Oct. 21, 2021

#54: Telling the good from the bad and the ugly: In-house cytology tips. With Dr Brett Stone

#54: Telling the good from the bad and the ugly: In-house cytology tips. With Dr Brett Stone
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Season 1

In this episode, we speak to Specialist Veterinary Clinical Pathologist Dr Brett Stone. Brett has extensive experience in both clinical pathology and histopathology. He has worked as a pathologist in Australia and the UK for over 15 years and has a special interest in cytology and immunocytochemistry. 

In our previous path episode with Dr Rebekkah Liffman, we talked about how to GET the perfect cytology sample. This time we’re going to look at it. And no - you shouldn’t just chuck it in one of those little blue boxes and send it on its merry way - you should have a look at it yourself. Tune in and you’ll hear why, and HOW. 

Brett starts with some great tips on how to get the most out of your microscope, and then gets onto the higher grade stuff, like what to look for, how to differentiate nasty from not so nasty, and how to plan your next steps, including deciding what samples you actually want to end up sending to the lab. 

Thank you to the SVS Pathology Network (https://www.vetqml.com.au/) for loaning Brett to us and for supporting this series of pathology episodes. Check out their other educational resources at the Clinical Excellence Support programme, which is a collection of pathology related continuing education talks, webinars and web content. (http://www.vetqml.com.au/NewsEvents/NewsEvents/EducationalVideos.aspx)

 

Go to https://thevetvault.com/podcasts/ for show notes and to check out our guests’ favourite books, podcasts and everything else we talk about in the show.

If you want to lift your clinical game, go to https://vvn.supercast.tech for a free 2-week trial of our short and sharp high-value clinical podcasts.

We love to hear from you. If you have a question for us or you’d like to give us some feedback please leave us a voice message by going to our episode page on the anchor app (https://anchor.fm) and hitting the record button, via email at thevetvaultpodcast@gmail.com, or just catch up with us on Instagram. (https://www.instagram.com/thevetvault/)

And if you like what you heard then please share the love by clicking on the share button wherever you’re listening and sending a link to someone who you know will enjoy listening.

 

Where do I don't say anything with well.Yeah, recording in progress.Thank you.Can I conservative you want?Let's see.Brett, just wisdom.Hi, I'm Hubert.This is Dorado.And you are listening to the vet bump clinical podcast.
In this episode, we speak to specialist, Veterinary, clinical, pathologist dr.Brett Stone rate, has extensive experience in both Clinical.Pathology and histopathology is worked as a pathologist in Australia and the UK for over 15 years and has a special interest in Psychology and immunohistochemistry in a previous Beth episode was dr.
Rebecca Lippmann we talked about how to get the perfect cytology sample.Now we're going to look at it and know you shouldn't just Chuck it into one of those little blue boxes and send it on its way.Way.You should have a look at it yourself, June, in and here, why?And how bread starts with some pretty basic stuff that your pathology.
Lectura probably tried very hard to teach you, but you weren't listening because you're too busy planning a weekend and now you don't really know how to use your microscope.Well, you can use it.But chances are that you're not getting the best out of it.Don't worry.Brett will fix that with some great advice.
Then we go on to some high-grade stuff like what to look for how to differentiate nasty from, not so nasty.How to plan your next steps?Including deciding what samples you actually want to end up sending to the lab.Now, you know, as well as I do that, some of this stuff is not easy for this episode, we've tried to keep it at a level that's practical.
We want to help you make better decisions not become a pathologist but even during our chat with bread he started going into detail of spindle Cells versus round cells and undifferentiated cells and list of DVDs and stuff that was read kinda over my head and even if you do know the theory it still takes a lot of This to get good at this stuff, which is why you often end up, sending it away.
Hopefully, after this episode, you'll send the right stuff away and ask for the right test, but eventually you'll need a bread or a flaminia or a Rebecca to help which is why it's good to know that when you send your samples off to one of the labs in the sba's pathology Network our sponsor for the series.
So that's fed bath in Western Australia in the NT.Q ml over here in Queensland bit gnostics and New South Wales in the ACT ASAP laboratory in Victoria and South Australia and tml in Tasmania.It will always be a specialist Veterinary pathologist, who looks at your samples and gives you your answers even blood smears from your CBC samples are reviewed by a pathologist for coming.
If the hematology scientist Flags anything unusual, that means that it's someone who spent many years of extra study and a residency and looking at slide after slide after slide to get that good beyond that.The sba's network also invest heavily in ongoing training and development of the pathologist regular attendance at local and International.
Frances remember those where you'll usually also see a few of them presenting and if not at conferences then webinars and talks and even podcasts but it's not just a pathologist who are constantly getting better.The sba's network has recently partnered with Phillips to give them access to equipment that digitalize has the slide and allows them to be sent anywhere between the labs at the speed of well, as far as the NBN will allow.
