I saw the thread on FNA and had to tell you about a horrible day I had today. 1st time this has happened to me.
Rosebud was a 14 year old cocker that I did an ultrasound on today. I am posting the cine of the spleen. She was one of my favorite Cocker Spaniels. I always got lots of loving.
I did a FNA of the spleen. Good technique- right into a nodule. Cytology pending. I used a 22 guage needle (should have used a 25). I observed the spleen for about 10 minutes and saw no issues. Late in the day Rosebud passed away from bleeding into the abdomen from my FNA.
I saw the thread on FNA and had to tell you about a horrible day I had today. 1st time this has happened to me.
Rosebud was a 14 year old cocker that I did an ultrasound on today. I am posting the cine of the spleen. She was one of my favorite Cocker Spaniels. I always got lots of loving.
I did a FNA of the spleen. Good technique- right into a nodule. Cytology pending. I used a 22 guage needle (should have used a 25). I observed the spleen for about 10 minutes and saw no issues. Late in the day Rosebud passed away from bleeding into the abdomen from my FNA.
I have always been willing to stick a needle in just about anything- but I did not expect this. I did warn the owner that bleeding was a possiblity- but I did not really believe this would happen.
I will let you know when I get the results of cytology back. Very sad day for Rosebud, her owners and me.
Comments
Wow, so sorry! I do a few
Wow, so sorry! I do a few FNA’s on patients at other clinics that don’t have access to U/S to check for bleeding and I do worry about that type of outcome too.
That spleen was crying out for a needle though. I will be interested what you get back. That is really sad but I would have made the same choice.
Suzanne
Wow, so sorry! I do a few
Wow, so sorry! I do a few FNA’s on patients at other clinics that don’t have access to U/S to check for bleeding and I do worry about that type of outcome too.
That spleen was crying out for a needle though. I will be interested what you get back. That is really sad but I would have made the same choice.
Suzanne
Ouch!! well I can only say
Ouch!! well I can only say the only time this has happened to me was von willebrands and mast cell or if I didnt sedate and the pet contracted the body wall so the needle goes one way and the spleen went another..mia culpa on that one I should have sedated because ears were pinned bag which is my “sedation sign” … but I can coount on one hand how many complications I have had with a 22 gauge needle in 18 years of doing US and these are the 3 causes…. & I typically don’t coag for fna unless suspecting mct or von willi in a specific breed or if platelets are <50k.
I have gone to 25 g exclusively on the spleen though unless i dont get recovery then i go to 22…
Regardless those nodules are targets and badness for sure mct one of the potentials. Cockers can get von willebrands though but tough to justify a BBT or VWBF on every fna. Tough break but Im sure you will get badness back on fna.
As my mentor once said you help a 100 animals/clients get a dx with a needle compared ot the ones that have complications. Complications typically happen in badness disease as well. Big picture here Randy. When this happens to many people they stop using needles and arrive at many less diagnoses that depend on the needle. Maybe review a video if you saved it on exactly where the needle went. If your technique is solid then its either MCT or VWB or other coagulopathy or just one of those red herring scenarios we never explain but don’t let it stop you from performing fna because it would be an injustice to every other case that comes across the probe. Cyto and histo are still the most SE and SP diagnostics we have.
Doing a coag before is never wrong.. but often not necessary and I would have thought round cell neoplasia here and fna wihtout a coag as well unless there was something about the dog that said it needed one… really morbund for example.
if suspecting MCT I give them benadryl 1 mg/kg im 10 min before fna but it want my first ddx here. LSA would be my first choice maybe mct maybe fungal or splenitis.
Ironically I just finished this chapter from the curbside guide coming out next month in digital and after in hard copy so here’s a preview that is applicable here:
Ultrasound-Guided Sampling Procedures & Expectations Regarding Interpretation
https://sonopath.com/resources/interventional-procedures
Description: Ultrasound-guided (US-guided) needle sampling is frequently used in the diagnostic evaluation of patients and is generally considered a safe procedure that carries minimal risk. Fine needle aspiration (FNA) has the advantage of requiring very little or no sedation, and carries very little risk of complications. Yet, information obtained via FNA alone may be inconclusive or incomplete, and conclusions based solely on cytological specimens may be incorrect. Needle core biopsy samples are generally more accurate than fine needle samples, but some degree of anesthesia is required and they carry a greater risk of complication, depending on which organ system is being sampled. Diagnostic yield and accuracy vary significantly among the different diagnostic procedures; they are also contingent on the specific organ being aspirated and the underlying disease process. As such, the clinician should be aware of the limitations and benefits of each procedure as they pertain to the organs and suspected disease processes in question.
Diagnostics: Since sampling of any sort may cause some local bleeding, it is important to know the coagulation status of every patient being sampled (i.e., the platelet count and clotting times [OSPT and APTT]). An elevated clotting time and/or a platelet count below 50,000 are both associated with increased risks. Clinical evidence of petechiae or ecchymoses should alert the practitioner to the need for a more elaborate coagulation assessment. Biopsy with caution if PT/APTT values are less than 1.3 of normal and conduct FNA if values are less than 1.5 of normal; treat with vitamin K and recheck if values are higher. If the parameters are higher than these standards, the client should be informed and a new risk justification assessment evaluated. Nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin therapy should be discontinued 1-2 weeks prior to biopsy, if possible. Von Willebrand’s titers and/or buccal mucosal bleeding times should be checked in patients at risk for platelet (functional) abnormalities, including those on chronic NSAID therapy. Buccal mucosal bleeding time (BMBT) is the best overall rapid clinical assessment of the primary clotting function, which is determined by both platelet and vascular activities. The most sensitive and ideal means of screening for bleeding complications is to repeat ultrasound examinations every 15 minutes for a few hours after the procedure; however, this is highly impractical and a follow-up examination 15-30 minutes subsequent to the procedure should be sufficient. A hematocrit should be taken pre- and post-biopsy, even though it may only drop 12-24 hours after a bleeding event has occurred.
