scott@vtx-cpd.com
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Replying to Ariane N. 01/09/2024 - 07:48
Thank you so much for the comprehensive reply!
These do seem to be very frustrating cases!
Scott 🙂
Replying to Maria W. 15/08/2024 - 19:46
We carried out FNA’s of the masses and analysis of the pleural fluid:
Cytology Report:
Specimen Received: 11 slides.
Site or Source: Chest mass-8 slides, axillary lymph node-2 slides.Microscopic Description:
Chest mass and axillary lymph node:
The slides appear cytologically similar. They are of high cellularity with many erythrocytes and many nucleated cells seen in a slightly basophilic background containing moderate numbers of lymphoglandular bodies and small amounts of nuclear streaming material.
The nucleated cells consist of intermediate-sized to slightly large lymphocytes with scant, deeply basophilic cytoplasm and a round nucleus with dispersed nuclear chromatin pattern. Rare mitotic figures are noted. Rare small lymphocytes and non-degenerate segmented neutrophils are seen. No infectious agents are observed.
Microscopic Interpretation:
Chest mass and axillary lymph node:
Consistent with lymphoma.
Comment: Both sites reveal an expansion of intermediate-sized to slightly large lymphocytes consistent with lymphoma. Immunophenotyping by flow cytometry may be considered for further characterization and potential prognostication and treatment options.
Specimen Received: Four mL of fluid in red top tube.
Site or Source: Pleural effusion.Analysis:
Appearance: Cloudy
Color: Orange
WBC count: 2.77 x10^9/L
RBC count: 0.02 x10^12/L
Total Protein: 18 g/L
S.G: 1.018
Microscopic Description:
Direct smears and cytospin preparations evaluated show modest cellularity with moderate numbers of erythrocytes and nucleated cells, predominantly macrophages with fewer small lymphocytes, occasional intermediate-sized lymphocytes, large lymphocytes, eosinophils, and non-degenerate segmented neutrophils. Occasional well-differentiated mast cells and few pyknotic nucleated cells noted. No infectious agents or neoplastic cells observed.
Microscopic Interpretation:
Consistent with modified transudate.
Comment: The effusion is most likely caused by the chest mass (lymphoma) causing increased hydrostatic pressure and/or lymphatic obstruction.
Replying to Maria W. 15/08/2024 - 19:46
Hey Maria!
I have popped the CT report below to give you some more detail regarding the imaging:
CT Report for Lucky
Diagnostic Interpretation:
Neck/Spine C1 – T2:
The right mandibular and medial retropharyngeal lymph nodes are moderately enlarged compared to the left.
In the oropharynx, there is a lobulated soft tissue structure that homogenously contrast enhances (precontrast: 49.9 HU, postcontrast: 104.2 HU). This structure is confluent with the ventral margins of the soft palate and occupies almost the entire ventrodorsal height and mediolateral width of the oropharynx at the level of the hyoid apparatus. The remainder of the included head is unremarkable.
The superficial cervical and middle and caudal deep cervical lymph nodes are mildly enlarged.
No abnormalities are noted in the thyroid gland.
Thorax:
Centered in the cranial mediastinum is a large rounded lobulated soft tissue mass that mildly heterogeneously contrast enhances (precontrast: 39.4 HU, postcontrast: 82.6 HU). The mass measures approximately 15.6 cm craniocaudally, 10.7 cm dorsoventrally, and 7.4 cm mediolaterally, occupying almost the entire dorsoventral height and mediolateral width of the cranial thorax.
The mass extends cranially to the thoracic inlet and caudally to the left ventral aspect of the heart, displacing the heart dorsocaudally and towards the right.
The mass causes dorsal elevation of the trachea, cranial thoracic esophagus, and brachiocephalic trunk and its branches. The cranial vena cava is dorsally elevated and narrowed.
The visualized tracheobronchial and cranial mediastinal lymph nodes are moderately enlarged. The sternal lymph nodes are not distinguished from the mass.
There is a large volume of bilateral pleural effusion with accompanying retraction and rounding of the lung lobes. Throughout the lungs, there are patchy ground-glass to soft tissue attenuations, more pronounced ventrally, most consistent with atelectasis.
There is marked enlargement and rounding of the left proper axillary lymph node.
Mild subcutaneous fat stranding and fluid attenuation are seen along the ventral thoracic body wall and axilla.
