Incidentalomas

Re: Incidentalomas

Rob Loxley — Tue, 08 Mar 2011 22:58:23 GMT

[quote user="alex gough"]the owner will often come back to you with "what would you do if it was your dog?"[/quote]

And most often my reply is "but it isn't my dog", in not too flippant a way, because I feel that it really has to be their decision. Maybe however most of my clients seem to be able to make reasonable decisions when presented with the relevant information.

Re: Incidentalomas

Bob Russell — Tue, 08 Mar 2011 17:50:36 GMT

This is a question that has become very relevant in humans as private whole body scans and healthy person checks are carried out.

Most of these are done privately but if things are shown up, further testing and procedures become necessary. Is it better to live in blissful ignorance of a problem or know about it and live with the stress associated with it? Apparently many of the things found eventually turn out to be benign and it is very unusual for an individual to significantly gain from it. The NHS rarely does this level of healthy person check but usually picks up the tab in the end!

Re: Incidentalomas

Anthony Todd — Tue, 08 Mar 2011 15:30:56 GMT

[quote user="robloxley"]biopsy/FNA/[/quote]

[off topic]

We have great difficulty finding a biopsy needle that gets good core tissue samples and does not sample the skin and/or subcut fat and muscle.

Could anyone recommend one that works, giving brand and codes if possible.

Tia, tt

Re: Incidentalomas

Alex Gough — Tue, 08 Mar 2011 15:08:08 GMT

True, but I never actually recommended a splenectomy given how small and innocuous this lesion looked.

Re: Incidentalomas

Peter Ding — Tue, 08 Mar 2011 15:05:40 GMT

Is there not a degree of irony that they could have paid for a splenectomy by now?

Re: Incidentalomas

Alex Gough — Tue, 08 Mar 2011 13:41:01 GMT

I actually have a dog that is brought in to me every three months to scan its 2 cm hypoechoic lesion in the spleen. I have been doing it for three years, and no matter how much I tell them that it is certainly benign now, and could we stop scanning it, or at least do it every 6 months, they insist I continue to monitor as they wouldnt forgive themselves if it changed now and they missed it!

Alex

Re: Incidentalomas

Mark Holmes — Tue, 08 Mar 2011 13:26:05 GMT

[quote user="Kate Richardson"]What I am saying is my advice and recommendations would be the same in every case, but the decisions made based on that advice would be different in each case. For example, if it was my dog, who is approx 15years old, hates needles, and is a happy, slightly senile, little old dog with mild chronic bronchitis, I would do nothing but maybe monitor. But I would not subject her to invasive tests or surgery as her quality of life is good and the stress of any investigations etc would impact detrimentally on her QOL, for her, in a big way. And at her age, quality is even more important than quantity. If the 'mass' turned out to be something sinister, then i would accept this and the minute her quality of life deteriorated and there was nothing I could do medically to improve this long term, then I would make the sad decision to euthanase her[/quote]

I had that dog with a splenic incidentaloma diagnosed on an imaging course, ignored it and the dog eventually died of incontinence.

Re: Incidentalomas

Alex Gough — Tue, 08 Mar 2011 13:09:06 GMT

[quote user="Richard Fox"]Just because its asymptomatic now doesn't mean it will continue to be surely?[/quote]

No, but it might continue to be. And spleens are the easy ones - you can remove them whole with a good success rate. What about a liver mass that might be benign - risk a biopsy/lobectomy? A lung mass? A brain mass?

Alex

Re: Incidentalomas

Richard Fox — Tue, 08 Mar 2011 12:47:25 GMT

[I think they call this the art of veterinary medicine lol...] Shudders at the thought !

Perhaps I see it in a bit more black and white - I always suggest to my clients to try and let the owner decide after hearings the options and background, risks and costs - sure some will ask you what would you do and then you would then give you your "personal" opinion but otherwise I always would seek for the informed owner decision.

Just because its asymptomatic now doesn't mean it will continue to be surely?

Re: Incidentalomas

Alex Gough — Tue, 08 Mar 2011 12:30:09 GMT

Yes, I largely agree with all that. But I was trying to highlight the particular difficulties of deciding what to do in an incidentally discovered, asymptomatic lesion, which may be benign or malignant, and for which the investigation and/or treatment carries a significant morbidity and mortality. There is no right or wrong answer, although if you just look at the mortalityy statistically, and ignore the morbidity of a splenectomy, then I think we would probably agree that a dog with an incidentally discovered splenic mass is far more likely to die from the mass than from a splenectomy. But then you need to add in the complication that if it is malignant, it may well die from the mass despite the splenectomy. I think they call this the art of veterinary medicine lol...

Alex

Re: Incidentalomas

Kate Richardson — Tue, 08 Mar 2011 12:15:15 GMT

What I am saying is my advice and recommendations would be the same in every case, but the decisions made based on that advice would be different in each case. For example, if it was my dog, who is approx 15years old, hates needles, and is a happy, slightly senile, little old dog with mild chronic bronchitis, I would do nothing but maybe monitor. But I would not subject her to invasive tests or surgery as her quality of life is good and the stress of any investigations etc would impact detrimentally on her QOL, for her, in a big way. And at her age, quality is even more important than quantity. If the 'mass' turned out to be something sinister, then i would accept this and the minute her quality of life deteriorated and there was nothing I could do medically to improve this long term, then I would make the sad decision to euthanase her.