US-Guided FNA: FNAs are conducted by administering a 22-25g needle in a “jab” motion to retrieve cells from a particular organ system. Sedation is at times necessary with this procedure. Coagulation panels are ideal, but used at the discretion of the sonographer based on the case and the sonographic presentation. One is not looking for structural parenchymal changes with this procedure, but rather assessing the cell population under investigation. Results can often be “suggestive” of mono-population diseases, such as lymphoma, mast cell disease, or carcinoma, even if they are not definitive. Sampling multiple organs suspected of neoplasia will aid in arriving at the definitive diagnosis. An example of this would be splenic and hepatic infiltrative patterns suggestive for lymphoma. FNA of both organs will allow the cytologist to better define the nature of the lymphoid population based on its distribution. It is recommended that one read the entire cytology report and not just the diagnosis portion as there is far more information contained in the cytologist’s descriptions. (The same holds true for biopsy descriptions provided by the pathologist.) Assessing the description also allows for an evaluation of the sample quality. If the sample is of adequate quality, then the results usually lie in the interpretation (although a second evaluation may be warranted) or they will indicate the potential need for a biopsy if a definitive diagnosis has not been determined (which is usually the case if a mono-population disease is not evident). If the sample quality is of low yield, then biopsy is likely more appropriate to determine the underlying pathology in the organ given that some diseased tissue may not readily exfoliate. It is recommended that one provide the pathologist with a still image that demonstrates the needle position with respect to the pathology being assessed. Given that a pathologist is usually only looking at a slide of cells that is poorly reminiscent of the affected organ tissue due to destructive pathology, sharing this kind of image helps to clarify which organ is being sampled.
US-Guided Biopsy: This procedure enables Tru-cut sections of a given tissue to be obtained in order to evaluate the parenchymal structure of an organ. It is a more definitive procedure for diagnosing mono-population disease (i.e., lymphoma, mast cell disease, carcinoma), but is especially necessary when structural evaluation of the parenchyma is required to arrive at a diagnosis (i.e., hepatitis, fibrosing diseases, copper storage disease, protein-losing nephropathy, and enteropathy with focal lesions, such as “bridging” lymphoma or inflammatory bowel disease [IBD]). This procedure absolutely requires a complete coagulation panel as well as deep sedation to at least stage 2 or a higher plane of anesthesia.
Drainage Procedures: Drainage procedures are often performed to enhance the therapeutic and diagnostic value of the pericardium, abdomen, thorax, abscesses (abdominal, prostatic, pancreatic), infected renal and hepatic cysts, and non-perforated gallbladders. In cases where abscesses have been drained, it is also possible to inject antibiotic directly back into the abscess cavity.
US-Guided Pericardiocentesis: Pericardial effusions typically cause some degree of cardiomegaly, which can be observed on radiographs. The presence of electrical alternans on an ECG is indicative of pericardial effusion. Some patients require light sedation, which can be achieved with ketamine/valium or an opioid; however, in most cases a local lidocaine block is sufficient. Pericardiocentesis can be used either as a diagnostic tool to help determine the nature of the effusion or a therapeutic tool to decompress the pericardial space and relieve the tamponade. The procedure occurs at the “cardiac notch” located on the right side of the heart, below the costochondral junction, which is located between the 4th and 6th intercostal spaces. At this site, the lung does not cover the heart and there is no risk of lacerating any of the coronary blood vessels. The area should be surgically prepared prior to the procedure. A large syringe, large-bore “thru-the-needle catheter,” and three-way stopcock are required, and the procedure is performed with the animal in a standing position. The needle is inserted through the intercostal muscles and into the pericardial sac. Once in the sac, the needle is withdrawn and the catheter is advanced slowly until the heart movement is felt, at which point one connects it to the three-way stopcock. The effusion is then drained.
ADAIN Procedure:Prostatic abscesses traditionally have necessitated surgical marsupialization, which is invasive and incurs significant expense and hospitalization. A simpler and easier method is the Abscess Drainage Antibiotic Injection and Neuter (ADAIN) procedure. The abscess is drained using a 14-16g IV catheter until only a very small cavity remains. Enrofloxacin (total dose of 5 mg/kg) is then injected directly into the abscess cavity; oral enrofloxacin (2.5-5 mg/kg BID) should be continued for 7-10 days following the procedure. If the animal is not neutered, then castration is advised. The results of this procedure have been effective in almost 100% of cases without complications.
The technique can also be used on abscesses that form in prostatic carcinomas, which usually occur in neutered males. The drainage and antibiotic injection, which decreases the volume of the abscess within the tumor, is typically a palliative treatment in these cases.
Intraoperative Ultrasound:Thistechnique can be used on any abdominal organ, but is especially effective in cases of infiltrative, focal, and multifocal GI lesions. Acoustic gel is placed inside a double surgical glove to keep the outside of the exposed glove sterile. The ultrasound probe is sprayed with alcohol and placed inside the glove, which is then pulled tightly over the probe to ensure that adequate probe/gel/glove coupling occurs and air entrapment is avoided. The bowel or target organ is exteriorized and saline is poured directly onto the tissue; it acts as a coupling agent. The organ is then scanned to ascertain the most representative region of the mural pathology, which is subsequently biopsied. (Further details can be found at http://www.sonopath.com/resources.html.)