But why is this important like most businesses?Probably your practice but ology labs.Image under the pump.Since you know what hit the scene last year, which makes it harder and harder to get results delivered at the same speed and standard that you've come to expect from your local lab.This technology means that if your career drops, your sample of add, for example, ASAP lab in Melbourne, but they completely overrun that they can just digitally with the slide over here to break that qml and he can get the job done, get your results back to you ASAP, get it ASAP.
ASAP blurbs never mind and they still have Time to chat you, when you call them to discuss the results, which I hope you're doing and maybe fill you in on some of those finer details around microscope technique that you missed in that lecture.Let's get back to bread and how to turn your microscope into a highly effective weapon.
Redstone, thank you for joining us on the red, felt welcomed, pleasure.Thanks for having me alone.So, previously, we talked to Rebecca about making us a good technique for making sure we get good smears.Now we're at the next step so I've stabbed my version 4 to 5 times in each mess, and I've squeezed and I've sticky taped or repression.
Smeared the crap out of it, but I don't just want to send it off to you because I don't want you to have all the fun.I want to look at it in House, at least make sure I get a good smear.I suppose let's start with the very basics.How am I going to make sure that I have a good lip, the optimal viewing experience or asking it another way?
What am I going to do?That's going to make it frustrating for myself.That's kind of mess up my beautiful slides that I've just made.Yeah, certainly I'm so I'll go back to the next topic as well.We're essentially the games often won or lost at your end before it even gets looked at.So, you know, rubbish in rubbish out, no matter how good the pathologist or clinician is a poor sample is going To give a sub, optimal result.
The next thing, when you actually looking at the slides, it's important to.I reckon it's invaluable to definitely, at least staying one in clinic even if you're going to send it to a pathologist to make sure there's cells on there.Cytology obviously looking at cells if there's no cells, you're on a hiding to nothing before you even start the process.
So I think right from the start with the oil away would be the first thing I'll lead with with regards to when you look at your slides and Just stay in them and then basically learn where to look.So, basically with cytology what we're looking for, is a mono layer or a single layer of intact cells.
Few make a nice preparation, some areas are going to be too thick, some areas going to be too sparse.But in general will be areas where cells are still intact because you haven't had a sort of Hercule and crush or smear of the slide and you can hear them screaming as you kill them and smear them across the slide.
But essentially then On your slide.You looking for areas where there's single layers of cells given enough space to look like they want to look like and then that's where you go in to have a look Hoon around at sort of a lower Power by 4 by 10 times objectives to find those areas and the once you've found those areas then go up to your by 20 by 40, magnification objectives and then interrogate the cells visually to, you know, see what you're dealing with.
So that's a first basis of where to look And how to have a look around.Then why are you looking around at low power?You also get a general feel for is everything on looking at in these areas, or, is there something over there that looks different to something over there on the slide.
So, remember cytology is one of those things where that the anatomic pathologist or this do paths have it easy because it's all still there in.Situ what we're doing is, we're reefing, bits of a mass or whatever word aiming at with our needle and syringe and then putting it on a slide and then visually to put Humpty back together again.
See where work a will have got a bit of that and a bit of that and a bit of that.How does that relate to what?It looked like back when it was still in the animal next to its friends and in its native environment?I never thought it would like that.You just basically disassembling.It's an unpacking it and you've got to try and build up a picture of what what was in there.
Exactly.And that's where I'd like you.I think you said four to five times.Not 45 times.Thank you.Could probably excise it.Nearly obvious for four to five days.Yeah.The important part of that is Imagine and that's that's the important part.Two is, get it.Get a representative sample.
You want to go in from a couple of different angles because you can imagine sounds aspirating a Christmas pudding.Okay.And I went in from one side and got a bit of this is a my story actually got it from someone but you're going from one side you get a bit of cake.Okay?So if I just looked at that slide, my answer would be cake if I went in from a different angle.
I might hit a bit of the fruit.Okay.So if I just look at those slides or that area Mike Soto inches going to be fruit.How is it for?Got a bit of cake and a bit of fruit on my slides.Well then my answer is going to be Christmas pudding.So the more representative a look at what you're aiming at, you have on your slides then the better you'll get Humpty back together again and get the right answer.
So logically I like that where you going to go next week because I still want to go back to the whole smearing thing.I still struggle with, look no matter what people say, I put again the sample and slide right?And then they just they just suck themselves together and Destroy themselves.
If I think the Impressions me, I think is a misnomer to a degree way.You can feel the surface tension and it sort of pulls that top slide down, I reckon then don't put any pressure, then just use the weight of the slide and that sort of suction and then just pull them apart.
And it's important because we get enough slides that, you know, they just spray the material under the slide and they don't actually smear it.And so what you end up is, you know, looks like someone sneezed or just snotted on to the slide and they can they can get heaps cells.But what I'm saying is we're looking for a mono layer.
Our cells.The cells are all just piled up on top of each other and it can be really hard to individually discern what they are.The other thing is when it's thick like that it dries slower so you get a lot of creation and so your creation artifacts are like distorted that they don't look like what they should be look like if it was a nice, you know.
