Clean margins

RE: Clean margins

Lou Dawson — Fri, 07 Apr 2017 19:27:26 GMT

Sorry for the late reply. I'd typed a beautiful long reply on my iPhone, which then crashed as I tried to edit it, and I've only just got around to logging on with a real computer.

[quote user="Thomas Johnson"]

I was advised that it if I'm sectioning a large mass before sending it for histopathology that I could place sutures around the outside to mark the lateral margins as an alternative to inking, I would always explain on the submission form that this is what I have done. Is this helpful to a pathologist?

[/quote]

Yes, really helpful. In general, if you submit a mass as two halves, we can usually piece them back together, but more sections than that and you will need to mark them for orientation. A clear explanation/diagram is always appreciated - saves us so much time and hassle trying to orientate random bits.

[quote user="Anthony Todd"]

In the one massive mammary tumour in a breeding queen that I remember I took as much as I dared to enable wound closure [it ran into the axilla] and then reoperated on the small tumours that did regrow, I think at least twice, with ultimate success.

After all "clear margins" with an obvious regrowth really isn't helpful together with the caveat that "clear margins" only applies to the sections submitted in that specific plane [cut your rotten apple] so doesn't guarantee anything really.

[/quote]

Now, I am not an oncologist, but there are some tumours for which I would consider clear margins to not mean a great deal in terms of prognosis. Anal sac adenocarcinoma, melanoma, feline mammary carcinoma are amongst these - yes, clear margins will mostly result in a longer disease-free interval, but I think the diagnosis itself is bad news for the patient whatever margins you have achieved (obviously, there are always outliers where margins are close and it's a horrid tumour but somehow never recurs/spreads).

[quote user="robloxley"]It'd be good to see something more on inking samples - how to do it, where to get the bits, when/how its useful.[/quote]

I'll have to get my notes out - and it would also be good to have some input from a surgeon on this. I'll get back to you soon!

RE: Clean margins

Thomas Johnson — Wed, 05 Apr 2017 08:56:34 GMT

[quote user="robloxley"]FNA is also great for sampling any internal structures that might be lymphoma, allowing diagnosis without biopsy, for cases that are usually treated medically rather than surgically[/quote]

Absolutely, it's a great tool for getting samples during an ultrasound scan. I scanned a cat last week which turned out to have a gastric mass and an enlarged gastric lymph node, FNA of both came back as mast cell tumour. Not a great answer and surgery to remove the mass not appropriate as it has already metastasised, but no need for an ex-lap or referral for laparoscopy to get a biopsy, I can go straight to discussing the best medical management.

RE: Clean margins

Rob Loxley — Tue, 04 Apr 2017 23:16:56 GMT

[quote user="Lou Dawson"]Some labs love inked samples. Personally I don't see many inked samples and I don't find it so useful[/quote]

It'd be good to see something more on inking samples - how to do it, where to get the bits, when/how its useful.

RE: Clean margins

Rob Loxley — Tue, 04 Apr 2017 23:02:04 GMT

[quote user="Kate Richardson"]Or you take wide margins unnecessarily leaving a larger wound to heal, taking longer and costing the owner more![/quote]

As one surgeon put it, your FNA result can help you determine what dose of surgery to give.

As for blood contaminated FNA samples, I always try 1st without suction. It also reduces damage to delicate cells eg. lymphoma.

FNA is also great for sampling any internal structures that might be lymphoma, allowing diagnosis without biopsy, for cases that are usually treated medically rather than surgically

RE: Clean margins

Anthony Todd — Sun, 02 Apr 2017 22:22:35 GMT

[quote user="Beats"]I'm sure someone will comment to help you get started.[/quote]

Thankfully, in some ways, those days are long gone, but it sounds as if my old way wasn't so bad after all.

RE: Clean margins

Beats — Sun, 02 Apr 2017 20:42:08 GMT

[quote user="Anthony Todd"]You can't hope to get mast cells every time with a 23G needle??[/quote]

You can. But in a highly vascularized MCT it can be very tedious to obtain a sample that is not so blood-diluted as to be non-diagnostic.

I would do an incisional (or sometimes excisionsal depending on location, size etc) biopsy most often rather than spending ages trying to get a blood free FNA, but it can be achieved usually if you have sufficient patience.

