– 10 year old FS Bermese feline with 2-3 week history of vomting and weight loss
– new grade 3/6 systolic heart murmur also found
– bloodwork elevated lipase and positive f PLi SNAP test – other parameters including T4 wnl
– echo showed a normal heart so assume that the murmur is either physiologic or DRVOTO not seen
– cystic mass in right pancreatic limb (DDx: pseudocyst, abscess, tumour)
– left pancreas hypoehcoic with slightly irregualr margins, mild surrounding hyperechoic fat; pancreticoduodenal LN slightly enlarged, reactive looking
– 10 year old FS Bermese feline with 2-3 week history of vomting and weight loss
– new grade 3/6 systolic heart murmur also found
– bloodwork elevated lipase and positive f PLi SNAP test – other parameters including T4 wnl
– echo showed a normal heart so assume that the murmur is either physiologic or DRVOTO not seen
– cystic mass in right pancreatic limb (DDx: pseudocyst, abscess, tumour)
– left pancreas hypoehcoic with slightly irregualr margins, mild surrounding hyperechoic fat; pancreticoduodenal LN slightly enlarged, reactive looking
– a trace effusion was also noted in the abodmen but too little to tap; biliary tree normal (no CBD distension); SI normal
The plan is to aspirate the right pancreatic lesion but it’s in a tricky region – any tips entering this region? I assume I should get out as much fluid as possible so will attach to an extension set and have a tech aspirate. I did not aspirate at the time as rDVM was not present that day and did not have a chance to discuss with the owners. (not sure why I am getting the shadowing artifacts in the second clip coming from the near-field – looks like rib shadows but I was not between the ribs)
Comments
Its pretty straightforward
Its pretty straightforward when sedated try right paralinear (line abla) or left paralinear pushing down to get the lesion against the body wall and then drain the cystic portion and then fna the parecnhyma.
thank you for sharing this
thank you for sharing this case. I have a question with regard to FNA in these cases in which one of the differentials would be pancreatic abscess. I have recently been in a course where they explained that if the lesion is cavernous and abscess is a possibility, then it is better to NOT FNA due to risk of more severe pancreatitis with more difficulty to control medically. That doesnt seem to be a concern for you. How often may that happen? And so, is there anything that is considered “negligence to FNA” except for suspected TCC? Apologies if this hacks the post. I know there are more “keen to FNA” vets vs “not so keen” vets and also if you dont FNA you barely get information, so just trying to clarify whether is really a NO-NO to FNA a potential pancreatic abscess or more an operator related preference…Thanks again for this interesting case.
Well bottom line is dont
Well bottom line is dont stick a tcc unless traumatic catheterization and dont stick anything that has pumping color doppler:).As one of my mentors said , “There are a ton more animals that benefit form sampling than those that die (< 2%) or have complications (5% ish) because of sampling.”.. So here’s a very opinionated response (EL SOAP BOX ALERT) but also one based on a very extensive caseload and direct technique: In my hands I have never seen complications from panc sampling happen… post surgical handling of the panc on the other hand? I have seen brutal pancreatitis happen lots … So I prefer the non invasive single definitive needle over the invasive surgical approach which is the other option for pancreatic necrosis or abscess or even mass. I have never had an issue on 17 years of US and needles sticking a pancreas of any type, abscess or not, and I core bx the pancreatic necrosis or mass lesions as do everyone in my circles that do a lot of sonography. I firnly believe its a well distributed falsehood that sticking a panc is a problem unless they are trying to stick it at 2-4 cm of depth and going through vessels and such or just do not have proper technique…the “scared to stick pancreas” issue is likely derived from technique deficits as opposed to sticking the pancreas from a body wall to target approach. If you think about it a pancreatic necrosis or abscess or even carcinoma is a walled off tissue with largely necrotic non functional tissue. How much damage is a well placed 22 or 25 g needle going to do in the abomen?… it would make more sense if fna or core bx of healthy tissue then causes pancreatitis… I can understand that argument but when the body has an island of necrotic pathology or abscess or carcinoma that usually has spread at the time of dx then why would a needle cause more of an issue with proper technique and supportive care?