FNA's - again

RE: FNA's - again

Anthony Todd — Sat, 15 Sep 2018 12:12:13 GMT

[quote user="robloxley"]I recently had an 8yo outwardly healthy dog in for dentistry go into acute renal failure postop. It happens. Or maybe not, BITD?[/quote]

Happened to me in 1963ish; standard poodle, aural resection with probably a period of heavy hypotension and the local human anaesthetist explained it to me as it was his friend's dog.....

Intraoperative hypotension - a neglected causative factor in hospital-acquired acute kidney injury; a Mayo Clinic Health System experience revisited

J Renal Inj Prev. 2015; 4(3): 61–67.

RE: FNA's - again

Lucy Fleming — Sat, 15 Sep 2018 11:19:54 GMT

[quote user="Martin Atkinson"][quote user="Lucy Fleming"]Not at all - taking an FNA from a histiocytoma fairly frequently triggers resolution of the lesion[/quote]No...it was going to resolve anyway in 2 weeks and by the time the owner brings it to you that process is already starting. Bit of placebo effect going on there!![/quote]

Well, very possible, but that was what the pathologists at uni taught us. of course, they may have just been trying to drum up business

RE: FNA's - again

Martin Atkinson — Sat, 15 Sep 2018 09:28:39 GMT

[quote user="Lucy Fleming"]Not at all - taking an FNA from a histiocytoma fairly frequently triggers resolution of the lesion[/quote]No...it was going to resolve anyway in 2 weeks and by the time the owner brings it to you that process is already starting. Bit of placebo effect going on there!!

RE: FNA's - again

Lucy Fleming — Sat, 15 Sep 2018 09:08:36 GMT

[quote user="Martin Atkinson"][quote user="Lucy Fleming"]Added bonus of doing an FNA on a histiocytoma is that the process itself tends to trigger regression and resolution of the mass, though![/quote]I presume that was tongue in cheek.[/quote]

Not at all - taking an FNA from a histiocytoma fairly frequently triggers resolution of the lesion

RE: FNA's - again

Anthony Todd — Sat, 15 Sep 2018 03:15:06 GMT

[quote user="Martin Atkinson"]if it does nothing else but give peace of mind while waiting to see if it will resolve spontaneously in a couple of weeks.[/quote]

It's " a bit ulcerated" already so I hope the obvious irritation/trauma doesn't turn it into a chronic bleeding mass [all over the wallpaper] while it "resolves spontaneously",or not, if the secondary damage is perpetuated and [usually] exacerbated......

Been there, seen that; very embarrassing as it is obviously avoidable, but given that this is under direct competent supervision you may be lucky.

RE: FNA's - again

Martin Atkinson — Fri, 14 Sep 2018 11:09:53 GMT

[quote user="Lucy Fleming"]Added bonus of doing an FNA on a histiocytoma is that the process itself tends to trigger regression and resolution of the mass, though![/quote]I presume that was tongue in cheek.

[quote user="Lucy Fleming"]I stabbed myself in the thumb so *I* bled everywhere as well,[/quote]No need for an FNA for these. I took an impression smear from the surface one that was a bit ulcerated yesterday. Stained slide hooching with histiocytes: diagnosis made with no stabbed dogs or vet!!

I might add that this was on one my nurses' 2 year old Dachsie. I was 90% happy with signalment that it was a histiocytoma (and she is foolish enough to trust me!) but in the interests of science I performed the procedure not really expecting to see much but a few blood cells. I may well use this technique in future if it does nothing else but give peace of mind while waiting to see if it will resolve spontaneously in a couple of weeks.

RE: FNA's - again

Lucy Fleming — Thu, 13 Sep 2018 16:20:59 GMT

[quote user="Julian Earl"]

[quote user="Robin Grimmer"]

Ever heard of a histiocytoma??!

Guess what - they disappear completely!![/quote]

I think histiocytomas are easy to spot based on the signalment and would tell people that we should remove them if they had not disappeared by a couple of months at he most.

[/quote]

Added bonus of doing an FNA on a histiocytoma is that the process itself tends to trigger regression and resolution of the mass, though! Why wait a couple of months? I remember one a few years ago, really jumpy little dog with a histiocytoma on distal limb, bled everywhere after I performed the FNA, I stabbed myself in the thumb so *I* bled everywhere as well, generally a nightmare. Called the owner a few days later with the lab report that it was a histiocytoma (I always think I should do more myself but tend to send most out as I hate looking at stuff down the microscope!) to be told it had completely disappeared and thank you very much!

RE: FNA's - again

Anthony Todd — Fri, 07 Sep 2018 16:40:01 GMT

[quote user="Julie Innes"]You can teach a dinovet new tricks![/quote]

OK,fair enough; it will all depends on how it is presented, and it sounds as if modvets do it better than dinovets......

RE: FNA's - again

Julie Innes — Fri, 07 Sep 2018 13:49:41 GMT

The thing is, if you had asked me 5 or so years ago, I might have agreed with Anthony- I did just tend to remove lumps, but there were a few that the owners opted to leave and monitor. Now, having done some CPD and having tried doing FNAs I am completely converted!