Included Cranial Abdomen:
There is moderate enlargement and rounding of the hepatic, splenic, gastric, and celiac lymph nodes.
The liver is mildly to moderately enlarged with smooth margins and homogenous contrast enhancement. There is possible asymmetrical thickening of the gastric pylorus with questionable reduction in wall enhancement. Within the included mid aspect of the spleen, there is a small isoattenuating and hypercontrasting nodule.
The remainder of the included abdomen is unremarkable.
Moderate non-bridging spondylosis is seen in the cervical, thoracic, and lumbar spine. Mineralization and protrusion of multiple thoracic intervertebral discs are noted, with no overt spinal cord compression. In the vertebral body of T8, there is a rounded hypoattenuating region, most consistent with a Schmorl’s node. The remainder of the included musculoskeletal structures are unremarkable.
Conclusions:
Large cranial mediastinal mass.
Multiple variably enlarged lymph nodes (head, neck, thoracic, and abdominal).
Bilateral marked pleural effusion.
No evidence of nodular pulmonary metastasis.
Ventral thoracic and axillary subcutaneous fat stranding and fluid attenuation.
Possible oropharyngeal mass.
Hepatomegaly.
Hyperenhancing splenic nodule – benign, less likely malignant.
Questionable gastric pylorus wall thickening.
Additional Comments:
The large cranial mediastinal mass and generalized lymphadenopathy are concerning for lymphoma. Other cranial mediastinal neoplasms (e.g., thymic epithelial neoplasia, ectopic thyroid carcinoma) with lymph node metastasis and/or lymph node hyperplasia are also possible. Cranial mediastinal granuloma cannot be entirely excluded.Ultrasound-guided sampling of the cranial mediastinal mass and affected lymph nodes (largest left axillary) is suggested for further characterization.
The bilateral pleural effusion can be due to neoplastic effusion, chyle, or less likely pus or hemorrhage. This can cause the reported panting and coughing. The rounded lung margins may suggest a chronic effusion. There is no evidence of nodular pulmonary metastasis, but this may be obscured by the suspected atelectasis.
Given the narrowed cranial vena cava, the subcutaneous fluid is suspected to be due to cranial vena cava syndrome (edema). A neoplastic effusion, cellulitis, or hemorrhage cannot be excluded. There is a possible oropharyngeal mass; however, this region is not entirely included in the field-of-view, and correlation with oral examination is suggested.
The questionable gastric wall thickening may be due to folding as this region is not completely included. Neoplastic infiltration or pyloric hypertrophy is possible. The hepatomegaly is nonspecific and can be due to a vacuolar hepatopathy, hepatitis, lymphoid hyperplasia, or less likely diffuse neoplasia. Clinical significance can be correlated with clinical history, and abdominal imaging can be performed if clinically indicated.
Replying to Kerida Shook 25/08/2024 - 17:14
Hi there,
Thanks for sharing your experience! I agree that while using certain techniques or avoiding particular procedures might make dentals a bit more challenging, it’s always worth prioritizing the safety and long-term well-being of the patient. The potential for post-GA blindness, while rare, is certainly something to consider, especially in our feline patients. It’s great that you’ve not encountered any cases, but as you mentioned, the effects might not always be immediately noticeable.
Scott 🙂
Replying to Kerida Shook 25/08/2024 - 17:42
Hello Kerida!
I hope you are safe and well. I agree with your recommendations! Here are the recommendations I made to the owners initially:
“Fluffy’s investigations are most consistent with inflammation of the lower airway.
Medication Adjustment: We recommend continuing the prednisolone at 0.5mg/kg once daily (2.5mg total dose once daily). Despite previous concerns over steroid use, these are the best medications to deal with airway inflammation. We recommend using this at this dose for a further 2 weeks.
Antibiotic Course: Due to the presence of some areas of consolidation, we recommend a course of antibiotics. We suggest using doxycycline at 10mg/kg/day orally. This medication can be dispensed by your referring veterinary surgeon.
Dietary Management: Given the suspicion that vomiting/regurgitation is related to eating too fast, consider feeding Fluffy smaller, more frequent meals or using a slow feeder bowl to prevent rapid eating. If vomiting/regurgitation is persistent, this may also need to be investigated as it could be contributing towards the coughing/gagging if any food material is being aspirated.