And other thing is just be gentle with your smearing, put your material down one end of the slide with a top slide on top gently smear and I tend to pull them parallel as opposed to leave them perpendicular.Because then you are two runways to work with as opposed to one being side on and you only smear it sideways on one slide so you like Landing an aircraft at the airport, put it down one end and give them the whole Runway to work with to actually smear it out and then air dry quickly, again, to limit that coronation slow drying out of that now.
Okay, so you in the end so you put it down as a cross and then you flick it around, so they actually in parallel with each other and, yeah, perfect brush perpendicular degrees and then, yeah.Okay.And then essentially two full slides of material on them.Say yeah.And there's other techniques, you know, they say Starburst were basically just sort of split on the slide and then use your needle to push it out in different angles by basically saying will be sick in the middle but then what the time you push it out and mice textbooks had the different sort of ways of making that sort of slide.
But I still think the best way is just wither two slides pulling apart with the blood film type method.That's a good method for a few doing fluids.Like if you had say a fluid and you You met a concentrated prep took off the supernatant, re-suspended that palette in a bit of fluid.
And then you basically make a slide with a blood smear technique and I'll just go right to the end where you can actually stop 3/4 of the way along.And then just take the top slide off.What you do is you end up dumping the slides in a line where you sort of pulled up one with that top slide.So you can concentrate thus root cells in that area to then go and have a look at.
So, okay?You had some aggressive that.Now, you said, avoid that oil.Question and this don't, you know, you're not happy about this.I see, not at all.I've just learned a few techniques earlier this year. 20 years in an hour.Oh, really his microscope technique that, that might be worth for other people to talk about as well.
I did a stint working at Australia Zoo at the wildlife hospital.That's a lot of Scientology.We look at a lot of poo and a lot of stuff, but I actually learned some new microscope techniques, first of the, the blue lens.So what's the magnification?And that's the 40 times 40 times.Just to be clear.
And it's obviously very basic for a lot of people, but that has to be looked at with a coverslip.Yes, exactly, right.So, what a lot of people will reason they probably go to oil, is the old rack up 10, 20 get to therefore t.i. looks all blurry.Oh, I'll have to go to oil.Yeah, reason for probably two reasons, it's blurry.
First, and likely reason is they got oil in it from going to oil all the time.The second reason is that objective wants an interface between the objective and the sample.So, basically, He wants the refractive index in the coverslip to then give you a clear image with regards to being able to use your 40 times.
So I think if you're doing that, then you're going to get more clarity at.You're 40 and don't go to 100, go to 100 to look for, you know, Toxoplasma, takizawa lights and bacteria.If you can't see them on by 40 and things like that.So don't go to 100 routinely to look at cellularity with regards to.
Is it near plastic?Is it malignant benign, Etc?So That was me forever.As go as you say, Do not skip forward is j-200 under oil, which is actually a new.I've got to get my head around that because I'm so used to looking under 100.And that is because I'll just skip that because I exactly, like you said, it was always for frustrating.
One question with the 40, you put anything on the slide before you put the covers turbine or was it?Just an outright, so the techniques called high dry.So basically you want to dried.Sorry.So basically, you want to dry your sample after you make your prep stain.It dry it.Then and then you just sit a coverslip dry on top of that dry slot.
Right?And go For Broke and because then you can take it off, then you can go to oil.And then if you want to get back to 40 cover slip back on when you go back to 40.So again, you got to cover slip between the oil and you 40 times objective lens.You're not going to get oil or peanut.So if you do have oily new 40 times lens, you need to clean that with alcohol solution.
So the stuff you might use to clean glasses with and things like that.So, alcohol, wipes or alcohol spray with a lens cleaning cloth, something like that to get any oil that is, in there out of that objective.I just hide the oil and then see how you go for a while, and then you'll find a nice Shiva such product.We had a while.
Here, certainly one of the Vets at the zoo, she had a technique.She called the sparkle technique where with that with the blue lens, she'd put the drop us a line on the slide and a theory was that it made it really bright.And really and it did was like, no, that's not how you do it.
I actually argued with that.She said, look at these slides and it was very pretty like it was a much, it was like a radiant slide, you had much better look better.If you ever come across that, that now I haven't done that so I left Detroit.Yeah.And thank you have to try some people.You do that or they can even put a drop of oil underneath the cover slip.
That's more to keep the cover slip on their Summit sliding off and things like that as opposed to necessarily I can't say it doesn't have any sort of benefit if I haven't tried it but it's not something I would routinely do know, okay cool.Probably if we stop this episode right there already, 80% of the audits have learned something new about the blue Lanes.
I know from many practices that nobody uses it and I think exactly for that reason.That's excellent.So next, are we looking at our slide?You said look for the mono layer.And I were looking at sales.Are we talking about?What are we actually looking for bread?Yes, that's a good idea.
So, essentially, we have the first question, will one do I have an adequate samples?So, let's get we do, if we don't The Animals still in the room or in the clinic, go back and get some more, okay, so that's where even if it's going to go to a lab stain, a slide to make sure we will have.