UG-Guided Endoscopic Laser Ablation (UGELAB) for Lower Urinary Transitional Cell Carcinomas in Dogs: Transitional cell carcinoma (TCC) of the bladder and urethra is often locally invasive and obstructive. UGELAB is a palliative treatment designed to improve obstruction of the distal urinary tract and maintain urine flow. Ultrasound monitoring of this process is an essential component to increase tumor ablation efficacy and prevent perforation of the urinary tract. Without it, endoscopy and laser alone comprise a “blind” intervention.
One should use an ultrasound machine that has either a 5-10 mHz microconvex probe or a 12 mHz linear probe in order to monitor the progression of the hyperechoic tissue necrosis line created by the diode laser ablation of the tumor. Power Doppler sonography allows for the precise guidance of the diode laser into the tumor vasculature, which in turn “starves” the tumor by cutting it off from its blood supply. A Storz 2.7 endoscope and 980 nm diode laser are used to perform the ablation. In animals that have not been responsive to traditional therapies, this procedure has been shown to maximize tumor volume reduction, minimize obstructive tumor bulk, increase urethral and ureteral patency, eliminate tumor vasculature, decrease the severity of clinical signs, and increase survival time. The current mean survival time (MST) is 356 days. Thus far, the only complication that has been reported was perforation during the procedure; however, this only occurred in two dogs and is much dependent on operator experience.
Bubble Study for Veno-Arterial Shunting: The performance of a bubble study is indicated when one needs to confirm whether blood is being shunted from venous to arterial flows. Veno-arterial shunting typically occurs in cases of reverse ventricular septal defect (VSD) or patent ductus arteriosus (PDA) (Eisenmenger’s syndrome). Twenty cubic centimeters (cc) of saline or hetastarch is drawn up into a syringe that contains a few cc of air. The syringe is vigorously agitated, the free air expelled, and the contents are then injected into the cephalic vein via an IV catheter. If a reverse PDA is suspected, the abdominal aorta should be imaged as close to the body wall as possible. With reverse PDA, bubbles will be seen in the abdominal aorta. If a reverse VSD is suspected, the probe should be positioned along the right parasternal long axis in order to image the heart. In cases of reverse VSD, bubbles will enter the right atrium, travel to the right ventricle, and then cross into the left ventricle and aorta through the defect. The bubbles are subsequently ejected into the aortic circulation without passing into the pulmonary circulation.
Conclusion: With careful preparation and patient evaluation, diagnostic samples can be obtained easily and in a relatively non-invasive manner using US-guided interventional procedures. The latter can be performed to extend the quality of life of patients that, in the past, have typically been considered terminally ill. Moreover, US-guided drainage procedures can diminish the need for expensive surgeries, such as those performed to resolve prostatic, abdominal, and pancreatic abscesses.
References:
Center SA. Diagnostic procedures for evaluation of hepatic disease. In: Guilford WG, Center SA, Strombeck DR, et al, eds. Strombeck’s Small Animal Gastroenterology. Philadelphia, PA: WB Saunders; 1996:130-88.
Center SA, Crawford MA, Guida L, et al. A retrospective study of 77 cats with severe hepatic lipidosis: 1975-1990. J Vet Intern Med 1993;7:349-59.
Cerf D, Lindquist E. Palliative ultrasound-guided endoscopic diode laser ablation of transitional cell carcinomas of the lower urinary tract in dogs. J Am Vet Med Assoc. 2012;240:51-60.
Kristensen AT, Klausner JS, Weiss DJ, et al. Liver cytology in cases of canine and feline hepatic disease. Compend Contin Educ Pract Vet 1990;12:1267-91.
Roth L. Comparison of liver cytology and biopsy diagnoses in dogs and cats: 56 cases. Vet Clin Pathol 2001;30:35-38.
Wang KY, Panciera DL, Al-Rukibat RK, et al. Accuracy of ultrasound-guided fine-needle aspiration of the liver and cytologic findings in dogs and cats: 97 cases (1990-2000). J Am Vet Med Assoc 2004;224:75-78.
Weiss DJ, Blauvelt M, Aird B. Cytologic evaluation of inflammation in canine liver aspirates. Vet Clin Pathol 2001;30:193-96.
Willard MD, Weeks BR, Johnson M. Fine-needle aspirate cytology suggesting hepatic lipidosis in four cats with infiltrative hepatic disease. J Feline Med Surg 1999;1:215-20.
Ouch!! well I can only say
Ouch!! well I can only say the only time this has happened to me was von willebrands and mast cell or if I didnt sedate and the pet contracted the body wall so the needle goes one way and the spleen went another..mia culpa on that one I should have sedated because ears were pinned bag which is my “sedation sign” … but I can coount on one hand how many complications I have had with a 22 gauge needle in 18 years of doing US and these are the 3 causes…. & I typically don’t coag for fna unless suspecting mct or von willi in a specific breed or if platelets are <50k.
I have gone to 25 g exclusively on the spleen though unless i dont get recovery then i go to 22…
Regardless those nodules are targets and badness for sure mct one of the potentials. Cockers can get von willebrands though but tough to justify a BBT or VWBF on every fna. Tough break but Im sure you will get badness back on fna.