Further Diagnostic Testing: Consider further diagnostic tests such as bronchoscopy, CT scan, and bronchoalveolar lavage (BAL) to confirm the diagnosis of lower airway inflammation and determine the best treatment approach.
Environmental Management: Ensure Fluffy is not exposed to environmental irritants such as smoke, dust, or strong odors, which can exacerbate lower airway inflammation.
Follow-Up: Make an appointment for a telephone catch-up with me in 2 weeks to discuss Fluffy’s progress and adjust her treatment plan accordingly.”
We did indeed have discussion about using inhaled therapy in the longer term.
Scott 🙂
Replying to Ariane N. 27/08/2024 - 07:06
Thank you so much for the reply!
Really helpful!
Scott 🙂
Replying to Liz Bode 01/09/2024 - 20:38
Hey Liz!
Fancy seeing you here!
Scott 🙂
Replying to Anna H. 01/09/2024 - 20:39
Hi Anna,
Welcome to the course! It sounds like you have a wealth of experience, and it’s great to hear you’re embracing the challenges of GP practice. I’m sure the course will be a great way to refresh your knowledge and boost your confidence after returning from maternity leave. Looking forward to learning alongside you and sharing experiences!
Let me know if you have any questions.
Scott 🙂
Replying to Karin V. 04/09/2024 - 13:01
Hi Karin,
I’m also looking forward to hearing Liz’s perspective on this topic, but I thought I’d share some of my own insights. From my experience, tracheal stenting can be a life-saving procedure for patients with very severe tracheal collapse. However, I often see referrals for patients with suspected tracheal collapse, even in the early stages, where stenting is being considered as though it’s a universally life-improving procedure that can be done at any time without complications. That’s simply not the case, and I think this paper highlights that well.
For me, it’s crucial to optimize medical management first, using combinations of antibiotics, steroids, and antitussive medications before even considering tracheal stenting. In my experience, many patients can be managed well for quite some time on medical therapy alone, even those with more advanced disease.
I actually have a patient this week (I’ve shared the radiographs below) who had a tracheal stent placed about two years ago but continues to experience recurrent bouts of bronchial pneumonia. This patient still coughs even with the stent in place, which is an important consideration when discussing long-term outcomes.
Looking forward to hearing your thoughts!
Best,
Scott
Replying to Karin V. 02/09/2024 - 19:19
Hi Karin, welcome to the course! It’s great to have you with us, and I’m sure your background in both clinical and industry roles will bring some valuable insights. Looking forward to learning and sharing experiences together. If you need anything, don’t hesitate to reach out!
Scott 🙂
Replying to Ingrid T. 06/09/2024 - 20:39
Thank you so much Ingrid!
We appreciate you!
Scott 🙂
Hi Rosanna,
Thank you so much for your question and for your continued support of VTX. We truly appreciate it!
There won’t be a live Q&A session associated with the course this year. In the past, we offered live Q&A sessions for many of our courses, but based on delegate feedback and challenges with attendance, we decided to remove it from some courses, including the dentistry course. Instead, we encourage using the discussion forum for any questions you may have, which has worked well for many delegates.
That said, we’ve tried to introduce other live elements to make up for the lack of Q&A sessions. For example, we’ve added live events such as the Cytology Rounds, Radiography Rounds, and Round Table Discussions, which provide interactive experiences and opportunities for engagement.
We’d love to hear your thoughts! If you feel that a live Q&A would be beneficial, we can certainly consider that for future courses. Your feedback is always valued, and we hope you’re enjoying the course overall.
Best regards,
Scott
Replying to Jenny G. 06/09/2024 - 15:04
Welcome Jenny!
Amazing to have you here!
Scott 🙂
Replying to Rosanna Vaughan 06/09/2024 - 11:10
Hey Rosanna, thanks so much again for your question! Ingrid has kindly added the links below—I hope they’re helpful. Please let us know if you need any more information.
You’ve raised an interesting point about dental or local nerve blocks, and this might be an area where we could provide more focused teaching. We’re definitely considering developing a webinar specifically on this topic, and it’s something we could also potentially include in future practical sessions. Let me know your thoughts on that!
Scott 🙂
Replying to Hannah Willetts 05/09/2024 - 09:09
Hi Hannah,
No problem at all! I’m glad the information was helpful. Feel free to reach out anytime if you have any more questions or need further clarification.
Thanks again,
Scott 🙂
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