You can teach a dinovet new tricks!

RE: FNA's - again

Robin Grimmer — Fri, 07 Sep 2018 13:22:05 GMT

RE: FNA's - again

Anthony Dennison — Fri, 07 Sep 2018 12:38:44 GMT

I give up. There is no point in arguing this point with Anthony anymore because everyone is just going around in circles.

He believes us 'modvets' are doing FNAs on every single lump that comes in rather than just choppnig it out like they do in the good old days. He rings up a histopathologist and gets a soundbite saying that he does see a lot of samples with fat cells. What he fails to realise is that when a FNA is taken, the vet taking it knows that he is in the mass and the clinical history is written with the request so whatever is seen under the microscope can then be interpreted with the clinical history.

Anthony, you are hearing what you want to hear and quoting what you want to quote to try and prove your point, which is often out of context. When no one is agreeing with you and trying to explain with examples what they mean (which you are also taking out of context and turning it on it's head when replying), do you not think it's time to accept that maybe your view on the matter isn't the standard approach anymore?

RE: FNA's - again

Beats — Thu, 06 Sep 2018 19:04:28 GMT

[quote user="Liz Barton"]I find it very useful to have some Giemsa in stock, as it stains granules better (e.g. helps confirm poorly differentiated mast cell tumours)[/quote]

Toluidine blue does granules on mast cells nicely. That's the only thing I bother to keep in addition to a modified romansky stain (speedy-diff from clin-tech) and new methylene blue. When I was in mixed practice had some ZN stain also for Johne's - I don't think I'd have the patience these days!

RE: FNA's - again

Liz Barton — Thu, 06 Sep 2018 17:14:19 GMT

[quote user="Julian Earl"]easy to do in house and very quick using Diff-Quik staining[/quote]

I find it very useful to have some Giemsa in stock, as it stains granules better (e.g. helps confirm poorly differentiated mast cell tumours), and some new methylene blue for reticulocytes (to extend the discussion to haematology). All so easy to use/do in house and especially useful when doing OOH.

RE: FNA's - again

Julian Earl — Thu, 06 Sep 2018 16:09:23 GMT

[quote user="Robin Grimmer"]

Ever heard of a histiocytoma??!

Guess what - they disappear completely!![/quote]

I think histiocytomas are easy to spot based on the signalment and would tell people that we should remove them if they had not disappeared by a couple of months at he most.

One other aspect of FNAs that I do not think has been emphasised enough is that they are easy to do in house and very quick using Diff-Quik staining. I've attended a couple of one day courses on the technique and the interpretation and it was arguably the most useful CPD that I did in the last ten years. I think that owners really appreciate a faster and cheaper explanation than full surgery and histopathology. It is also immensely job-satisfying as well plus generating a little bit of extra income for the practice. The rules of thumb for interpretation of stained smears seem very reliable. Just explain to owners that it has its pitfalls but it is a good start towards making the right choices for removal etc. Staining and examining a side takes perhaps ten or fifteen minutes so not very long at all.

I thoroughly recommend this CPD.

RE: FNA's - again

Anthony Todd — Thu, 06 Sep 2018 13:54:20 GMT

[quote user="Gillian Mostyn"]Aspirated a small amount of clear colourless fluid, whereupon the mass couldn't be felt at all. [/quote]

So [a] what was the cytology of the fluid? and, more importantly [b] won't it fill up again and probably get bigger? and [c] why not remove the "cyst" when you had the best, cheapest and obvious chance, [which you don't mention but may have done?]

[quote user="Gillian Mostyn"]Sometimes FNAs really are diagnostic.[/quote]

I don't get this?

RE: FNA's - again

Gillian Mostyn — Thu, 06 Sep 2018 13:29:04 GMT

Today. 6yr old retriever in for castration. 1cm mass LHS neck. Unknown duration but likely 1+year. O requested FNA (I was actually recommending removal). Aspirated a small amount of clear colourless fluid, whereupon the mass couldn't be felt at all.

Now obviously in this case the dog was under GA, but this could easily have been done in a consultation.

Sometimes FNAs really are diagnostic.

RE: FNA's - again

Thomas Johnson — Thu, 06 Sep 2018 10:28:24 GMT

[quote user="Anthony Todd"]I decided to ring one of the best vet histologists in the country, and apart from saying he wasn't of the pre-op FNA group he then said " yes, FNAs are getting better, but we still get some with fat cells, and we can't say whether it's a lipoma or just a bit of fat mixed with the sample", unscripted or prompted.[/quote]

It is true that normal subcutaneous fat cells and lipoma cells look the same, but as the vet who took the FNA I know whether the sample is likely to be representative of the mass. If it was a 2cm diameter mass, the dog was well behaved when I took the FNA and I know that I got the sample from the centre of the mass then I would be confident to say that it was a lipoma. If the mass had been small, the dog didn't sit still and I thought the sample might have come from the subcut fat around the mass rather than from the mass itself then I wouldn't be so sure of the diagnosis. We all use our clinical judgement with all of the information we have available to us.

