Page 277 - WSAVA2017
P. 277

Is visual monitoring acceptable?
Even the most experienced veterinarian or oncologist cannot look at or palpate a mass and know whether
it is malignant or not. Cancer is a cellular diagnosis! It
is always recommended to evaluate masses that are growing, changing in appearance, or irritating to the patient. But these guidelines are not enough. All skin and SQ masses that are >1 cm and have been present for 1 month should be aspirated for cytologic evaluation. Biopsy is indicated if cytology does not provide a diagnosis.
Methods of Diagnosis
Aspirate and Cytology
Fine needle aspiration (FNA) and cytology provide a diagnosis for many skin and SQ masses, especially those that that exfoliate well. FNA is useful to distinguish neoplasia from inflammation. Cellular morphology may also allow for the determination of benign or malignant phenotype. FNA is useful for identifying benign masses including lipomas and sebaceous adenomas. For malignant tumors, cytology provides information that assists in formulating diagnostic and treatment plans.
The advantages of cytology include: minimally invasive approach, low risk, low cost procedure, and results are available more quickly than biopsy results. The disadvantages of cytology are that it may be non- diagnostic or equivocal. This may be due to a small number of cells in the sample, poor exfoliation of the cells, or poor sample quality. If the sample is non- diagnostic or equivocal, histopathological confirmation may be required for definitive diagnosis.
Unless the sample is comprised exclusively of only fat, clear cystic fluid, or acellular debris, the sample should be submitted to a trained cytopathologist. WHEN IN DOUBT, SEND IT OUT. Including an adequate history helps the pathologist in diagnostic accuracy.
Biopsy
If cytology is non-diagnostic, a pre-treatment biopsy is recommended PRIOR to complete tumor removal. The pre-treatment biopsy will determine the optimal treatment plan.
The role of excisional biopsy is controversial, even among oncologic surgeons. A practical recommendation for non-diagnostic cytology and the lesion fits in an 8 mm punch biopsy, then PUNCH IT OUT. If the mass is larger than an 8 mm punch biopsy, an incisional biopsy (wedge, tru-cut, punch) is required for diagnostic confirmation.
It is tempting to remove the mass right away. An excisional biopsy establishes a diagnosis and removes the tumor at the same time. However it is not recommended for undiagnosed skin and superficial masses. Malignant tumors often require 2 to 3 cm
An Urban Experience
margins. When an excisional biopsy (or debulking surgery) leads to incomplete margins for malignant tumors, more treatment, more morbidity, and more expense ensue. Thus removing the mass entirely is not recommended without a cellular diagnosis prior to definitive excision. Surgical approaches vary with different tumor types. Research confirms that the first surgery is the best chance for a cure.
Staging diagnostics are often indicated prior to curative intent surgery. Consultation with a veterinary oncologist is recommended.
After the Aspirate/Biopsy
If the mass is benign:
Benign tumors may not need to be removed. A variety of factors, including mass location should be considered. Surgery should be recommended when a benign tumor is causing pain, irritation, bleeding, or infection. Surgery should also be recommended if an increase in growth would prevent a surgery in the future.
Alternatively, if removing the tumor requires a complicated surgery (i.e. near a joint, on the distal limb with minimal surrounding tissue for reconstruction)
or the pet has other pre-exiting issues, you and the pet owner may make an educated decision as to whether proceeding to surgical removal is warranted. PETS WITH MASSES NOT REMOVED SHOULD BE MONITORED (via measurement) BY THE VETERINARIAN EVERY 3 TO 6 MONTHS.
If surgery is performed, most benign masses require smaller surgeries, as wide margins are typically not needed.
If the mass is malignant:
If the aspirate/biopsy reveals malignancy, consult
with veterinary oncologist for appropriate staging recommendations. For malignant tumors, the first surgery should be a wide excisional surgery.
If wide excisional surgery is not possible due to the size or anatomic location of the mass, consultation with
a veterinary oncologist or board-certified surgeon is indicated. Surgeons may be able to perform specialized surgeries such as axial pattern flaps to remove the tumor completely.
Debulking (cytoreductive) surgery may not be recommended, as this will not obtain margins, and additional post-operative treatments such as radiation will be required to prevent recurrence. In some cases, cytoreductive surgery may be performed for palliation, or with an understanding that adjunctive therapy such as radiation therapy will follow the procedure.
277
                   





































































   275   276   277   278   279