Tricky case on day 2 in practice - any thoughts?

Re: Tricky case on day 2 in practice - any thoughts?

Carolyn — Sun, 04 Sep 2011 16:38:29 GMT

Thanks for the advice - just to give you an update:

The owners elected to go for palliative tx with steroids. 10days on, the mass has reduced in size by 10% so we are continuing. The dog is still happy and doesn't seem too bothered about the tumour. The owners are aware it's just a matter of time, but I'm pleased with how this one is going!

Re: Tricky case on day 2 in practice - any thoughts?

Andrew Kent — Mon, 29 Aug 2011 17:06:51 GMT

[quote user="Stephen Courtney"]Ultimately it comes down to client choice.[/quote]

Very true, but with the number of budget insurance policies capping at as low as £1500, you may only get 3 or 4 months of masitinib.

But it is a great drug when it works!

Andy

Re: Tricky case on day 2 in practice - any thoughts?

Stephen Courtney — Mon, 29 Aug 2011 14:20:02 GMT

One dog had treatment stopped once a good clinical result was arrived at...he's still fine 6 months after the last treatment. you don't have to give it forever, especially if finances are being squeezed.

and with an otherwise terminal disease, using up all the insurance money isn't necessarily a disaster compared with the alternative!

Ultimately it comes down to client choice.

Re: Tricky case on day 2 in practice - any thoughts?

Andrew Kent — Mon, 29 Aug 2011 11:15:56 GMT

Costs of TKI's is pretty eye watering, we are finding that even in insured clients they can be cost prohibitive. There is no doubt that in some cases the results with them are astounding but I would still go for surgery if possible. In a big labrador vinblastine/pred is probably less than £100 a month whereas masitinib is £300-£400 before any monitoring. This would eat up an insurance limit pretty quickly especially as most of them will need to be on it long term.

Re: Tricky case on day 2 in practice - any thoughts?

Stephen Courtney — Fri, 26 Aug 2011 23:20:25 GMT

[quote user="Martin Atkinson"]

[quote user="Stephen Courtney"]

[/quote]

I haven't used it yet but went to Gerry Polton's talk 18 months ago and saw the future. I know its expensive but how does the cost compare in real terms with palliative surgery alongside other old fashioned not very successful chemotherapy?

[/quote]

I can't comment on costs as I'm not directly involved. but a couple of dogs riddled with MCT have 'normalised' with no side effects whatsoever.

I think this sort of treatment is the future for cancer therapy, at least in the medium term - drugs that control and inhibit, rather than try to cure.

Re: Tricky case on day 2 in practice - any thoughts?

David Mills — Thu, 25 Aug 2011 11:26:16 GMT

Are people using the tyrosine kinase inhibitors as an adjunct to debulking surgery or straight off? Never used it but the blurb we got advocated surgery is the very best things for these with chemo if couldn't remove everything.

As for this mass, shave it to sample it - by the time you've prepped the slides, it might have a lovely erythematous reaction if an MCT (and it'll bleed a fair bit). Likewise elsewhere preds can give palliative reduction in size - which would be good in this dog given its location. Also gut protectants in addition to preds/abxx - omeprazole's my fave.

Re: Tricky case on day 2 in practice - any thoughts?

Martin Atkinson — Thu, 25 Aug 2011 10:39:40 GMT

[quote user="Stephen Courtney"]

[/quote]

Re: Tricky case on day 2 in practice - any thoughts?

Stephen Courtney — Wed, 24 Aug 2011 17:45:27 GMT

No reason why an in-house cytology should be too expensive - it would be good practice in harvesting the sample, making good smears and reading them.

Diagnosis before preds - it doesn't have to be a tumour but probably is.

We have had brilliant results with masivet for MCTs. it is costly but we have had long term remissions - more than 6 months and still going strong for 2 that i know of - and I would certainly rather try that than chopping the poor dog around again. and the cost issue is for the owners to decide, the vet's job is to give informed options - and that means you need the best diagnosis you can get.