RE: FNA's - again

Julie Innes — Wed, 05 Sep 2018 18:31:23 GMT

[quote user="Anthony Todd"]I was going to respond with some, almost forensic and [obviously] diagnostic, confirmation, as we all know on here, diagnosis is obligatory and the be-all-and-end-all but thought "sh1t, I'm in enough trouble on here, with veterinary bleeding biopsies, so I d better not.........[/quote]

Quite right Anthony, or you might find a strange lump on your own head .

RE: FNA's - again

Anthony Todd — Wed, 05 Sep 2018 17:36:27 GMT

[quote user="Julie Innes"]At a youthful 45 years old, I'll take that as a compliment[/quote]

I was going to respond with some, almost forensic and [obviously] diagnostic, confirmation, as we all know on here, diagnosis is obligatory and the be-all-and-end-all but thought "sh1t, I'm in enough trouble on here, with veterinary bleeding biopsies, so I d better not.........

RE: FNA's - again

Julie Innes — Wed, 05 Sep 2018 17:23:23 GMT

[quote user="Anthony Todd"] but it's the modvet way....................[/quote]

At a youthful 45 years old, I'll take that as a compliment

RE: FNA's - again

Anthony Todd — Wed, 05 Sep 2018 17:14:20 GMT

True, but also support for removing every, and any, lump [and doing post-op histo if suss.

[that's me by the way][quote user="Robin Grimmer"]- numerous examples on this thread have been given where an FNA would be beneficial prior to surgery.[/quote]

And I could say "consulting a VS would be beneficial" or even looking at Google "could be beneficial" etc. but, IMHO, once it's out, the rest is history and hope, but it's your best chance and ASAP!

And there the twain shan't meet, more's the pity , but it's the modvet way....................

RE: FNA's - again

Robin Grimmer — Wed, 05 Sep 2018 15:40:13 GMT

[quote user="Robin Grimmer"]

[quote user="Anthony Todd"]

True, but also support for removing every, and any, lump [and doing post-op histo if suss]

[/quote]

May I remind you - you said

"Not all (lumps need removing), and not every case"

[/quote]

We're going off topic here again - so once again I draw your attention to the above as an example of your inconsistency. I will repeat again - numerous examples on this thread have been given where an FNA would be beneficial prior to surgery.

RE: FNA's - again

Anthony Todd — Wed, 05 Sep 2018 13:02:03 GMT

[quote user="Julie Innes"]To me, anything that helps me justify a decision rather than just 2my opinion" is helpful[/quote]

My only point was that any VS is much more capable and competent to make any clinical decision, even if it is arguable or not possible, than most owners, with occasional exceptions.

[there was a lovely scene on the Beeb a while ago when the "ozone layer" was the main topic.

A smarmy, condescending Beeb reporter strolled up to a semi-naked sunbather in a park and asked "What do you know about the ozone layer, expecting a moronic reply?

"Quite a lot, actually, I'm a nuclear physicist" was the laconic reply......]

So there are exceptions.

RE: FNA's - again

Julie Innes — Wed, 05 Sep 2018 12:34:48 GMT

[quote user="Anthony Todd"]How on earth is any client, unless they are, a medico or a pathologist, capable of making any decision better than a vet, and not any vet, but one who deals with these things every day, all day?[/quote]

So all vets make absolutely the right decision all the time? All decisions are black and white?

There are some cases where I can indeed predict the future (if you don't treat your dog with diabetes it will die. If you leave that pyo pouring pus, it will die) But the rest of the time I find I am not dealing in absolutes. You need to involve the owner in your decision making process, as they are the ones who will have the repurcussions of those decisions, so they should know the risks.

I am not a financial whizz, but when my financial advisor comes to see me about ISAs and such he doesn't just pat me on the head, tell me he knows best and invest my money however he sees fit!! He asks me about my attitude to risk, whether I am more interested in long/ short term results etc etc.

Similarly I had a dog that presented to our OOH provider with a severe tachycardia, which subsequently resolved. The owners brought him to me to see where we go next. He is not insured, and they feel he is "fine now" and are a bit miffed at having spent £££. What is my "advice"? What would yours be, Anthony? Do you adv leaving it or insist on full cardiac work-up? Something in between? Interested to see other views. Is it always black and white? If I say "leave and see" and the dog has an underlying myocardial pathology, develops life-threatening V-tach and dies, did I make the right decision? If I refer to a cardiologist and spend another £600 of their money and there is still no diagnosis is that the right decision?

To me, anything that helps me justify a decision rather than just 2my opinion" is helpful

RE: FNA's - again

Anthony Todd — Wed, 05 Sep 2018 09:49:11 GMT

[quote user="Gillian Mostyn"]Tell me the facts, but also the uncertainties, and let me decide.[/quote]

How on earth is any client, unless they are, a medico or a pathologist, capable of making any decision better than a vet, and not any vet, but one who deals with these things every day, all day?

This, to me, is the seismic change in vet. practice since I left it.

Just doesn't make any sense, to me, at all.

Funnily enough London Underground may have hit on my, and I think, most dinovets' attitude:

"See it, Say it, Sort it"