I don't know what the hell I'm looking at, but that sells on there.So, someone who does will be able to give me an answer as opposed to all the cells are ruptured or there's no cells.Okay, I'll go.Some more if you are sending to the lab also, send unstained slides, if you can try not to stain them all because we use different stains to what you would be using routinely and Clinic if quick and they stain things in a different way.
So Marcel granules, for instance, stain better by our right stain or right Gibbs at type stains it.We're using the lab nucleoli, chromatin nuclear details, things better with those sorts of stain.So, we want to use those stains when they come to us and it It's difficult.If they've all been stained often, pick the best-looking slide.
Not someone that I stay.Yeah.And all the islands are Rubble.There are three weeks than you guys.Yeah, I'll go to relook at your in the slide.Bad stains with horatiu, the div quick grit all over it.Yeah, after you and measly Cohen oil.Yeah, so already over it before I even turned a microscope on.
So, okay, so this is pretty much the thought process where I'm looking at a slide every single side.Okay.Yeah we got cells first.Shin, is it inflammatory?Or is it non-inflammatory?Okay, so that's my first decision process.Is it inflammatory or is it non-inflammatory?
Now essentially, if I'm going to call it inflammatory and I don't want to see any other neoplastic sort of criteria or malignant criteria there as well.So you know, squamous cell carcinoma, on the nose of a white cat.Yeah.Okay.That's probably going to be neutrophils because it's all serrated, potentially infected, but I'm still going to see naughty malignant looking cells, as well.
Okay, inflammation there.And nothing else that concerns me essentially.So then okay, well I'm dealing with an inflammatory process, so qualify that so inflammatory process.So obviously no cells that you go with the rock is that?Yeah, but what are we looking at for, what are your qualifiers for inflammatory?
And so inflammatory will inflammatory cells in numbers that are higher than they say, any blood contamination?Its present would suggest, it's just you do the him a dilution of the slide, you know, a few neutrophils and blood contamination right now.I'm going to ignore them and then.Okay.Well no.Too many neutrophils here from seeing plasma cells and macrophages, and things like that.
Well, that's, you know, if there's blood contamination there, they're not in Blood and routine contaminant.Then textbooks would then say, okay it's inflammatory, okay, is it septic or non septic.So based, you know is infectious or non-infectious?I reckon that's a half-ton job and I'd go a different way for say.Okay, it's inflammatory what sort of inflammation is it because then that really changes my differentials.
So if it's neutrophilic inflammation, then I'm going to spend time, I'd even get that oil.From wherever I hid it from and, you know, look for bacteria, if I still think if there's bacteria there, quite often, you'll see it on by 40 anyway.And again, cytology doesn't always give us a definitive answer.
Sometimes the cytology answer is or what do I do next?You know, do I culture this Dua?Excise it do histopath, do I leave it?Because it looks benign and they it's not bothering the dog.So neutrophilic inflammation if took of still at the animal there, I'm probably going to look at culturing that if it's something that I'm worried about is an infectious process going on granulomatous.
So Lots of macrophages finally looking macrophages evacuated cytoplasm or piyo granulomatous mixture of neutrophils and macrophages, they sort of have similar ideologies.So foreign body, type reaction for run closest, you know, ruptured, follicles follicular cyst, it's ruptured, an inflamed, the Keratin as a foreign body type response.
It's also something where I'm going to be thinking about, you know, yes bacteria.But then maybe something else other than bacteria mycobacterial infection fungi.You know, Toxoplasma if you're dealing with it you know, ba l or a lung aspirin or something like that, so it's not just a routine.
If you like bacterial infection eosinophils, like allergic, hypersensitivity type reactions parasite, maybe fungal maybe if I see you soon at Phil's.I'm going to spend time looking for mast cells.Okay, we see Marcel tumors it can be greater than 80 90 percent eosinophils with the mast cells there as well.
They talk to each other by And things like that.So, quite often a mast cell tumor.Some eat muscle tumors are predominantly used in a fills as far as the cell population that's there.So if you see eosinophils I'm always going to make sure you know are there any Marcel's there?
So if it's granulomatous Pia granulomatous I might not just do a bacterial culture.I might also do a fungal culture and an acid fast or a micro bacterial culture as well.Okay?So might dictate what I do next based on the type of inflammation that we've got that.
It's really useful.Well yeah, I was just like is it back to, no bacteria, your symptom onset to go?I don't like it.We can do better.Yeah, I'm pretty sure I learned that from you bread when I was at Uni.So I'll take that as a win.Girona, I do know anyone.
Learn anything for me.Well, we went to regards Reformation inflammatory took different types of cells.I also love you factory.We threw in the defeat, what's next?Yeah.Well sometimes you get these like Big inflammatory cells.We just like, is that neoplastic or not neoplastic, you know, the huge that kind of big nucleus in them and stuff as well.