If you are stuck with preds and antibiotics until pts sooner than later, so be it. It's not a bad option if it is the only option before PTS.

Re: Tricky case on day 2 in practice - any thoughts?

rhona kerr — Wed, 24 Aug 2011 09:54:45 GMT

Hope I'm not too late! Would go for fna if owner willing, spending lots of money on a horrible/expensive/waste of time is the kind of thing that gets us vets a bad name!! Would be honest about the outlook, if chemo not an option then would not worry about fna, give pred and abx as ulcerated. Often the owners just need time to realise this is a bad tumour, will spread quickly whatever we do, realistically it sounds like referral/thousands of pounds would still result in a very poor cost/benefit ratio for owner and dog as it doesn't sound like even all this would help. Good luck, hope things go well.

Re: Tricky case on day 2 in practice - any thoughts?

Martin Atkinson — Wed, 24 Aug 2011 08:51:00 GMT

If it is a MCT then if funds are not totally limited you could try Masivet or Palladia rather than invasive surgery.

Re: Tricky case on day 2 in practice - any thoughts?

Hannah Wynne Richards — Wed, 24 Aug 2011 08:49:58 GMT

Just check with the boss before you do the diff-quick-so that you charge properly-otherwise an unauthorised FOC treatment on day 3 might set your carreer off wrong

Wynne

Re: Tricky case on day 2 in practice - any thoughts?

Carolyn — Wed, 24 Aug 2011 07:48:33 GMT

Thank you for all your advice - it is great to wake up and have 8 informed opinions on this one.

I'm seeing the clients again today, will have (another) long chat about it all - hadn't considered diffquik and examine the FNA myself actually - I can certainly give it a go - we did enough of them at uni!

Will let you know how I get on.

Thank you again.

Re: Tricky case on day 2 in practice - any thoughts?

Richard Fox — Wed, 24 Aug 2011 07:42:04 GMT

[quote user="Carolyn"] I have found FNA so frustrating when more than half the time the pathologist won't commit them self" [/quote]

- Michaeal - CYTOLOGY IS A GUIDE - IT IS RARELY DEFINITIVE - Do you phone your pathologists to find why they could not come to a conclusion?

I can only speak of my practice but we try so very hard to come to a conclusion but often due to above it is not possible. Often we get forms without ANY history.

MCT are very easy to diagnose on cyto with a decent prep! Go for it and FNA this mass :) Could this be a lymph node given the location?

Re: Tricky case on day 2 in practice - any thoughts?

Evelyn Barbour-Hill — Wed, 24 Aug 2011 01:38:58 GMT

[quote user="Carolyn"]I got a second opinion from a colleague who said it may be possible to remove the bulk of it - although the dog will probably need a perineal urethrostomy - and of course it will probably grow back pretty quick. [/quote]

MAY be possible to remove the BULK of it??? And even for that would need a perineal urethrostomy? And then it would grow back quickly?

In plain language it is inoperable.

Options therefore:

1. Do nothing (or give placebo) and euthanase when it's in trouble.

2. Try palliative prednisolone, entirely empirically.

3. Consider chemotherapy, which would demand diagnosis. FNA first because it's quick and easy. If the report is inconclusive, excisional biopsy. No point in any of this if the owner doesn't fancy chemotherapy.

[quote user="Carolyn"]Money is an issue,[/quote]

Your job is to present the options. The owner can make the financial decisions.

[quote user="Carolyn"]although they want to do the best for their dog[/quote]

They may need time and a bit of talking, to come to the realisation that the best for their dog may not be textbook medicine but acceptance of the inevitable.

And, oh yes, welcome to the world of practice

Re: Tricky case on day 2 in practice - any thoughts?

Michael Woodhouse — Tue, 23 Aug 2011 23:21:00 GMT

There's no point putting the dog through diagnostics if the mass is not operable.

It is amazing the benefit that preds plus or minus antibiotics can have on some of these masses.

As a rule is we remove a mass and the owners decline histology we will keep a small piece in a universal in formalin. That way if something comes back you can always send that off without chopping bits off the dog.