As my mentor once said you help a 100 animals/clients get a dx with a needle compared ot the ones that have complications. Complications typically happen in badness disease as well. Big picture here Randy. When this happens to many people they stop using needles and arrive at many less diagnoses that depend on the needle. Maybe review a video if you saved it on exactly where the needle went. If your technique is solid then its either MCT or VWB or other coagulopathy or just one of those red herring scenarios we never explain but don’t let it stop you from performing fna because it would be an injustice to every other case that comes across the probe. Cyto and histo are still the most SE and SP diagnostics we have.
Doing a coag before is never wrong.. but often not necessary and I would have thought round cell neoplasia here and fna wihtout a coag as well unless there was something about the dog that said it needed one… really morbund for example.
if suspecting MCT I give them benadryl 1 mg/kg im 10 min before fna but it want my first ddx here. LSA would be my first choice maybe mct maybe fungal or splenitis.
Ironically I just finished this chapter from the curbside guide coming out next month in digital and after in hard copy so here’s a preview that is applicable here:
Ultrasound-Guided Sampling Procedures & Expectations Regarding Interpretation
https://sonopath.com/resources/interventional-procedures
Description: Ultrasound-guided (US-guided) needle sampling is frequently used in the diagnostic evaluation of patients and is generally considered a safe procedure that carries minimal risk. Fine needle aspiration (FNA) has the advantage of requiring very little or no sedation, and carries very little risk of complications. Yet, information obtained via FNA alone may be inconclusive or incomplete, and conclusions based solely on cytological specimens may be incorrect. Needle core biopsy samples are generally more accurate than fine needle samples, but some degree of anesthesia is required and they carry a greater risk of complication, depending on which organ system is being sampled. Diagnostic yield and accuracy vary significantly among the different diagnostic procedures; they are also contingent on the specific organ being aspirated and the underlying disease process. As such, the clinician should be aware of the limitations and benefits of each procedure as they pertain to the organs and suspected disease processes in question.
Diagnostics: Since sampling of any sort may cause some local bleeding, it is important to know the coagulation status of every patient being sampled (i.e., the platelet count and clotting times [OSPT and APTT]). An elevated clotting time and/or a platelet count below 50,000 are both associated with increased risks. Clinical evidence of petechiae or ecchymoses should alert the practitioner to the need for a more elaborate coagulation assessment. Biopsy with caution if PT/APTT values are less than 1.3 of normal and conduct FNA if values are less than 1.5 of normal; treat with vitamin K and recheck if values are higher. If the parameters are higher than these standards, the client should be informed and a new risk justification assessment evaluated. Nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin therapy should be discontinued 1-2 weeks prior to biopsy, if possible. Von Willebrand’s titers and/or buccal mucosal bleeding times should be checked in patients at risk for platelet (functional) abnormalities, including those on chronic NSAID therapy. Buccal mucosal bleeding time (BMBT) is the best overall rapid clinical assessment of the primary clotting function, which is determined by both platelet and vascular activities. The most sensitive and ideal means of screening for bleeding complications is to repeat ultrasound examinations every 15 minutes for a few hours after the procedure; however, this is highly impractical and a follow-up examination 15-30 minutes subsequent to the procedure should be sufficient. A hematocrit should be taken pre- and post-biopsy, even though it may only drop 12-24 hours after a bleeding event has occurred.
US-Guided FNA: FNAs are conducted by administering a 22-25g needle in a “jab” motion to retrieve cells from a particular organ system. Sedation is at times necessary with this procedure. Coagulation panels are ideal, but used at the discretion of the sonographer based on the case and the sonographic presentation. One is not looking for structural parenchymal changes with this procedure, but rather assessing the cell population under investigation. Results can often be “suggestive” of mono-population diseases, such as lymphoma, mast cell disease, or carcinoma, even if they are not definitive. Sampling multiple organs suspected of neoplasia will aid in arriving at the definitive diagnosis. An example of this would be splenic and hepatic infiltrative patterns suggestive for lymphoma. FNA of both organs will allow the cytologist to better define the nature of the lymphoid population based on its distribution. It is recommended that one read the entire cytology report and not just the diagnosis portion as there is far more information contained in the cytologist’s descriptions. (The same holds true for biopsy descriptions provided by the pathologist.) Assessing the description also allows for an evaluation of the sample quality. If the sample is of adequate quality, then the results usually lie in the interpretation (although a second evaluation may be warranted) or they will indicate the potential need for a biopsy if a definitive diagnosis has not been determined (which is usually the case if a mono-population disease is not evident). If the sample quality is of low yield, then biopsy is likely more appropriate to determine the underlying pathology in the organ given that some diseased tissue may not readily exfoliate. It is recommended that one provide the pathologist with a still image that demonstrates the needle position with respect to the pathology being assessed. Given that a pathologist is usually only looking at a slide of cells that is poorly reminiscent of the affected organ tissue due to destructive pathology, sharing this kind of image helps to clarify which organ is being sampled.
US-Guided Biopsy: This procedure enables Tru-cut sections of a given tissue to be obtained in order to evaluate the parenchymal structure of an organ. It is a more definitive procedure for diagnosing mono-population disease (i.e., lymphoma, mast cell disease, carcinoma), but is especially necessary when structural evaluation of the parenchyma is required to arrive at a diagnosis (i.e., hepatitis, fibrosing diseases, copper storage disease, protein-losing nephropathy, and enteropathy with focal lesions, such as “bridging” lymphoma or inflammatory bowel disease [IBD]). This procedure absolutely requires a complete coagulation panel as well as deep sedation to at least stage 2 or a higher plane of anesthesia.