But if I had found an incidentaloma in her 10 years ago, when she was in her prime, I would have investigated further, under anaesthetic if necessary (and did have to at one stage). She was a lot more tolerant of things then, (although has never been good with needles!) I can and have blood tested her for example recently, and she gets over it within seconds, but unless the results of any tests are going to change what I do, not just in her, but in any patient, I won't perform tests. But I would have to think long and hard about performing major abdominal surgery. If it was the spleen involved I would be more likely to proceed, but if it was the liver I would be less inclined.

Ultimately animals live in the here and now, and have no comprehension of what may be going on, all they know is how they feel right now. So if an owner of a younger animal declined all investigations, and said what will be will be, and the animal wasn't suffering in any shape or form, then i would be happy with their decision as long as it was a fully informed one. So what I am trying to say, is that I don't think there is a right or wrong answer, the decisions made have to be based on individual circumstances, case by case.

Re: Incidentalomas

Alex Gough — Tue, 08 Mar 2011 11:20:13 GMT

[quote user="Kate Richardson"]The fact that the 'mass' is an incidentaloma makes no difference in my mind as to how you should then proceed. [/quote]

Again, discussing with the owners the differentials etc is also a given, but as these are rarely black and white, and not always easy for us to judge what the best thing to do is, the owner will often come back to you with "what would you do if it was your dog?"

And if you say it makes no difference if the mass is an incidentaloma, which by definition is asymptomatic and incidentally discovered, are you really saying that your recommendations, or decision making if it was your own dog would be the same if it was symptomatic or asymptomatic?

Alex

Re: Incidentalomas

Kate Richardson — Tue, 08 Mar 2011 10:52:04 GMT

[quote user="alex gough"]

was thinking more along the lines of what do you do with a potentially benign lesion in which the risks of investigating may or may not outweigh the risks of surgery. Maybe we should remove every spleen we see with a mass in, although we would remove a lot of innocuous spleens if we did. Alternatively, a wait and see approach, with a rescan for small, non-aggressive looking lesions could be prudent, but then if it is an early haemangiosarcoma and you wait a month to rescan, it will probably have metastasised by then.

What about a liver mass? As with the spleen, it is common to find nodules within the liver in older dogs, and hepatectomy isn't an option. Should we biopsy them all? Try to remove them. There will be a significant morbidity and even mortality associated with this. What about a small solitary lung mass?

[/quote]

I agree, informing the owner is a given. And then surely one should discuss the differentials, implications of each differential and then discuss what you can do to find out more, discussing the risks and benefits of each procedure as you would do in any case. Then the owner can make an informed decision about how to proceed. As in every case, it will be an individual choice with many variants- the age of the animal, the owners wishes regarding any invasive procedures, the costs involved, etc etc. The fact that the 'mass' is an incidentaloma makes no difference in my mind as to how you should then proceed.

Re: Incidentalomas

Laurence Webb — Tue, 08 Mar 2011 10:29:25 GMT

[quote user="Peter Ding"]i would tend to take the view that your actions depend on the specifics of the case, the nature of the owner and whether it is insured.[/quote]

Why on Earth should the insured status of an animal make any difference to your recommendations? I'm assuming that you don't offer different levels of service and fees to insured and uninsured clients! It may influence their choice of action, but shouldn't alter your decision about informing them

Re: Incidentalomas

Peter Ding — Tue, 08 Mar 2011 10:11:25 GMT

I'm well aware of the consequences of inaccurate information and making presumptions Hanna. I'm only talking of clients that you know very well indeed, having looked after them for 10 or more years with several generations of pets. Bonded clients that you are close to and know well who share their troubles with you. I have had numerous very grateful clients in such circumstances who could not have coped at the time with knowing the full truth. You are pretty obviously obliged to keep Joe Bloggs informed of all relevant details and options.

As I said it depends on all the circumstances; the presence of insurance removes any financial worry for bonded clients, so it's one less thing to consider. We do direct claims in such circumstances. The opposite isn't true of course unless you are sure of your facts, the owner having told you clearly of their intentions should a significant cost be involved.

Owners also have a right not to be upset unnecessarily. 95% or so perhaps 99% can cope with the truth but I won't tell an owner if an animal has a benign tumour if I KNOW that owner will immediately have the pet PTS because "cancer" has affected them seriously in the past and no-one can guarantee that it won't turn into a malignant tumour at some point.

Re: Incidentalomas

Alex Gough — Tue, 08 Mar 2011 10:10:16 GMT

I agree, I hadn't intended this to be a discussion about whether to tell the owner or not, I think that has to be a given. Think where you would be if a month later it came back with haemoabdomen or lung mets, and the nurse said to the owner it's a shame the spleen wasn't removed a month ago.

