Unhelpful referral comments!

RE: Unhelpful referral comments!

Bob Russell — Fri, 31 Mar 2017 11:55:45 GMT

[quote user="vs0u "]

[quote user="Martin Atkinson"]Aren't we just saying the margin is incomplete not the surgeon's skills [/quote]

I think Bob's point was that the path report said that the original margin was clear but the referral report implied to the client it wasn't! (unless I've completely misunderstood!)

[quote user="Anthony Todd"]FNA are going to become the norm, I'm sure[/quote]

I think they pretty much already are...can be very useful for certain types of lump...cheaper than biopsy as no GA needed but with less accuracy.

[/quote]

The whole point was that comments made by the referral practice clearly suggested 'incomplete excision' where the pathology suggested this was not the case. There may be tumour cells that have been undetected but there is absolutely no indication that it was incomplete.

The choice to excise further was perfectly sensible and I had discussed this with the client.

Why potentially aggravate a client with this sort of comment and why try to justify logical further surgery with the suggestion that tumour cells are likely to be present when there is no evidence they are?

Just seems a particularly pointless and unhelpful thing to state and fails to support the referring vet!

I have to say it has massively reduced my confidence in using this centre in the future!

I suspect aggressive chemo will be next despite no evidence of metastatic disease but I very much doubt I will be involved in the discussion.

Fortunately the more local referral centres treat us with far more respect and consideration and are more careful how they phrase things.

RE: Unhelpful referral comments!

Anthony Todd — Fri, 31 Mar 2017 11:42:08 GMT

I think my apple with the brown spot is better, but the point is the point.

RE: Unhelpful referral comments!

Martin Atkinson — Fri, 31 Mar 2017 09:07:47 GMT

[quote user="vs0u "]

[quote user="Anthony Todd"]FNA are going to become the norm, I'm sure[/quote]

I think they pretty much already are...can be very useful for certain types of lump...cheaper than biopsy as no GA needed but with less accuracy.

[/quote]A pathologist made a good analogy to me the other day. In terms of the work involved and information you can glean, think of an archaeologist: an FNA is like finding one or two bricks of an old building, a biopsy is like finding one wall, having the whole lump is like finding the intact structure.

RE: Unhelpful referral comments!

Dagmar Steele — Fri, 31 Mar 2017 06:50:12 GMT

[quote user="Anthony Todd"]

[quote user="vs0u "][quote user="vs0u "]can be very useful for certain types of lump...[/quote]cheaper than biopsy as no GA needed but with less accuracy.[/quote]

but not when you obviously have to remove the lump anyway......

[/quote]

Well to explain it again: It is about how you remove the lump. Some of them you can remove with 1cm margins and your patient will be fine. In a mast cell tumor or a malignant hemangiosarcoma or a cat's fibrosarcoma you'll need at least 3-4cm margins, not only lateral but also in depth to attempt to be curative. So if you skip the FNA or biopsy you can either a) do all lumps with ridiculously wide margins (imagine removing ribs or abdominal wall and it wasn't even necessary) or b) doing them all with small margins which means you didn't give your fibrosarcoma cat a fair chance of survival or you have to go back in immediately after path results are back (two GAs, two surgeries). Do you think you might get the point why it is a good idea to know beforehand what you're dealing with? (Unless of course you have x-ray eyes I'm not aware of)

The days of "hey it's a lump, we'll cut it out and hope it's not growing back" are gone, we can and must do better, at least if clients want us to.

RE: Unhelpful referral comments!

Anthony Todd — Thu, 30 Mar 2017 23:44:16 GMT

[quote user="vs0u "][quote user="vs0u "]can be very useful for certain types of lump...[/quote]cheaper than biopsy as no GA needed but with less accuracy.[/quote]

but not when you obviously have to remove the lump anyway......

RE: Unhelpful referral comments!

vs0u — Thu, 30 Mar 2017 21:37:13 GMT

[quote user="Martin Atkinson"]Aren't we just saying the margin is incomplete not the surgeon's skills [/quote]

I think Bob's point was that the path report said that the original margin was clear but the referral report implied to the client it wasn't! (unless I've completely misunderstood!)

[quote user="Anthony Todd"]FNA are going to become the norm, I'm sure[/quote]

I think they pretty much already are...can be very useful for certain types of lump...cheaper than biopsy as no GA needed but with less accuracy.

RE: Unhelpful referral comments!

