinical-questions/30848/what-would-you-do-young-labrador-with-a-swelling/243182#243182"]Can I ask why an FNA wasn't performed before a CT scan?[/quote]

You can but I don't know the answer

This wasn't my case.