I was thinking more along the lines of what do you do with a potentially benign lesion in which the risks of investigating may or may not outweigh the risks of surgery. Maybe we should remove every spleen we see with a mass in, although we would remove a lot of innocuous spleens if we did. Alternatively, a wait and see approach, with a rescan for small, non-aggressive looking lesions could be prudent, but then if it is an early haemangiosarcoma and you wait a month to rescan, it will probably have metastasised by then.

Another place this has an implication in human medicine is these whole body CT scans that you can buy to reassure yourself you are in good health. Apart from the 1:1500 chance of dying from contracting a fatal cancer from the radiation of the CT, say they found a small liver mass, there is also between a 1 in 500 and 1 in 10000 mortality rate with a liver biopsy, depending on who you read, to find out whether it is benign. Much more complicated if you find a small brain mass.

Alex

Re: Incidentalomas

Richard Fox — Tue, 08 Mar 2011 09:46:51 GMT

Is it ethical to withhold important information even if it will be upsetting - That's life - it infrequently throws up stressful or upsetting situations - it how we as individuals are able to deal with it? I am sure the RVCS wouldn't look kindly on withholding important info? Isn't it all about informed decisions? I am not taking about differential diagnoses that are unlikely so you don't mention them i.e. you don't tell clients every scenario just give them the salient info as not to overwhelm them but if you have found important information I would have to tell the owner?

Re: Incidentalomas

Hannah Wynne Richards — Tue, 08 Mar 2011 09:40:56 GMT

Peter Either the animal may be insured without your knowledge-because until now it's been healthy so has only recieved neutering, vaccinations/worm/flea treatment,or even if uninsured, the owner may have the will/means to pay-as the veterinary press keeps saying "don't Xray owners pockets " You can't go on appearences-in a previous practice I worked in, often the scruffiest man in the waiting room was the local landowner, and member of the Houseof Lords-if you looked at the holes in his elbows, you would have thought he'd be hard pressed to pay the basic consult fee !!!!!!!!!!!!!!!!!!!!!!!!!!

I would be very annoyed if I was denied the opportunity to give a beloved animal the chance of a cure-in fact the reason I will never use a certain referral centre again is that I feel they were making decisions on my behalf when 1 of my horses was referred for colic surgery-and the outcome could have been better if they hadn't been trying to save me money-I didn't tell them to save me money-I told them to do their utmost tosave my horse

Owners have a right to know

Wynne

Re: Incidentalomas

Peter Ding — Tue, 08 Mar 2011 09:12:53 GMT

Doctors frequently keep the full truth from their patients. We are responsible for any consequences of what we tell owners. Who would tell an owner and child of an incurable tumour in their beloved pet the night before their A levels? etc.

Don't miss the fundamental difference.

In a consultation the owner is present, and will probably notice your attention has been drawn to a lump they themselves have missed.

When a pet is in for a procedure the owner will stay blissfully unaware unless you tell them.

i would tend to take the view that your actions depend on the specifics of the case, the nature of the owner and whether it is insured.

Does an owner have a right to know anything you are aware of regarding their pet? Or do they merely have a right to know the conclusion of your thought processes in terms of what you think is in the best interests of the owner and animal?

I'm happy to do the worrying for the owner in some cases. Usually though you can find someone within the family to share your concerns with and agree a sensible approach.

Personally i would tend to remove a spleen with a mass (or at least do an ex lap, as my evaluation is that it's a bigger risk if you do nothing).

Re: Incidentalomas

Hannah Wynne Richards — Tue, 08 Mar 2011 09:10:36 GMT

ALWAYS tell the owner-take it from there-we don't have either the legal or moralright to withold this information

Wynne

Re: Incidentalomas

Richard Fox — Tue, 08 Mar 2011 08:45:45 GMT

Exactly Rob - On first inspection some cases one doesn't know what it is - thus we suggest further examination - I think better to find it early before significant clinical signs then for it to be undiscovered and potentially life threatening when clinical signs ensue?

However I am not an advocate of life scans!

Re: Incidentalomas

Rob Loxley — Tue, 08 Mar 2011 08:42:39 GMT

Turning the question around, is it much different to say finding a skin/soft tissue lump that hasn't previously been noted when the dog comes in for routine vaccination. It has now been found so discuss the options (remove/biopsy/FNA/monitor) and the pros/cons of each and with the owner come to a decision? OK with an internal mass the 'difficulty' of sampling and potential for complications and maybe the cost will be higher, but the discussion is similar.

Re: Incidentalomas

Richard Fox — Tue, 08 Mar 2011 08:36:07 GMT

From a path point of view we see many non-neoplastic lesions in dog spleen and liver - Most of them nodular hyperplasia in older animals - These do not need resecting although some can bleed - However although with experience one can tell what the lesion is is most cases one can never be sure and therefore the ball has started rolling and therefore you end up suggesting biopsy/splenectomy. Howerver routine scans and laparotomies also have very positive outcomes - visualisation leads to dx of a mass / lesion which was not thought of or ID'd before on US or Rads or discovery of a lesion without clinical signs which does need treatment - so swings and round abouts?