How would you differentiate?How would you then go to non-inflammatory from?Yeah.Well, what you'll probably talk about is, you know, multinucleated giant cells, okay?So, you might see that particularly, like, foreign body reactions ruptured follicles, and things like that in some instances, you just can't be sure but as soon as there's something, there goes, hang on a minute.
That worries me.Well then it's, you know, lab solid just time or potentially Time to say, but I'm going to guess do, but I'm also going to take a fresh tissue biopsy beat-down from this lesion for fungal culture, for micro bacterial, culture for bacterial culture.So I'm not just doing my histo and then, the histo comes back in a couple of days or however long.
It takes to then say, I know it's inflammatory in your heart.Now, I want a culture, okay, dog, back, whatever you have to go through.So it might you've done this?I do already go.Okay, well, it's inflammatory, but I'm worried about those cells, and take some for histo and some for culture either.There's no inflammation.Well, there's inflammation.
And something else that's concerning me.Well, then we're sort of down the non-inflammatory path.Okay, so, yeah, there's inflammation there at.There's no information now.I want to know what else is going on.So for all intensive purposes we're going to have, then, you know, neoplastic or a non near plastic type process can be a little bit academic, really because a non neoplastic is just, you know, say something like we might you get your diagnosis of a, you know, fibrous hamartoma or a fibroadenoma X or hamartoma which essentially the mass but it's Not a neoplasm.
This is basically a disorganized proliferation of normal constituents of the dermis Kelson Isis.Circum scripter for instance was a mass.It's not a neoplasm.Okay, so we can that they exist, but essentially once we're in that category, the next important question is well is it malignant or is it benign?
Because then that dictates what do I do next?Do I leave it?Do I take it off?If I take it off, how much of the animal will I have to get take with it?That's a really Penny dropping moment to write a pointed it out again, but that I think it's about expectations because I can't you do even a Nico.
I want my diagnosis from this but I like seeing it.As a know, this is going to help me plan that that section.Exactly what you said that about of all.It's this kind of information.I kind of know the things I'm looking for and these are the tests I'm not just going to send that off to you.I'm going to say okay.So it could for example, me and I'm not even going to send you that slide.
I'm going to go.Yeah, there's weird stuff there.I'm just going to get my biopsy now and send you the biopsy and culture at the same time.Yeah, and that's between you and the owner and money and all those words question gets right into it.But ideally this, what I think it is, do you get it confirmed or not?Well, that's just comes back to how comfortable you are in your decision and what you had seen and where you want to go next.
And the other thing too, is it might not necessarily what I do next.I mean, if we see an inflammatory, lesion Pia, granulomatous, and then I see crypto will have an etiological, diagnosis.I don't have to do anything else or granuloma, Roberta cryptococcal.Ryan, I just got a cryptococcal pie, granulomatous lymphadenitis, whatever wherever I went for my sample.
Okay, I'm gonna get a baseline elk at Tighter and I'm going to treat my cat for crypto, you know.So it's not just a way, just to say, okay well, what do I do next?Sometimes you can get your eat a lot.Yeah.Well, tickle diagnosis, cytologically and you're done so you're talking about okay.
Should I go sample?That could be infectious ripe this neutrophilic or it's probably gonna let us write the linear seeable for culture.Do you just get an F an A and you spray it and yellow container?Or do you get in that van in you sprayed on a culture?Bob stick and stick it in the gel.
Like how do you get enough sample?From an F in a?Yeah, you could do both.So comes down to how much sample you get.So if you can aspirate the material out, put it on the individual swab.And then into the transport medium, you can get enough sample that you can put in say a sterile urine container that you know, normally send a urine culture for then you can put that material in air and send it off to the lab for things like these.
A typical infections, it's always the more material that we get and the more likely we have Culturing, what's there?Some of these are can either be, you know, fastidious or slow growing and we need one as much material as we can get.As opposed to just putting a bit on the end of a swab and hoping that that grows.
So even a deep fresh tissue biopsy a chunk of the tissue of, you know those cat with those weeping fatty ventral abdominal, tight leash, get it nice big chunk of that tissue, if you can and send that.But again, if you can aspirate a lot of that material out and send that off, or then we lab can send that.
All right, I just assumed when you said, Culture that you need to get a sample.I didn't realize that you so you can't so it is worth it.Sometimes if you just have a few aspirants to try and culture that I didn't even come solutely.Yeah, it depends.How much you can get out.If you get enough material out, then yes, it, that in, for culture.Yeah.Because of often get centered, but I've never been to shovel that actually, you guys could use it.
It's like, hey, this is the best that I can get, from this deep ass, you know, lesion in the middle of this cat's abdomen and it looks a bit gross, but don't exactly want to do an ex-lap on it.And I'm like, I just ended up on a swab.Stick and and stops grows, but I get surprised by it and we're supposed to show up that was thing, you know, and again, particularly you could see stuff there.
Well, then, yeah, absolutely.Sent that become.Then that's going to dictate what antimicrobial therapy.You know.You can dictate on culture results as opposed to her.Well, let's just start with this and see how it goes.I can see bacteria.Well, you can see bacteria, most times you can grow bacteria.A practical question that I've never understood.
