What do you think of this x-ray & case?

Re: What do you think of this x-ray & case?

Alex Allen — Wed, 22 Dec 2010 11:49:42 GMT

Although unlikely to be the situation in this particular case film faults can mascarade as pathological diseases. In a previous life I worked for an x-ray company where I saw lung masses and pelvic bone metastasies that were nothing more than dodgy equipment faults.

Worth checking older films/cassettes etc as some of the equipment I came across in practices was downright shocking. Often rejected by NHS departments for failing QC tests these cassettes+screens would then find their way into vets for bargain basement prices....

If your equipment (films, cassettes, processor etc) hasn't been tested recently I would recommend contacting one of the xray companies to see how to get it done. This applies to BOTH analogue and digital processing.

Re: What do you think of this x-ray & case?

Richard Carter — Wed, 22 Dec 2010 09:02:31 GMT

Oops - good case and good reminder biology is amazing!! You didn't have a wet cloth under the dog in the first?? Have to go back to trying to raise enough to pay the staff this month. Merry Christmas everyone

Re: What do you think of this x-ray & case?

Richard Fox — Tue, 21 Dec 2010 19:42:40 GMT

I showed this post to my wife who is an radiographer (MRI) and she wondered given the history about transient osteoporosis in humans or something similar (also looked up Transient Osteolysis):

"Transient osteoporosis is characterized primarily by bone marrowedema. The disease most commonly affects the hip, knee, andankle in middle-aged men. Its cause remains unknown. The hallmarkthat separates transient osteoporosis from other conditionspresenting with a bone marrow edema pattern is its self-limitednature. Laboratory tests usually do not contribute to the diagnosis.Plain radiographs may reveal regional osseous demineralization.Magnetic resonance imaging is used primarily for early diagnosisand monitoring disease progression. Early differentiation frommore aggressive conditions with long-term sequelae is essentialto avoid unnecessary treatment. Clinical entities such as transientosteoporosis of the hip and regional migratory osteoporosisare spontaneously resolving conditions. However, early differentialdiagnosis and surgical treatment are crucial for the patientwith osteonecrosis of the hip or knee."

Re: What do you think of this x-ray & case?

Utlendigur — Tue, 21 Dec 2010 19:17:10 GMT

I had a case last year - middle age black lab cross, rapidly growing ulcerated lump suddenly appeared on toe. It didn't look nice but the owner wanted biopsy before thinking about toe amputation. Histopath came back as melanoma so we took the toe off. No xrays or FNA of lymph nodes (owner declined). 3-4 weeks later the dog came back with a prescapular lymph node the size of a tangerine. FNA confirmed metastasis of the melanoma. The dog went home for a last few weeks of TLC - reappeared a year later for mild GE with no detectable evidence of neoplasia and normal LNs.

Re: What do you think of this x-ray & case?

Richard Fox — Tue, 21 Dec 2010 18:06:36 GMT

Don't get me wrong you can get a good result on FNA of bone lesions but a good histopath bx IMHO far outweighs cyto - I am of course a bit biased as I am primarily a histopathologist (60%) but I do believe cyto should be regarded, in most instances, a guide for further investigation / symptomatic treatment responce. There are not many instances where cyto gives a definitive diagnosis although I am sure if more clinical pathologists were Vet Forum members then you would possibly hear a different opinion. As a histopathologist I have the benefit of relating cyto interpretations to histo interpretation, often they match, sometimes they do not!

Sorry, waffling again.........

Erm....... Good Case .......

Re: What do you think of this x-ray & case?

Mark Holmes — Tue, 21 Dec 2010 17:50:44 GMT

With the right biopsy tool, (vet instrumentation do a nice autoclavable jamshidi needle) a core biopsy is actually bearly different to an FNA in ease to obtain.

Re: What do you think of this x-ray & case?