You also can't expect the obvious granules in the mast cells to stain up every time with a speedy-diff type stain, but you will still see a round cell tumour, usually with fibroblasts and eosinophils and occasional stained granules if you look carefully (as well as criteria of malignancy). A drop of toluidine blue will stain them if any doubt remains (I do this rarely if sitting on the fence on whether histiocytoma or MCT with granules not staining on quick stain).

Just pick up a 23G needle and 5ml syringe and try your next 5 "lump" consults. Can post the pictures up from the microscope if you like and I'm sure someone will comment to help you get started.

RE: Clean margins

Beats — Sun, 02 Apr 2017 20:27:45 GMT

ANthony,

A FNA is like a reverse injection.

you simply stick a needle in and suck a few cells and squirt them on a slide.

If the client has presented a patient with a lump for the consult, then I typically do this as part of the consult and check it under the microcope - I don't personally charge extra assuming the consult takes no more than 10mins in total.

If I aspirate just fat (and sometimes with keratinized material) I don't bother to exmaine under the microscope. even if you don't have a couple of stain jars and a microscope you can still get helpful info that helps your decision making.

I don't personally remove the most common old dog lumps such as keratinizing cysts or lipomata, for instance, unless they are causing a problem to the dog - the suggestion of subjecting the patient to a general anesthetic to obtain "wide" margins on such a mass simply to send it to the lab seems massively unappealing to me. If I did want to remove one, then I would not obtain wide margins as this just adds to morbidity.

Equally, a MCT is obvious on cytology after an FNA, but not always easy to differentiate grossly from a histiocytoma, keratinizing cyst or something that can safely be left alone to regress or benignly sit merrily not causing a problem.

You can still do an incisional, or excisional (narrow or wide margins) after doing an FNA. The only downside I can think of is you might have wasted 5mins of your life without obtaining useful information, but even if you just get a little "non-diagnostic" fresh blood back you know you have a solid vascularized tumour rather than, say, a keratinizing cyst. So while I might not get a "diagnosis" on more than 50-80% of FNA's, I get "actionable information" on >90%.

RE: Clean margins

Anthony Todd — Sun, 02 Apr 2017 20:25:20 GMT

[quote user="Evelyn Barbour-Hill"]

Is he? Gosh. Sounds a bit like Joe "Mr. Piano" Henderson.

[/quote]

Go on Evelyn, play the ball and not the man.

RE: Clean margins

Evelyn Barbour-Hill — Sun, 02 Apr 2017 17:58:22 GMT

[quote user="Anthony Todd"]Dr. Demian Dressler, DVM is known as the "dog cancer vet".[/quote]

Is he? Gosh. Sounds a bit like Joe "Mr. Piano" Henderson.

RE: Clean margins

Anthony Todd — Sun, 02 Apr 2017 17:41:43 GMT

This is probably worth a look while I try to gain some composure....

http://onlinelibrary.wiley.com/doi/10.1111/vco.12090/full

Cytological grading of canine cutaneous mast cell tumours

Authors

Filippo Scarpa
Silvia Sabattini,
Giuliano Bettini

RE: Clean margins

Anthony Todd — Sun, 02 Apr 2017 17:25:14 GMT

[quote user="Robin Grimmer"]

You clearly don't know what a FNA (fine needle aspirate) is, the clue is in the title.

FNA and a tru cut biopsy are completely different things. The former gives you cytology and can be done conscious, the latter gives you a core of tissue but requires some form of anaesthesia. Mast cell tumours exfoliate very well, so the hit rate with an FNA is good. From a paper entitled

Clinical Exposures: Cytologic examination of a cutaneous mast cell tumor in a boxer

In general, cytologic examination is useful in diagnosing round cell tumors. These tumors tend to exfoliate well when aspirated, so samples are often highly cellular.

[/quote]

Fair enough, retires gracefully, but if you read your quote it may be that a core biopsy would be as accurate as sectioning the mass after removal and desirable in some locations [foot]

I think, on suspicious masses I'd still go for a wide excision and histo sections even if the needle biopsy was negative. You could do a core biopsy on a foot lesion and be more sure that you were right?

RE: Clean margins

Robin Grimmer — Sun, 02 Apr 2017 17:11:04 GMT

You clearly don't know what a FNA (fine needle aspirate) is, the clue is in the title.