I know you're not a microbiologist, but look culture samples that have to go in the fridge that just to me is counter-intuitive you want it to grow.So why don't you want to leave it out in there?Nice tropical heat so that it can ringing grow before he still have.Why does it have to go in the fridge?
We only want to grow this stuff that's supposed to grow.You don't want to grow the kitchen sink and everything else that might be there as well.If it's got its they're old.Yeah you do.Most times it is.So there's medium in there that basically helps Support the bacterial longevity and and livability.
So therefore basically that's the right specimen and also when they're set up for culture, he gets can't moderate heavy growth and things like that.So essentially we can work out significance as well to say.Well, okay, from that sample, how heavy is a grown excetera, you can't do that for things like say a blood culture bottle, okay?
That you might take, you know, more about a septic arthritis.And so the preference here would be to send a bit of joint fluid in a blood culture bottle.Supposed to want to swab or something like that because often we're dealing with low numbers of organisms.So we got to give them a bit of help.So we need enrichment media to then try and get these low numbers of bacteria.
That potentially might be present in a septic joint to grow in those instances.And those blood culture bottles, don't go in the fridge because we do want the any bacteria there to have a party.Exactly?Right.And and make friends exactly but like urine samples, Stephanie swab sticks and things like that.
That preacher preach.Yep, that's been a point of contention now.Good Clarity around.I know I know that's what they say but I was like that doesn't makes no sense what happens if it's like a time frame time frame that you guys use.
Most practices only have that difficult and again at the zoo because we looked at a lot of stuff ourselves.We had other stains as well, is it worth it for normal practice to have other stains on the shelf?Or are we going to do with the bulk of our work fine?With the diff quick thing?I see both bulk of the work is going to be fine with difficulty, staying, again, easy honest, answer.
I know some places used to have told you it in blue stain in a syringe and pull your leg.Wound is the super vital stain stain to Marcel granules really well and things like like that.So I guess it's one way.People are worried about a mast cell tumor, for instance, the problem with the super Vital Signs is is no longevity.
Basically, once it dries out, it's gone.And I'd always say you should be keeping your side hos slides.If you look at them you should have a little repository of your slides but you should keep for a period of time to then go back.You know, if hey, I diagnosed this three weeks ago or a month ago or whatever and it isn't working out, well you still got the slides, you can send them to the lab and To date.
You can't, if they're in the bin I have a whole heap in my locker in a disorganized fashion with oil, coming all over him unlabeled with no name.And so now you would know that idea where they're going or who they came from.Just don't live the lie on the bed because that's a sure way of really pressing everything is.
Yeah, they're in the bin.Yeah, that's right.So we talked about differentiating, those big Angry cells from new plastic cells.What is your, what is it?R is criteria for neoplasia had to get decide this This one's bad.That's right.Poor in the neoplastic category, so let's think.
Okay, so benign or malignant disease is my next question.Okay.So, but nine basically, Easy one is the cells look like each other.Okay, so that's good there homogeneous or monomorphic.So they lack a lot of variability and what they look like.
Quite often, there are smallish type cell.You know, when we describe things, we have to use a size marker.So most people 10, he's a red blood cell.So you would read your reports, you know?One to one point, to RBC nuclear diameter.Okay?So why description of already said one that sells not very big and to, they don't Me too much because it one to one point, two red cells nuclear diameter.
They tend to have an even staining chromatin.So the chromatin across the nucleus is evenly staying as opposed to darker in some areas.So, clumpy or stippled things like that, we tend to not see nucleoli, or if we do, we don't see many in this small, okay?And they also tend to look like the cell they came from.
So good example, that be a sebaceous.Adenoma, not only do the cells.Will look like each other.They look like a Well, differentiated sebacean cells.Small, nucleus lot of cytoplasm with lipid.Clear vacuoles in its Silo nuclear cytoplasmic ratio.
Small, nuclei, no prominent nucleoli Etc.But nine apocrine gland tumor, you know, small cuboidal to short columnar cells, all looking like each other, things like that.So the converse is then the malignant criteria is so big cells macrocytosis And variability with how they appear some around some more angular, that not just sort of carbon copies of each other.
Hi, a nuclear decided plasmic ratio prominent may be multiple, nucleoli, the chromatids clumped as opposed to nice and even hyper Chrome, Asia of the cytoplasm.So blueness to the cytoplasm is a particular criteria of malignancy particular, epithelial cells, frequent mitosis, you know, more rapidly dividing.
So tends to be malignant feature, things like nuclear molding and is a cytosis variation in cell size and is 0, carry osis, variation in new clip size, word of the day is an is 0 nucleosis, okay.Variation in the size of the nucleoli, some are bigger than some are smaller.
So not only are they, there are they multiple but their varying in size.Okay.So what's a big words that I should be able to spell but at the same time one on their own doesn't mean malignant, okay?So the way I was sort of taught when I Was going to UNI and also and I went back and did my training was it's like opening a bank account phone, open a bank account.