Drainage Procedures: Drainage procedures are often performed to enhance the therapeutic and diagnostic value of the pericardium, abdomen, thorax, abscesses (abdominal, prostatic, pancreatic), infected renal and hepatic cysts, and non-perforated gallbladders. In cases where abscesses have been drained, it is also possible to inject antibiotic directly back into the abscess cavity.
US-Guided Pericardiocentesis: Pericardial effusions typically cause some degree of cardiomegaly, which can be observed on radiographs. The presence of electrical alternans on an ECG is indicative of pericardial effusion. Some patients require light sedation, which can be achieved with ketamine/valium or an opioid; however, in most cases a local lidocaine block is sufficient. Pericardiocentesis can be used either as a diagnostic tool to help determine the nature of the effusion or a therapeutic tool to decompress the pericardial space and relieve the tamponade. The procedure occurs at the “cardiac notch” located on the right side of the heart, below the costochondral junction, which is located between the 4th and 6th intercostal spaces. At this site, the lung does not cover the heart and there is no risk of lacerating any of the coronary blood vessels. The area should be surgically prepared prior to the procedure. A large syringe, large-bore “thru-the-needle catheter,” and three-way stopcock are required, and the procedure is performed with the animal in a standing position. The needle is inserted through the intercostal muscles and into the pericardial sac. Once in the sac, the needle is withdrawn and the catheter is advanced slowly until the heart movement is felt, at which point one connects it to the three-way stopcock. The effusion is then drained.
ADAIN Procedure:Prostatic abscesses traditionally have necessitated surgical marsupialization, which is invasive and incurs significant expense and hospitalization. A simpler and easier method is the Abscess Drainage Antibiotic Injection and Neuter (ADAIN) procedure. The abscess is drained using a 14-16g IV catheter until only a very small cavity remains. Enrofloxacin (total dose of 5 mg/kg) is then injected directly into the abscess cavity; oral enrofloxacin (2.5-5 mg/kg BID) should be continued for 7-10 days following the procedure. If the animal is not neutered, then castration is advised. The results of this procedure have been effective in almost 100% of cases without complications.
The technique can also be used on abscesses that form in prostatic carcinomas, which usually occur in neutered males. The drainage and antibiotic injection, which decreases the volume of the abscess within the tumor, is typically a palliative treatment in these cases.
Intraoperative Ultrasound:Thistechnique can be used on any abdominal organ, but is especially effective in cases of infiltrative, focal, and multifocal GI lesions. Acoustic gel is placed inside a double surgical glove to keep the outside of the exposed glove sterile. The ultrasound probe is sprayed with alcohol and placed inside the glove, which is then pulled tightly over the probe to ensure that adequate probe/gel/glove coupling occurs and air entrapment is avoided. The bowel or target organ is exteriorized and saline is poured directly onto the tissue; it acts as a coupling agent. The organ is then scanned to ascertain the most representative region of the mural pathology, which is subsequently biopsied. (Further details can be found at http://www.sonopath.com/resources.html.)
UG-Guided Endoscopic Laser Ablation (UGELAB) for Lower Urinary Transitional Cell Carcinomas in Dogs: Transitional cell carcinoma (TCC) of the bladder and urethra is often locally invasive and obstructive. UGELAB is a palliative treatment designed to improve obstruction of the distal urinary tract and maintain urine flow. Ultrasound monitoring of this process is an essential component to increase tumor ablation efficacy and prevent perforation of the urinary tract. Without it, endoscopy and laser alone comprise a “blind” intervention.
One should use an ultrasound machine that has either a 5-10 mHz microconvex probe or a 12 mHz linear probe in order to monitor the progression of the hyperechoic tissue necrosis line created by the diode laser ablation of the tumor. Power Doppler sonography allows for the precise guidance of the diode laser into the tumor vasculature, which in turn “starves” the tumor by cutting it off from its blood supply. A Storz 2.7 endoscope and 980 nm diode laser are used to perform the ablation. In animals that have not been responsive to traditional therapies, this procedure has been shown to maximize tumor volume reduction, minimize obstructive tumor bulk, increase urethral and ureteral patency, eliminate tumor vasculature, decrease the severity of clinical signs, and increase survival time. The current mean survival time (MST) is 356 days. Thus far, the only complication that has been reported was perforation during the procedure; however, this only occurred in two dogs and is much dependent on operator experience.
Bubble Study for Veno-Arterial Shunting: The performance of a bubble study is indicated when one needs to confirm whether blood is being shunted from venous to arterial flows. Veno-arterial shunting typically occurs in cases of reverse ventricular septal defect (VSD) or patent ductus arteriosus (PDA) (Eisenmenger’s syndrome). Twenty cubic centimeters (cc) of saline or hetastarch is drawn up into a syringe that contains a few cc of air. The syringe is vigorously agitated, the free air expelled, and the contents are then injected into the cephalic vein via an IV catheter. If a reverse PDA is suspected, the abdominal aorta should be imaged as close to the body wall as possible. With reverse PDA, bubbles will be seen in the abdominal aorta. If a reverse VSD is suspected, the probe should be positioned along the right parasternal long axis in order to image the heart. In cases of reverse VSD, bubbles will enter the right atrium, travel to the right ventricle, and then cross into the left ventricle and aorta through the defect. The bubbles are subsequently ejected into the aortic circulation without passing into the pulmonary circulation.