Clinical Exposures: Cytologic examination of a cutaneous mast cell tumor in a boxer

In general, cytologic examination is useful in diagnosing round cell tumors. These tumors tend to exfoliate well when aspirated, so samples are often highly cellular.

RE: Clean margins

Anthony Todd — Sun, 02 Apr 2017 16:57:36 GMT

[quote user="Robin Grimmer"]I don't know why you are so against them?[/quote]

That's because I thought you meant this device and not just a needle, which must be less accurate than this, which is apparently used all the time for human breast biopsies,

No wonder the error rate with needle biopsy is not zero and my supposition of a GA or at least local...

I'd be happier with this "kit" [which isn't as easy as it looks to get the right sample] but has to be more likely to be accurate.

Best if you nick the skin first after a bit of local, from memory or you just get a really good skin sample.....

Tell me if this is all baloney? You can't hope to get mast cells every time with a 23G needle??

RE: Clean margins

Robin Grimmer — Sun, 02 Apr 2017 16:11:57 GMT

The only 'kit' you need is a syringe, 23g needle and microscope slides!

I don't know why you are so against them? Probably because they weren't done in your day. No-one is suggesting them as a replacement for histology. They have their limitations but can be done quickly and easily in a conscious animal and you can look at them yourself initially. Two things you can readily diagnose yourself are mast cell tumours and lymphoma, both of which are going to change your treatment plan quite a bit.

RE: Clean margins

Anthony Todd — Sun, 02 Apr 2017 14:58:04 GMT

[quote user="Anthony Todd"]FNA[/quote]

PPS what does one of these cost and do they use the disposable kits now?

RE: Clean margins

Anthony Todd — Sun, 02 Apr 2017 14:46:12 GMT

[quote user="Kate Richardson"]

Or you take wide margins unnecessarily leaving a larger wound to heal, taking longer and costing the owner more!

[/quote]

Come on, wounds heal from the sides and you haven't the cost, unless you charge by the inch, and the aggro of a false negative FNA.....

And less chance, with any tumour, even with the uni or biplanar "clear margins", of regrowth.

PS I'm not saying "no histo" on any mass, except perhaps an obvious lipoma, just that the most accurate way is to submit the whole mass and skip the FNA, in most cases.

RE: Clean margins

Kate Richardson — Sun, 02 Apr 2017 14:40:18 GMT

Or you take wide margins unnecessarily leaving a larger wound to heal, taking longer and costing the owner more!

RE: Clean margins

Anthony Todd — Sun, 02 Apr 2017 14:39:41 GMT

Touche? so then having done your FNA and so taken as wide margins as possible then having read the quotes "on wide margins and FNA" above.....

Your MCT regrows and your histo says "clear margins" and your client then asks.....

With a foot I'd take as wide a margin as possible and warn the client that regrowth may need a further operation.

PS You have the benefit of the better histo of the mass, so you can be very grave with prognosis rather than the possible false optimism of "FNA in conclusive" and/or "clear margins". And, unless you do your own histo, no delay in surgery.

RE: Clean margins

Robin Grimmer — Sun, 02 Apr 2017 14:18:39 GMT

[quote user="Anthony Todd"]

[quote user="Robin Grimmer"]Which is why you need to perform an FNA first as you don't know It's a MCT until then![/quote]

Or you could just be careful and take wide margins on any skin mass, which is what most of us did anyway.

Also avoids the embarrassing regrowth on a "margin clear" histo report.

[/quote]

So what if your mass is on the dog's foot? Because the only way you'll get wide margins is to amputate!

So better to know beforehand by doing an FNA!!

RE: Clean margins

Anthony Todd — Sun, 02 Apr 2017 14:07:53 GMT

[quote user="Robin Grimmer"]Which is why you need to perform an FNA first as you don't know It's a MCT until then![/quote]

Or you could just be careful and take wide margins on any skin mass, which is what most of us did anyway.

Also avoids the embarrassing regrowth on a "margin clear" histo report.

RE: Clean margins

Robin Grimmer — Sun, 02 Apr 2017 13:34:28 GMT

You say: I can see more of a case for a FNA in a skin mast cell tumour

But then quote this

MCTs are known as the great pretenders for a good reason – they can mimic the appearance of anything from a lipoma to a soft tissue sarcoma, histiocytoma or plasmacytoma.