… that being said even in hot vascular pancreatitis I still stick as well and again have NEVER had an issue… knock on wood of course… I have had issues with oozing on a 22 g fna of a lipidotic liver though… but never a pancreas or raging pancreatitis after a stick. If you push the body wall down to the lesion and fna body wall through peritoneum to hypoechoic bad panc… its a matter of < cm of distance and sticking walled off tissue. Honestly most the people I hear saying this are not doing a lot of US or they are afraid of using needles because they saw a bad complication in school or they just dont have it in their character… I may get some rebuttal here and I’m willing to support this statement but in the sonography world there are “needle” people and “handfuls of pills” people and others that jump back and forth. The needle people typically have the best diagnostic efficiency because cyto and histopath with proper technique beats a PLI/amylase/lipase any day when differentiating pancreatic necrosis from nodular hyperplasia from carcinoma to pancreatitis… again with proper technique which takes focus and practice and mentorship and experience. In addition the predominant cell type is key here in how to treat short term and manage long term. If a neutrophilic pancreatitis abs/fluids and supportive care are key while in LP pancreatitis pred/fluids and +/- abs and antigen surveillance issues are key and how would you know otherwise without a needle? Crucially there are tons of nodular hyperplasia and panc necrosis (2 very common presentations in older pets that may be very clinical for panc path or other) cases misdiagnosed for panreatic neoplasia that get put down because the owners hear the “Pancreatic Cancer” word or “Mass” word form sonographers making the histopathological US approach to the case which can be tragic.. That’s reality but if the “dont stick a pancreas” montra weren’t an issue then the needles would help keep those animals upright and away from gloom and doom conversations with proper therapy that lets them chase frisbees and laser pointers again.The ones that agree with me do a ton of cases and we weild needles daily…… thats just my experience… here are some panc sampling cases to show you and just look at the distance… its a glorifiied US-guided cysto essentially once you practice:) Soap box OUT:
http://sonopath.com/members/case-studies/cases/0500191-zoey-m-pancreatic-carcinoma-carcinomatosis
http://sonopath.com/members/case-studies/cases/pancreatic-abscess-7-year-old-mn-cairn-terrier
http://sonopath.com/resources/cases-month/pancreatic-necrosis-vs-pancreatic-neoplasia
Thanks EL. I was expecting
Thanks EL. I was expecting this response. I wish there wasn’t so much grey areas or different opinions when teaching newbies.
I’ll work on my technique and start with the easy ones so that I can reach to more diagnosis. By the way, I never meant to question Pankazs decision, just get a boost of confidence for myself, which you managed to do beautifully:)
Thanks again.
Thank-you GCSM for this
Thank-you GCSM for this question as it is a good one, and EL for your opinion which I entirely agree with. I think there is a real fear of the pancreas out there and I have some rDVM’s look at me like I have six heads when I recommend poking it – we were all taught to respect it – as we should, in vet school. One of the radiologists who trained me said you really can’t harm very much by sticking a small needle in it and said how many times do you think the colon is accidently entered when attempting a blind cystocentesis on a patient where the UB is not easly palpable. We were also taught to respect the dirty colon. The exceptions to FNA she advised: a suspected urinary bladder TCC due to possible risk of seeding, feline hepatic lipidosis which she had a bad experience where the liver bascially fractured and the patient bled out (I will FNA these but will recommend supportive care and Vitamin K first), and adrenal glands (I know EL is more brave with adrenals then I am)
Thanks Pankatz, I didn’t know
Thanks Pankatz, I didn’t know tha fatty liver one… I’ll soon post about an adrenal mass in a cat… I’m not planning FNA;) at the end of the day, I don’t have EL experience:)
Lipidotic livers I always use
Lipidotic livers I always use a 25g x 1.5 and just dont get oozing and vit k and support always good but th eones that are risky are the cats that dont care what you do… Gi shutdown and such… remember K is produced in the gut owing to flora balance and when the GI isnt moving the flora is having its own party and not the one producing K. So when you see that GI shutdowna nd stasios pattern think about the bigger picture on the K and needle thing. But go 25 g you only need a small sample and a couple of smooth passes at 2-3 sdifferent angles.
Regarding practice: stick any after hours cadaver for practice… its really tough to kill anything with a 22 g needle and even harder with a 25g and even harder in a cadaver:) Its also a good way to get a post mortmm dx on anythign you want wihtout doing a necropsy.
FNA becomes a problem when the bevel becomes a scalpel and you slash through something in a cutting fashion like when the deer in headlights dog or cat moves when doing splenic fna without using sedation…. problem solves with sedation if they arent completely down and out:)
Nice post everyone