Conclusion: With careful preparation and patient evaluation, diagnostic samples can be obtained easily and in a relatively non-invasive manner using US-guided interventional procedures. The latter can be performed to extend the quality of life of patients that, in the past, have typically been considered terminally ill. Moreover, US-guided drainage procedures can diminish the need for expensive surgeries, such as those performed to resolve prostatic, abdominal, and pancreatic abscesses.
References:
Center SA. Diagnostic procedures for evaluation of hepatic disease. In: Guilford WG, Center SA, Strombeck DR, et al, eds. Strombeck’s Small Animal Gastroenterology. Philadelphia, PA: WB Saunders; 1996:130-88.
Center SA, Crawford MA, Guida L, et al. A retrospective study of 77 cats with severe hepatic lipidosis: 1975-1990. J Vet Intern Med 1993;7:349-59.
Cerf D, Lindquist E. Palliative ultrasound-guided endoscopic diode laser ablation of transitional cell carcinomas of the lower urinary tract in dogs. J Am Vet Med Assoc. 2012;240:51-60.
Kristensen AT, Klausner JS, Weiss DJ, et al. Liver cytology in cases of canine and feline hepatic disease. Compend Contin Educ Pract Vet 1990;12:1267-91.
Roth L. Comparison of liver cytology and biopsy diagnoses in dogs and cats: 56 cases. Vet Clin Pathol 2001;30:35-38.
Wang KY, Panciera DL, Al-Rukibat RK, et al. Accuracy of ultrasound-guided fine-needle aspiration of the liver and cytologic findings in dogs and cats: 97 cases (1990-2000). J Am Vet Med Assoc 2004;224:75-78.
Weiss DJ, Blauvelt M, Aird B. Cytologic evaluation of inflammation in canine liver aspirates. Vet Clin Pathol 2001;30:193-96.
Willard MD, Weeks BR, Johnson M. Fine-needle aspirate cytology suggesting hepatic lipidosis in four cats with infiltrative hepatic disease. J Feline Med Surg 1999;1:215-20.
Thanks EL. I won’t stop
Thanks EL. I won’t stop aspirating.
I will probably go with that 25 g on the spleen to start with.
Thanks EL. I won’t stop
Thanks EL. I won’t stop aspirating.
I will probably go with that 25 g on the spleen to start with.
So sorry to hear this Randy.
So sorry to hear this Randy. This would be every ultrasonographer’s nightmare for sure. I once did an FNA on a nasty liver and once I pulled the needle out the patient went into a grand mal seizure and then never fully recovered from it despite aggressive anti-seizure treatment. We euthanized the next day. It ended up that the dog was full of cancer – but I still felt horrible. I think sometimes cancer can do weird, unpredictable things.
So sorry to hear this Randy.
So sorry to hear this Randy. This would be every ultrasonographer’s nightmare for sure. I once did an FNA on a nasty liver and once I pulled the needle out the patient went into a grand mal seizure and then never fully recovered from it despite aggressive anti-seizure treatment. We euthanized the next day. It ended up that the dog was full of cancer – but I still felt horrible. I think sometimes cancer can do weird, unpredictable things.
Thank you all for your
Thank you all for your support. I wish I could say it is good to be humbled on occasion.
I had good aspirates- so I am confident I will get a diagnosis- for all it is worth now.
I will post the results of cytology when they are back.
Thank you all for your
Thank you all for your support. I wish I could say it is good to be humbled on occasion.
I had good aspirates- so I am confident I will get a diagnosis- for all it is worth now.
I will post the results of cytology when they are back.
Playing devils advocate – how
Playing devils advocate – how sure are that Rosbud exsanguinated from the FNA as the splenic masses appeared fairly solid. How much blood was in the abdominal cavity? As Eric says complications are fairly rare with FNA. One case that stands out for me is a dog with splenic neoplasia that developed severe hemorrhage a few hours after FNA turned out to have a mesenteric artery aneurisym and not from the FNA site on PM.
Playing devils advocate – how
Playing devils advocate – how sure are that Rosbud exsanguinated from the FNA as the splenic masses appeared fairly solid. How much blood was in the abdominal cavity? As Eric says complications are fairly rare with FNA. One case that stands out for me is a dog with splenic neoplasia that developed severe hemorrhage a few hours after FNA turned out to have a mesenteric artery aneurisym and not from the FNA site on PM.
I opened her up and the
I opened her up and the abdomen was full of blood. I did not look to see if it was a mesenteric artery. I suspect it was what EL described “ I didnt sedate and the pet contracted the body wall so the needle goes one way and the spleen went another”. I feel that is what happened here. Once I was in I could clearly see my aspirate from one of the nodules.
I actually watched the site for 10 minutes and saw no sign of bleeding- so I sent her home.
This dog had a heart problem and was suffering from severe bronchitis and or broncho-pneumonia. I did not think I would have to sedate her. As they say “hindsight is 20-20”.
I origianally thought she was not feeling well because of her respiratory issues and did not pick up the splenic mass till the recheck visit 5 days later. I am certain the mass was there- but I did not pick it up.
I opened her up and the
I opened her up and the abdomen was full of blood. I did not look to see if it was a mesenteric artery. I suspect it was what EL described “ I didnt sedate and the pet contracted the body wall so the needle goes one way and the spleen went another”. I feel that is what happened here. Once I was in I could clearly see my aspirate from one of the nodules.
I actually watched the site for 10 minutes and saw no sign of bleeding- so I sent her home.
This dog had a heart problem and was suffering from severe bronchitis and or broncho-pneumonia. I did not think I would have to sedate her. As they say “hindsight is 20-20”.