Hannah Wynne Richards — Tue, 21 Dec 2010 17:44:58 GMT

I'm one of the many who would have diagnosed sarcoma on radiographic appearene-and been wrong I'm glad though that a pathologist considers FNA to be less reliable than a biopsy-with modern anaesthesia, the additional risk of taking a proper biopsy is (IMHO ) less than that of getting the diagnosis wrong

Wynne

Re: What do you think of this x-ray & case?

shaun sinclair — Tue, 21 Dec 2010 17:11:13 GMT

Not only was I obviously wrong in calling this one (I recommended amputation), BUT it also is now completely resolved (and only had a mere whiff of metacam for a few days.)

I'd have thought whatever was causing the appearance (neoplasia, infection) it would have left a crumbling humerus.

Any rational explainations? I haven't!

Does anyone biopsy these sort of things? Or do most people go on radiography alone?

Re: What do you think of this x-ray & case?

HMC — Tue, 21 Dec 2010 17:00:25 GMT

This is a great conundrum. I am very glad that it has been posted. One notch to working cases up diligently and not jumping the gun.

Re: What do you think of this x-ray & case?

Richard Fox — Tue, 21 Dec 2010 16:26:39 GMT

At a bit of a tangent:

I think cytology is underused as a animal -side test i.e. in-house for discriminating different types of lesion (mostly skin). Don't get me wrong I enjoy reading cyto and I am doing myself out of a job as most people do not have the time, facilities or sometimes interest in doing cytology and so send it all to a cytologist.

I think there is a habit to over interpret cytological samples IME - I think because its convenient and low cost then it is quite often considered to try and give a diagnosis and sometimes the pathologist is under pressure to provide more info than should be given. Spindle cells is a terminology given to cells which are spindle shaped (obviously) - nothing else. These could sometimes be epithelial i.e. basal cells but mostly mesenchymal - If the population is very pure and atypical then a neoplasm is very likely but if mixed with inflamm gets very difficult. I dislike reporting boney lesions on cyto as the variation of cells you see in different conditions means there is a huge crossover. But again the cyto and the rads so suggest a tumour so I was also going down that path due to influence of the cyto report.... In the defence of the cyto they did suggest a bx but as you say Malcolm to discriminate not to confirm! .

Sorry back on topic......

Re: What do you think of this x-ray & case?

Malcolm Ness — Tue, 21 Dec 2010 16:16:31 GMT

[quote user="Richard Fox"]Cytology my view is overused to give a diagnosis[/quote]

I agree completely and I very rarely use FNA and only occassionally any other cytology from masses. I fell into the well laid trap here and I believed the pathologist!. My radiographic differential included infection but I discounted that (in error!) on the basis of the cytologist's report which on one hand seemed to report little consistent with infection/inflammation yet appeared to record, without qualification or equivocation, neoplastic spindle cells with, I understood, the only speculation being about the precise origin of the neoplastic cells.

I am in the habit of using a well known path lab in the South West and I don't ever recall a report as cryptic as this one!!

Re: What do you think of this x-ray & case?

Bob Russell — Tue, 21 Dec 2010 16:05:02 GMT

[quote user="Richard Fox"]

Nice hat Bob!

[/quote]

It keeps the eyepieces of my new microscope warm at night!

Re: What do you think of this x-ray & case?

Richard Fox — Tue, 21 Dec 2010 15:54:44 GMT

Nice hat Bob!

Re: What do you think of this x-ray & case?

Bob Russell — Tue, 21 Dec 2010 15:49:04 GMT

[quote user="Mark Holmes"]

I thought posting the way you did was great, more memorable and therefore a better learning opportunity. If you had just posted look at these two radiographs isn't that weird, the response would have been "yes weird" and then it would have been forgotten. As it is it sits in the long term memory better!

[/quote]

Over the years I have become used to patients making me look a fool (hopefully less often nowadays). The whole point of this forum is that we can all freely submit different opinions and comments.

This was not an exam and nobody has looked foolish so far! (other than me and the stupid hat I was made to wear)

Re: What do you think of this x-ray & case?