Lou Dawson — Thu, 30 Mar 2017 21:23:31 GMT

I try and provide accurately measured margins for tumours whenever appropriate. If it's something like a follicular cyst that's been completely excised, I say it's clear. I try and leave any further interpretation regarding width of margins (e.g. inadequate) to the clinician/oncologist. I don't feel it's my place to say "your margins are inadequate" when you've battled to remove a soft tissue sarcoma from a distal hindlimb and already are aware margins won't be great!

RE: Unhelpful referral comments!

Anthony Todd — Thu, 30 Mar 2017 18:06:59 GMT

Well yeah [and in your case, having never met you etc. etc., which is actually relevant] but pathologists issuing, in print, public reports should be very very careful NOT to write things that, particularly by a layman, could be misinterpreted and exaggerated or misinterpreted.

[see my review of Martin Atkinson, technically true, but not significant or relevant]

"Inadequate" and loads of others, are, while being technically correct, negative words!!

Why not say "margins were 2mm and 1mm" Message received??

Sounds fine to the layman if not the vet......

RE: Unhelpful referral comments!

Martin Atkinson — Thu, 30 Mar 2017 17:55:41 GMT

[quote user="Anthony Todd"]I said to you your knowledge, behaviour and skiing ability was"incomplete" how would you feel. [/quote]That you are absolutely correct but I rarely admit it! Aren't we just saying the margin is incomplete not the surgeon's skills or have I done my usual 'man read' and missed the point?

RE: Unhelpful referral comments!

Anthony Todd — Thu, 30 Mar 2017 17:46:53 GMT

[quote user="Martin Atkinson"] I can't see how this defamatory.[/quote]

Yes, but if I said to you your knowledge, behaviour and skiing ability was"incomplete" how would you feel.

It's a silly thing for anyone to say but typical of some professionals who may be great at their speciality, and technically correct, but mindless of consequences.

RE: Unhelpful referral comments!

Dagmar Steele — Thu, 30 Mar 2017 17:26:01 GMT

I have yet to find the dog I want to GA for a FNA, quick needle stick in there, not more effort than vax.

RE: Unhelpful referral comments!

Evelyn Barbour-Hill — Thu, 30 Mar 2017 17:02:57 GMT

[quote user="Bob Russell"]Similarly no evidence of mast cells in the enlarged wound has been changed to they are probably there but the pathologist cannot find them despite numerous sections from around the wound.[/quote]

RE: Unhelpful referral comments!

Martin Atkinson — Thu, 30 Mar 2017 16:59:14 GMT

The pathologist can only report on what he/she sees and if that is an incomplete margin then that's what it is. Even if you leave a large surgical margin around the grossly visible mass, cells can migrate into surrounding tissue depending upon the type of tissue barrier around it. I can't see how this defamatory.

RE: Unhelpful referral comments!

Bob Russell — Thu, 30 Mar 2017 16:48:41 GMT

My idea of a FNA is to stick a needle into the mass, draw up some cells and diff quick them. No G/a and I look at them within a few minutes.

I am no cytologist but mast cells are pretty simple to identify and if in doubt I get a cytologist to double check.

Additional cost to owner £25 if stained.

I admit this time I was fooled but removed with 'sensible' if not overly aggressive margins. This is an elderly giant breed dog!

RE: Unhelpful referral comments!

Anthony Todd — Thu, 30 Mar 2017 16:42:25 GMT

Sorry, I was really meaning discrete mobile S/C masses where I'm blowed if FNA are going to add anything to the treatment or a diagnosis,

I think even I would suspect a sinister mast cell tumour and widely resect anyway.

FNA are going to become the norm, I'm sure, add to the cost, and probably another GA. and in many cases won't add anything at all to the successful outcome; it's modern veterinary practice, I'm afraid.

RE: Unhelpful referral comments!

Dagmar Steele — Thu, 30 Mar 2017 15:45:33 GMT

I wasn't talking about redoing it once it has grown back but going back immediately after getting the path reports which suggest you needed wider margins. Mast cell tumours and hemangiendothelioma are good examples here. If you don't you are robbing the patient of the chance to heal completely in many cases, at least that is what the oncologists tell you in every seminar I have attended lately.

RE: Unhelpful referral comments!

Bob Russell — Thu, 30 Mar 2017 15:39:44 GMT

Perhaps I have been lucky but I have found clean margins generally mean clean margins!

RE: Unhelpful referral comments!

Anthony Todd — Thu, 30 Mar 2017 15:29:01 GMT

[quote user="Dagmar Steele"] Or did you just hope and pray and cling to the fact they wrote "clean margins" (Which we all know is often not enough)?[/quote]

I'd rather reexamine the site than rely on "clear margins" [the section of rotten apple I just bit can't have been in the section with "clear margins"].