I origianally thought she was not feeling well because of her respiratory issues and did not pick up the splenic mass till the recheck visit 5 days later. I am certain the mass was there- but I did not pick it up.
Here are the results of the
Here are the results of the cytology.
STANDARD CYTOLOGY W/ DESC(1 SITE)
Test
SOURCE/HISTORY
Standard cytology from a 10-year-old female spayed American Cocker
Spaniel. Sample from spleen. Two slides are received and evaluated,
one that was previously stained.
MICROSCOPIC DESCRIPTION
The smears are moderately to highly cellular and moderately to densely
bloody. There is a prominent population of hemic precursors including
occasional megakaryocytes, scattered progranulocytes as well as
myelocytes and band neutrophils with fewer rubriblasts, prorubricytes,
and metarubricytes. Occasional small to intermediate sized lymphocytes
and plasma cells are also found admixed with occasional distorted
aggregates of stromal elements and clotted material. There is also a
population of small to moderately sized, cohesive appearing cell
elements. These cells have scant to moderate amounts of medium blue
cytoplasm occasionally with punctate vacuolization and ovoid to
polygonal nuclei with smudged to reticular chromatin occasionally
containing multiple small, prominent nucleoli. These cohesive
appearing clusters are rarely crowded and disorganized with slight
nuclear molding found and mild anisocytosis and anisokaryosis
appreciated.
CYTOLOGICAL INTERPRETATION
Moderate to marked extramedullary hematopoiesis with clusters of
mildly atypical cohesive appearing cells
COMMENTS
Extramedullary hematopoiesis can be an incidental, age related finding
in the canine spleen and liver and may form nodules. Alternatively,
this finding may be related to increased peripheral demand for red
blood cells, white blood cells and/or platelets. It also can be seen
adjacent to splenic pathology associated with neoplastic lesions,
hematomas, or areas of thrombosis. The cohesive appearing cells are of
uncertain origin and significance. They are minimally pleomorphic and
may represent concurrent aspiration of an epithelial population.
Alternatively, they may represent metastatic cells. A representative
smear was reviewed with Dr. Jim Matthews who concurs that the cohesive
population is of concern. Correlation with clinical history and
appearance (was there a splenic mass or history of neoplasia that may
have spread?) may be useful, as may tissue biopsy for histopathologic
evaluation of architecture as warranted.
Looking at the target lesions in the cine- can anyone make a case for benigh pathology?
Here are the results of the
Here are the results of the cytology.
STANDARD CYTOLOGY W/ DESC(1 SITE)
Test
SOURCE/HISTORY
Standard cytology from a 10-year-old female spayed American Cocker
Spaniel. Sample from spleen. Two slides are received and evaluated,
one that was previously stained.
MICROSCOPIC DESCRIPTION
The smears are moderately to highly cellular and moderately to densely
bloody. There is a prominent population of hemic precursors including
occasional megakaryocytes, scattered progranulocytes as well as
myelocytes and band neutrophils with fewer rubriblasts, prorubricytes,
and metarubricytes. Occasional small to intermediate sized lymphocytes
and plasma cells are also found admixed with occasional distorted
aggregates of stromal elements and clotted material. There is also a
population of small to moderately sized, cohesive appearing cell
elements. These cells have scant to moderate amounts of medium blue
cytoplasm occasionally with punctate vacuolization and ovoid to
polygonal nuclei with smudged to reticular chromatin occasionally
containing multiple small, prominent nucleoli. These cohesive
appearing clusters are rarely crowded and disorganized with slight
nuclear molding found and mild anisocytosis and anisokaryosis
appreciated.
CYTOLOGICAL INTERPRETATION
Moderate to marked extramedullary hematopoiesis with clusters of
mildly atypical cohesive appearing cells
COMMENTS
Extramedullary hematopoiesis can be an incidental, age related finding
in the canine spleen and liver and may form nodules. Alternatively,
this finding may be related to increased peripheral demand for red
blood cells, white blood cells and/or platelets. It also can be seen
adjacent to splenic pathology associated with neoplastic lesions,
hematomas, or areas of thrombosis. The cohesive appearing cells are of
uncertain origin and significance. They are minimally pleomorphic and
may represent concurrent aspiration of an epithelial population.
Alternatively, they may represent metastatic cells. A representative
smear was reviewed with Dr. Jim Matthews who concurs that the cohesive
population is of concern. Correlation with clinical history and
appearance (was there a splenic mass or history of neoplasia that may
have spread?) may be useful, as may tissue biopsy for histopathologic
evaluation of architecture as warranted.
Looking at the target lesions in the cine- can anyone make a case for benigh pathology?
Randy, first of all, Im so
Randy, first of all, Im so sorry to hear what happened but at the same time I appreciate you sharing your experience and all the information that has come out from this thread, since I was the one to trigger all the FNA post before.
I´m afraid I cannot help you. But I wanted to comment anyways.
Thank you again for sharing this.
Randy, first of all, Im so
Randy, first of all, Im so sorry to hear what happened but at the same time I appreciate you sharing your experience and all the information that has come out from this thread, since I was the one to trigger all the FNA post before.
I´m afraid I cannot help you. But I wanted to comment anyways.
Thank you again for sharing this.
Randy nothing good in th
Randy nothing good in th ebody does this:
“clusters of mildly atypical cohesive appearing cells”
Your sample was solid… the term “atypia” seams to be in vogue in the cytology world as a “sort of call maybe can’t tell what it is” unfortunately. I would get a reread honestly or pair with post mortem histopath.