I have found FNA so frustrating when more than half the time the pathologist won't commit them self. The economics of biopsy don't add up IMO - I'd rather remove and send for histo.

Re: Tricky case on day 2 in practice - any thoughts?

Utlendigur — Tue, 23 Aug 2011 23:19:48 GMT

Can I add another vote to FNA. I must admit MCT sprang to mind. I certainly would be wary of trying to remove it in that site, that size lump, that breed, rapid regrowth, possible metastasis...(One thing I sometimes do in cases where the owner decides against histo but I'm worried a lump might be problematic is to keep the sample in formalin but not send it off - then if the lump recurs/metastasises you can just send the sample off without having to operate again).

Just an anecdote but I had a callout one Christmas Day to a dog with a suspected inguinal hernia the size of a grapefruit (in between the cat RTA, dog stitch up, the gastroentertitis case whose owners saw the door open and just thought they'd drop in, and collecting a the dog that had been dead for 2days....). The owner (a nun) swore it had come up overnight. The dog had had a small skin lump removed from its tuber ischium a few weeks previously. The "hernia" turned out to be metastasis of a MCT to the inguinal lymph node.

Re: Tricky case on day 2 in practice - any thoughts?

Rob Loxley — Tue, 23 Aug 2011 22:51:25 GMT

+1 for FNA'ing the mass. And maybe some of the other 'lumps and bumps'?

[quote user="Carolyn"]I assume this is the original testicular/scrotal tumour recurring[/quote]

Would be top of my list, and MCT would be my top guess (but then I did remove the stitches from a boxer that had had its 3rd MCT removed only to find a new tiny lump from which the FNAs came back as - well, you guess!)

Then not sure I'd be going down the surgery route, but you really need a diagnosis to make a decision.

[quote user="Carolyn"]My boss said to try a conservative approach and try it on preds 2mg.kg for a week and see if that made a difference.[/quote]

If there's no money for diagnostics or further treatment then maybe I'd try the pred, but it sounds like there's some will to do some diagnostics.

Re: Tricky case on day 2 in practice - any thoughts?

Clive Ansell — Tue, 23 Aug 2011 22:42:48 GMT

[quote user="Carolyn"]

Owners didn't want send anything off for histo.

Money is an issue, although they want to do the best for their dog

Carolyn

[/quote]

They should have had histopathology first time around, I always advise for all masses I remove. Had a similar case 2 weeks ago; mammary mass removed May this year, histoology declined by owner, mass now returned and owners not happy because we don't know what it is and how to manage the case without ga/biopsy.

if no money then it's preds or/then pts.

Agree with others, if its a Boxer it's a walking neoplasm with a dog attached somewhere.

Re: Tricky case on day 2 in practice - any thoughts?

Stephen Courtney — Tue, 23 Aug 2011 22:21:56 GMT

You need a diagnosis first and foremost. A fine needle aspirate is easy to do, use diff quick and read it yourself. Mast cells are easy to identify. For some reason MCTs spring to mind first, but could be almost any other. Neoplasia is the most likely, and it doesn't sound like further surgery is likely to benefit this dog at all, given the history and the findings you describe.

But you need a diagnosis before you can offer anything meaningful, and certainly before you fill the dog full of preds!

Re: Tricky case on day 2 in practice - any thoughts?

Rob Reid — Tue, 23 Aug 2011 21:24:24 GMT

Several differentials to consider. Your most likely ones would be neoplasia (either recurrence of scrotal mass, new mass or met from somewhere else, MCT etc), hernia or other more acute causes of a mass/swelling eg abscess or haematoma.

If owners are looking to treat, imaging (ultrasound +/- xray) and FNA would be a good non-invasive way to start. Possibly moving on to exploratory surgery, biopsy etc if want to do anything more invasive.

Speaking personally, I would suspect neoplasia - at risk of sounding cynical, Boxers are tumours waiting to happen...

Hope this helps & welcome to the joyous (and often frustrating) world of vet practice!