I was really talking about discrete sub-cut masses. I remember redoing a mammary tumour in a breeding queen about three times which got there finally.

Easy to say "I/we never had regrowth" when, I certainly, have no statistics.

If you read the reference there is an error factor in FNA anyway, which must cause hiccups when there is a need for more surgery or surgery at all.

PS Noel changes gloves when he, or the assistants have been handling a tumour!!

RE: Unhelpful referral comments!

Dagmar Steele — Thu, 30 Mar 2017 15:14:22 GMT

There's more to the FNA thing than just knowing if it's benign or not. It's about the margins you have to cut, how to plan surgery (removal of ribs, skin flaps, whatever). Good to know in advance what you're dealing with although I agree it is not always conclusive. Anthony, when in your day you just cut it out and sent it off, did you go back in with wider margins if it came back as something really nasty i.e.. mast cell tumors? Or did you just hope and pray and cling to the fact they wrote "clean margins" (Which we all know is often not enough)?

RE: Unhelpful referral comments!

Bob Russell — Thu, 30 Mar 2017 15:06:50 GMT

It turned out to be a mast cell tumour therefore could have been identified as such with a FNA! I am happy that I did everything right and surgery was competently carried out with sensible margins.

With hindsight I would have made a bigger hole than the pretty ample one I did.

It is the wording of the discharge note that put my back up because it suggests inadequacy on my part. Similarly no evidence of mast cells in the enlarged wound has been changed to they are probably there but the pathologist cannot find them despite numerous sections from around the wound.

Much easier for them to say these tumours can be tricky, safer to give wider margins then thankfully we did not find any tumour cells after the further surgery. Everyone wins, no hint of 'the referring vet did not do a good enough job" which would be the message I would get from the discharge form.

RE: Unhelpful referral comments!

Anthony Todd — Thu, 30 Mar 2017 14:44:02 GMT

[quote user="Bob Russell"]I routinely do FNA's on pretty much every lump that comes in!![/quote]

I do hope this doesn't become the norm.

With a discrete definable mass surely it will need removal and surely you will get a better picture and diagnosis by the examination of the whole mass, and probably that will involve multiple sections if diagnostically necessary.

I'd love to see some scientific statistical correlation between FNA and excision path.

This is one quote:

RESULTS:

Of 292 specimens, 49 (from 44 dogs and 5 cats) were excluded due to poor cellularity of the cytologic specimen (retrieval rate 83.2%, n = 243). A cytologic diagnosis of neoplasia was obtained in 176 cases (175 true positives and 1 false positive compared with histopathology). Sixty-seven cytology samples were classified as non-neoplastic (46 true negatives, 21 false negatives compared with histopathology). Overall, the cytologic diagnosis was in agreement with the histopathologic diagnosis in 90.9% (221/243) of cases. For diagnosing neoplasia, cytology had a sensitivity of 89.3%, a specificity of 97.9%, a positive predictive value of 99.4%, and a negative predictive value of 68.7%.

from

Vet Clin Pathol. 2006 Mar;35(1):24-30.

Correlation between fine-needle aspiration cytology and histopathology in the evaluation of cutaneous and subcutaneous masses from dogs and cats.

Ghisleni G1, Roccabianca P, Ceruti R, Stefanello D, Bertazzolo W, Bonfanti U, Caniatti M.

And the first line sort of supports my concern, after all the lump will have to be removed.

RE: Unhelpful referral comments!

Bob Russell — Thu, 30 Mar 2017 13:49:26 GMT

Due in apparently for suture removal but unclear if we are going to do that or the referral centre will.

I will discuss the matter with the referral centre in due course in the hope they will think more carefully about their phrasing.

Our usual referral places have never been a problem. If I have screwed something up or made a mistake I would hope to have a quiet discussion before being honest with the owners.

In this case I made an assumption (looked like a cyst, behaved like a cyst) which I should not have done. I routinely do FNA's on pretty much every lump that comes in!!

RE: Unhelpful referral comments!

Thomas Johnson — Thu, 30 Mar 2017 12:23:43 GMT

[quote user="Bob Russell"]My complaint does not relate to the pathology report nor the actual actions of the referral clinicians. I do resent the statements that excision is incomplete when all the evidence is that it is not! What the heck are they actually telling the client? Really should be a tangent![/quote]

Have you spoken to the client since? Have you spoken to the referral centre and asked them what they said to the client?