Mark Holmes — Tue, 21 Dec 2010 15:23:11 GMT

Re: What do you think of this x-ray & case?

Richard Fox — Tue, 21 Dec 2010 15:09:16 GMT

Shaun - I had no problem with this - I don't care if I look like a fool sometimes, its better to contribute than not in my experience. If you had posted this up as a case for discussion or a "what's your diagnosis" we would have automatically stepped back and thought, like in an exam, this is a trick. Don't take offence, I understood you wanted peoples initial thoughts without being influenced, hindsight is a wonderful thing and if we all had the power of seeing into the future medicine would become very easy!

Re: What do you think of this x-ray & case?

shaun sinclair — Tue, 21 Dec 2010 14:55:41 GMT

No intent to trip anyone up.

Just baffled. And humbled by what seemed to be a one way ticket for that dog.

And have wondered what I'd do in the same position next time.

Apologies is anyone felt it was underhand, I was challenging my own assumptions as much as anyone else's.

Re: What do you think of this x-ray & case?

Richard Fox — Tue, 21 Dec 2010 14:31:07 GMT

Sorry I obviously misinterpretated your post! No malice intended - I was just trying to suggest I was not being big headed - and 99% of the time I expect this dog would have a tumour - Just by chance I happened to see the other side - I hope you did not take offence

This reminds me of a recent case I diagnosed as lymphoma, high grade in a 9 week old puppy. Muticentric skin involvement, 3-4 week later ALL the lesions disappeared. In the interim immunohistochemistry was performed an all markers -ve. Sent to a specialist immunopathologists and stains revealed it was lymphoid, possibly NK cell. Clonality testing came back last week and its clonal and therefore consistent with a neoplasia of T-cell origin. Spontaneous regression! So I went from confident, to embarrassed back to confident but confused

Re: What do you think of this x-ray & case?

Bob Russell — Tue, 21 Dec 2010 14:21:37 GMT

A great Xmas post (from an old Bah Humbug!) - I would have advised amputation or euthanasia! Who say miracles never happen?

Re: What do you think of this x-ray & case?

Gillian Mostyn — Tue, 21 Dec 2010 14:17:13 GMT

I did wink! We'd all taken due note of you being proved correct - it was meant to be a bit of a compliment!

Re: What do you think of this x-ray & case?

Richard Fox — Tue, 21 Dec 2010 14:16:22 GMT

Are you taking to me Gillian? I was making a very serious point actually I do say "never say never" - I was not being arrogant but people were happy to criticise me? We are all human and I think it was a very good example of how we can get blinkered into going down one channel - I include myself in that

Re: What do you think of this x-ray & case?

Bob Russell — Tue, 21 Dec 2010 14:14:44 GMT

Great case! A bit of a warning to us all. No criticism of the way you posted from me! You did not ask for help but simply asked what we think of this radiograph!

I would have diagnosed FDS from the radiograph! Did you check the microchip to make sure it is not a ringer?

Re: What do you think of this x-ray & case?

Gillian Mostyn — Tue, 21 Dec 2010 14:14:15 GMT

Saying 'I told you so' is not attractive and was really not needed - we'd all worked that out already!

Re: What do you think of this x-ray & case?

Richard Fox — Tue, 21 Dec 2010 14:08:25 GMT

Good case - I have seen a lot of cases of assumptive dxs which have turned out better or worse after biopsy. My philosophy is "never say never", honestly. That's not to say there wasn't a tumour which has regressed or that the clinical signs warranted limb excision but ? .....

Re: What do you think of this x-ray & case?

Vikki Halliday LLB — Tue, 21 Dec 2010 13:59:57 GMT

[quote user="Gillian Mostyn"]I do understand your amazement at this case and your request for help[/quote]

I don't Gillian. If the case had a positive outcome, why not publish it as an abstract rather that attempt to make a fool of some of the contributors to this thread?

And as for why it happened, who knows? Maybe it recieved a dilution of car bumper from an unknown homeopath, and this rectified the problem!