Which is why you need to perform an FNA first as you don't know It's a MCT until then!

RE: Clean margins

Anthony Todd — Sun, 02 Apr 2017 12:54:20 GMT

[quote user="Kate Richardson"]I cannot see what your argument against FNAs is.[/quote]

This says it better than I did although written for lay people.

First of all, a fine needle aspirate is not a biopsy. [etc etc.]

What is good about this technique? Well, it takes about 2 minutes to do, and your dog gets to go home without sedation, anesthesia, or hospital stay. Quick, easy, outpatient…nice. This is a good technique to diagnose TYPE of growth (in my hands about 75% of the time you get this info from the path lab after submitting the slide).

How about downsides? A fine needle aspirate cannot tell if the cancer cells have moved inside the body or spread into neighboring areas. There is a little inaccuracy in this technique as well. My experience is that about 1 out of 4 of these come back “inconclusive”, meaning there was not enough on the slide for the path folks to give a diagnosis. Sometimes the vet will get a big sample, but the cells are just not the right kind to make a diagnosis (blood, connective tissue, etc.). Some tumors have a good cell yield, and others do not. Occasionally, we get an incorrect diagnosis with a fine needle aspirate.

from:

Dr. Demian Dressler, DVM is known as the "dog cancer vet".

I can see more of a case for a FNA in a skin mast cell tumour [if the accuracy was more than 75%!] but I suppose I was stimulated to reply when a friend of mine had a grape sized discrete S/C mass removed from his dog which would be classic for a nice removal and histo yet had a FNA first.

But this says the opposite so take your pick:

It is essential to confirm the tumour type either through fine needle aspiration cytology (Figure 2) or tissue biopsy for histology, as this dictates the most appropriate treatment. Although the gross appearance of a tumour may suggest a diagnosis, MCTs are known as the great pretenders for a good reason – they can mimic the appearance of anything from a lipoma to a soft tissue sarcoma, histiocytoma or plasmacytoma.

from: http://www.veterinaryirelandjournal.com/images/sa_apr_2015.pdf

but there is a reference to "tissue biopsy" so this may be a better and more accurate way. I suppose many these days do both? [as happened with my friend....]

RE: Clean margins

Kate Richardson — Sun, 02 Apr 2017 11:23:03 GMT

[quote user="Anthony Todd"]

Is reoperating on an early tiny regrowth such a big deal anyway?

What else are you going to do? Deny the obvious??

Please give some critical comments with the inevitable one star.

[/quote]

For some tumours it may not be a big deal, other than subjecting an animal to another anaesthetic and surgical procedure, which may or may not be a big deal, depending on the animals health/fitness for ga/owners finances to name just a few

For other tumours, it may be an enormous deal as the surgery and incomplete excision ie margins not big enough could lead to massive stimulation and regrowth in a much more aggressive fashion than was there originally. Some mast cell tumours for example.

I cannot see what your argument against FNAs is. The only time I can see it makes little difference is if it is in a locaton where wide margins are not going to be achieved short of amputating a limb or removing an eye and the owner does not want to be that aggressive with surgery and just wants palliative surgery even if it means there is a possibility of regrowth. Which is absolutely fine.

The other valid reason for doing an FNA for masses in difficult areas is that if it comes back as likely benign and slow growing leaving it well alone may be a valid option as well.

RE: Clean margins

Jo Dyer — Sun, 02 Apr 2017 08:02:01 GMT

Thank you everyone for your input, it's been a very helpful discussion. Glad I asked now!

[quote user="Bob Russell"]Soft tissue sarcomas I just hate![/quote]

I'm with you there Bob.

RE: Clean margins

Anthony Todd — Sat, 01 Apr 2017 13:31:11 GMT

Is reoperating on an early tiny regrowth such a big deal anyway?

What else are you going to do? Deny the obvious??

Please give some critical comments with the inevitable one star.

Clean margins

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Cytological grading of canine cutaneous mast cell tumours

Authors

Filippo Scarpa

Silvia Sabattini,

Giuliano Bettini

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Clinical Exposures: Cytologic examination of a cutaneous mast cell tumor in a boxer

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