I need 100 points of ID.So I need my birth certificate.I need my Medicare card and whatever else you need student ID, whatever.So your criteria of malignancy, I want three or more of those things that I've rattled off to then say, is this malignant?
Okay, yeah they're big.Yeah, they vary a bit and is a cytosine is a carry Isis prominent?Multiple nucleoli?And I'm seeing my tosi's Etc.So The more of those criteria of malignancy, I have.And, or the more obvious those criteria are were, then I can go from all suspect possible, probable?
Yep.This is malignant.Okay.So there's, you know, some subtleties are my go, all these worried me a little bit.Could it be a sarcoma?Could it be a carcinoma a year?But there's only a couple of those criteria versus.It's got eight of them and it's got an 8 in Spades, it's malignant.
Now, you talked about the difference between benign and He didn't, can you grate it on cytology?Now, there's some new plastic process as Marcel's where you can grade them on cytology hurts.Yeah.So, with caution and in trepidation will be my answer.So there's definitely papers basically, cytologic grading of canine, mast cell tumors based on things used for the cubicle to tear histo taneous.
My search immigrating, and so they found this definitely aspects to the tumors that could indicate a higher versus lower grade cytologically.There's Other papers been coming out more recently where they've done similar things for, you know, soft tissue, sarcomas are their criteria that we can see cytology psychologically that histologically might then give us an indication of higher or lower grade.
So I'd say, can we grade them?No.Okay.Can we use features to suggest, would it be a higher or a lower grade?Yes, based on Publications that have come out recently, some a bit longer 20. 16 doesn't seem like that long ago, but that's when the mast cell tumor for the cytology.
Great paper came out.Let's make it practical for decision-making.So I do my even a and I see lots of angry, mast cells.That's one of the easier ones that we can do in our house.Is there any point be sending that slide to you or do I just go either?That's must tell let's cut it out and send the historic to break.
Short answer is you probably won't gain anything further, cytologically.If you've already decided yes, it's a mast cell tumor.Yes, it needs to come off, spend the money and effort in surgery taking the mast cell tumor off with appropriate margins.Stabbed the regional lymph node for psychology if you want to send some cytology let's stage it as opposed to yes it's a mast cell tumor.
I want it checked the ones we probably would be getting a ones where I'm seeing some Mast cells.But not many, do you think it's a muscle tumor versus?Is it an inflammatory type reaction with mast cells present.So they're ones that might be worth getting checked but yeah, I think, realistically trying to talk myself out of any work, but if you have made a decision psychologically, that's a mast cell tumor, you're happy.
It's a mast cell tumor.Then, you know, there's a patient in owner with a wallet at the other end of it.So spend their money on what needs to happen next rather than You know, spend it on hematology if in a of its Regional lymph node going to the surgery and histopath.
Hmm, that, that comment is great.We had an episode of on mast cell tumors with an oncologist and that's something I didn't used to do, is to go and aspirate the lymph nodes, just focus on the mass, but it's such an obvious thing but it makes so much sense as well aspirate that to make sure that that's clean.
And if and when they get referred well then we get a spritz of spleen and liver you know, particularly if there's any subtle abnormalities of spleen and liver on an ultrasound.So That's the next level of staging as well that they potentially might be doing it.So am I done with my job in clinic?So I go yet but I've got an idea what it is.
I'm going to see in these all for not seeing all that we finished and house or is there anything more than all I guess you've decided benign or malignant?Well then we can.So can we do better?Can we go further?So for both the benign cells and all the malignant cells, can I put them into a basket?
Is it epithelial versus spindle versus round?So Sheamus said, they tend to be the categories.I think I'll leave all those decisions to you, Matt.It's very interesting but I would rather that's where I step out and go yet.It's in this to the professionals.Yeah, but again, if you get to benign or malignant, then I think that what do I do next?
So, that's where you're at.And again, if you've got good cellular samples, I think it's malignant.That's when probably should go to a pathologist.Do they agree with me before?I'm going to, you know, exercise, this dog, however, large mass?Or is this an amputation, or is this a, whatever else, depending on where it is.
His and things like that.Mmm.So I get to that point, right?And then I start googling images and stuff trying to Picture Match, its pitch matching helpful with, that's what you'd be doing.If you had a textbook rather than Google, you'd sort of looking Picture Match to see what is the other thing too, is remember, the friends they keep, Okay?
So we've already talked about eosinophils and mast cells, okay?So if I see round cells and I'm seeing eosinophils as well, then I'm thinking, you know, again, if it's not obvious, this could be an a granular Mass, so it My said either it's already be granulated or it's a, you know, malignant version.
That is not very well granulated.So if I'm seeing eosinophils Marcel's, are going to be on my radar for around search humor and Lymphoma, okay?Tends to have eosinophils some degree as well.If it's a history of side Toma quite often, I'll see small lymphocytes around because we just I just said that T cell cell, mediated immune systems, what comes in and wipes out the history of sight?