Randy nothing good in th
Randy nothing good in th ebody does this:
“clusters of mildly atypical cohesive appearing cells”
Your sample was solid… the term “atypia” seams to be in vogue in the cytology world as a “sort of call maybe can’t tell what it is” unfortunately. I would get a reread honestly or pair with post mortem histopath.
Randy I ran your results by
Randy I ran your results by my sonoPath cytologist pairing the sonogram findings wiht your cyto description and here is is reponse:
Eric:
The first differential I have is carcinoma cells—metastatic. The second is histiocytic cells such as a fibrohistiocytic nodule or histiocytic sarcoma. Does this help? Third is a sarcoma of a spindle cell nature.
EMH is observed in approximately 90% of dog spleens whether ill or not.
We at sonopath have the advantage of conveying the sonogram findings/report/fdiffs with my own trusted cytologist that I have been working with going on 18 years now in some capacity but in sonopath entity for about a year now.
Combining sonogram diffs with a cytologist that doesn’t fence dwell is a huge advantage in dx efficiency as long as we get solid samples, which your swas here. This is exactly why we defined and restructured the SonoPath telecytology program, Im not posting this to push my program but simply letting you know why we created it; to eschew fence dwelling and get a rapid read while keeping theslides in hand and in house and be able to have this type of combined findings discussion.
great post lots covered here:)
Randy I ran your results by
Randy I ran your results by my sonoPath cytologist pairing the sonogram findings wiht your cyto description and here is is reponse:
Eric:
The first differential I have is carcinoma cells—metastatic. The second is histiocytic cells such as a fibrohistiocytic nodule or histiocytic sarcoma. Does this help? Third is a sarcoma of a spindle cell nature.
EMH is observed in approximately 90% of dog spleens whether ill or not.
We at sonopath have the advantage of conveying the sonogram findings/report/fdiffs with my own trusted cytologist that I have been working with going on 18 years now in some capacity but in sonopath entity for about a year now.
Combining sonogram diffs with a cytologist that doesn’t fence dwell is a huge advantage in dx efficiency as long as we get solid samples, which your swas here. This is exactly why we defined and restructured the SonoPath telecytology program, Im not posting this to push my program but simply letting you know why we created it; to eschew fence dwelling and get a rapid read while keeping theslides in hand and in house and be able to have this type of combined findings discussion.
great post lots covered here:)
Thank you EL. As you know I
Thank you EL. As you know I have used your service. Your reports give me comfort that I have not missed something obvious. I also like it because I csn go back and review your findings. I suspect Rosebud had pancreatic adrnocarcinoma. I did post images on the forum previously.
Thanks for all your help
Thank you EL. As you know I
Thank you EL. As you know I have used your service. Your reports give me comfort that I have not missed something obvious. I also like it because I csn go back and review your findings. I suspect Rosebud had pancreatic adrnocarcinoma. I did post images on the forum previously.
Thanks for all your help
makes sense… pancreatic
makes sense… pancreatic carcinoma cells are “sticky” on cyto. Thats the scenario I would stay with. … ps I was going to say “stick with” but didnt want to pun:)
the service I was referring to is the telecytology service not the telemed even though they would in synchrony.
great post!
makes sense… pancreatic
makes sense… pancreatic carcinoma cells are “sticky” on cyto. Thats the scenario I would stay with. … ps I was going to say “stick with” but didnt want to pun:)
the service I was referring to is the telecytology service not the telemed even though they would in synchrony.
great post!
Thanks Eric for the book
Thanks Eric for the book preview. Randy, you are very brave to post this, and you are certainly not alone. I think if you do any kind of invasive procedure enough times, at some point, there is going to be a complication. I know of at least 2 vets who accidentally caused fatal hemorrhage in their own cats when performing fna’s on lymph nodes. One of the cats had lymphoma. I am very cautious about peforming fna’s on normal size intra-abdominal lymph nodes as they are very mobile and sit close to major vessels. For core biopsies or fna’s on high risk patients, I always recommend that the clinic monitor the pet in hospital for 4 hours.
Thanks Eric for the book
Thanks Eric for the book preview. Randy, you are very brave to post this, and you are certainly not alone. I think if you do any kind of invasive procedure enough times, at some point, there is going to be a complication. I know of at least 2 vets who accidentally caused fatal hemorrhage in their own cats when performing fna’s on lymph nodes. One of the cats had lymphoma. I am very cautious about peforming fna’s on normal size intra-abdominal lymph nodes as they are very mobile and sit close to major vessels. For core biopsies or fna’s on high risk patients, I always recommend that the clinic monitor the pet in hospital for 4 hours.
Good point Electrocute, the
Good point Electrocute, the mid abdominal LN or mesenteric LN sitting at the ileocecal junction sandwich th emesenteric artery so its important to angle away from the vessel and pin the ln against the body wall and let the vasculature sit to the side of it. You only stick that mesenteric artery once … once…:( Luckily I’ve never had a life threatening event there but I certainly ahave done some clinical sonography twister around those vessels often.
Good point Electrocute, the
Good point Electrocute, the mid abdominal LN or mesenteric LN sitting at the ileocecal junction sandwich th emesenteric artery so its important to angle away from the vessel and pin the ln against the body wall and let the vasculature sit to the side of it. You only stick that mesenteric artery once … once…:( Luckily I’ve never had a life threatening event there but I certainly ahave done some clinical sonography twister around those vessels often.