So depending on where it is, in the sort of Of timeline of the history of saitama.If it's a young histiocytosis there probably won't be many lymphocytes there yet, but if its way down the end stage version quite often, it'll just look like a lymphocytic inflammatory process with some histiocytes there because that's that's what's there.
Now it you better take it off before takes itself away.So again, yeah, the company they keep my give you some indication and then obviously histopath, there's more, mm, you know, stains and things like that available in sight.
G, we suddenly have Amino Saito chemistry available to us as well.So we more use that for.Yes, this is a lymphoma the next step is okay.Well, we can now do Amino stains on these.Cytology slides to say is that at T or a b-cell lymphoma, okay, which has prognostic indications and also what sort of chemotherapy you you're going to throw out the animal based on its immunophenotype are they good resources to have a next to your microscope in your in-house lab to help you with these things?
Like zero is there, a specific text book or website, or anything that would help box to put your oil in would be definitely.So probably, you know, one could cow and Tyler diagnostic cytology the dog and cat.And there's also Raskin and Meyer diagnostic cytology again, I think of the dog and cat.
So they're too good textbooks.I would have in clinic and that there's plenty of others out there as well, but I think it's certainly Is good pictures I think is great and one with flowcharts I think it's always a good one there.Do you send some really cool pictures?I'll put those in the show notes of people want to head to the website and check out the pictures, which one bike one is caldas like 260 bucks.
And looks like as if I read that I'm going to become a specialist pathologist the other ones like naughty bikes like the manual of Diagnostics.I don't like is that which is a bit more user-friendly.I suppose, I could look over here, I'd spend the money and get cow and Tyler, is he honest?
Answer the end.It's lots of pictures.Not too verbose, good flow, charts fits nicely packed up into organ systems and things like that as well.Yeah I think you can do is you go hard, don't know what I'm looking at that?A look at it, make notes, write down what you think it was then when you send it off to the lab.
See what they saw.No, okay.Well, that's what I was looking at or I didn't see that.Okay.Did I keep a slide in-house versus send everything off and, you know, and things like that?So your pathology report can help train you to what you're looking at psychologically as well.Old.
So you don't necessarily always just have to you know hey Google and the textbook your way out of an issue.I like that.I do that it's kind of fun.Like I'll always send them off.I'm always going to get a Pathologists opinion on it but I do like having my own diagnosis and then comparing the lesson in that for me as its.
I'm so often wrong that it's definitely still with me.Keep sending them off steam.Are we done anything we missing out on?Not really, not really.Any say, also, you know, looking down a microscope, all days and everyone.As idea of fun.So that's probably why you are where you are.
And I am where I am but you should have an open line of communication with your Pathologists and whatever lab you're using.You should be able to think, look, I got the report back.I wasn't sure what they meant by this comment or what they saw.I thought I saw something different.
Then you should be ringing them and just having a chat to say, you know, what should I do?Better next time.What should I do differently next time?So you can learn it.She go, you should have a good rapport with your Pathologists.We're The Jeep's will ya fixing or, you know, putting back together.
So we need to interdigitate with how we attack these things.What I see cytologically might not fit what you're seeing clinically or you know I might have a list of differentials that with a bit more clinical information.I can reshuffle my differentials in a different order based on what you do or don't have.
So don't send slide with a blank fight you know I'll probably get a couple of week where I'm lucky to know, if it's a dog or a cat.I definitely don't know what's been sampled.What?I'm seeing at my description part of that report, won't change.Yeah, my interpretation and my comments might change, based on all the information I have.
Okay, so you have that information, it's essential.Yeah, there are, you should stop doing them, a, you're annoying bread.Start filling out a freaking but I get lazy though.I don't label every single slide with the patient's name and all that kind of stuff but yeah it's labeled label the slides not the slide holders back to my Run through some of that sort of stuff.
At least the name putting animals name on there because slide holders get unpacked on a bench and their slides come out on a bench.And so if the names on the slide holder, not to slide or slide hold it pops, open and a slide comes out.And I literally go through, where the hell did that come from?
Or if you're going to sample, more than one site, put each site relevant on the slides because, you know, one's a lipoma, one's a carcinoma, but you haven't labeled your sights on the slide.So, back to the dog, you go to work out.Which one needs to be taken off?
Which one can be left alone?So there is it little things to help us help you, I guess, awesome?Right.Thank you so much for your time.There was really insightful.Like I said, we could have it of just talked about the blue lens and still teach a lot of people.A lot of things.You know, those conversations that you have at conferences, back in the days, when we still had big bed conferences, when people are chatting to the lectures and asking questions, and you hear things like this isn't really in the books.
But here's what I think, it's in those kinds of conversations at the best nuggets of wisdom appear, the nitty-gritty of real-life details that you can only get from here is and years of experience.And it's exactly those kinds of conversations that we try to emulate on the vet V clinical podcast, we don't want lecture We want to hear about the challenges, the tips, the stuff UPS there.
This is how I do it.Go to VV n dot super cast, dotnet to join in the conversation.

Dr Brett Stone