Good evening, everybody, and welcome to another Thursday night members webinar. I hope all of you are staying well and, staying safe. And for those of you that are in self-isolation, welcome to the best channel for CPD.

So tonight's speaker is a very well accomplished speaker. Nikki has graduated in 1997 from the University of Liverpool. She spent several years working in mixed general practise before undertaking a residency in anatomic pathology at the University of Pennsylvania School of Veterinary Medicine.

After her residency, she initially remained at Penn before relocating to join the faculty at Tufts University Cummings School of Veterinary Medicine. In 2009, Nikki moved to a position as chief of pathology in the division of Comparative Medicine at Massachusetts Institute of Technology, or MIT. In 2014, she set up a business as an independent pathology consultant.

Nikki is the author of numerous journal articles and book chapters on a variety of pathology topics, and has served on several professional committees almost continuously since 2005. Nicola, welcome to the webinar vet and over to you. Well, thank you so much, Bruce.

Thanks for having me here today and, and for that very kind and generous introduction. And hello and, and thanks to all of you who are here joining me tonight. It's, it's great fun to be here and I promise I'll do my best to keep you all awake for the next hour or so.

Well, we're going to have a bit of a whirlwind tour through some key points in, in key areas. So do hold on tight and grab some snacks, come and go as you please. I'll warn you now that I've had laryngitis, so I will do my best to prevent you all suffering through any coughing fits that I might have.

But let's start off, I'd like to begin by if I can get my In to work? There we go. I'd like to start off by, by mentioning how pathologists get to be on the receiving end of a lot of stereotyping.

Many vets in, in practise who I speak to, they've never even spoken to a pathologist before. Yet one of the most common stereotypes that, that I get feedback about is that we apparently have no social skills because we, we tend to spend our days away from civilization with dead bodies. Or we're locked away in in dark rooms with microscopes and never speaking to, to human beings.

And I often also hear from vets in practise about how unhappy they might be with, with their pathologists, just because they don't feel that they're often getting the Definitive diagnoses or the helpful comments that they might need for, for some of their more challenging cases. So today, what I'm hoping to do is to convince you all that in general, we pathologists, we're not those socially unskilled monsters that you think we all are, and that we're actually vets who you should definitely talk to when you have problem cases. And I think most Most importantly, for those of you who might never have spoken to a pathologist, but maybe you've, you've cursed your reports at times, what I'd like to try and do is to flip your thoughts from something like this, where you might be cursing your pathologist.

To something like this, where you might be thinking, wow, this pathologist is a great tool. So what can I do to, to make the best use of my pathologist and, and therefore maximise what I get back from them in return? Because if you all haven't yet realised this, you play an extremely important role in the return that you actually get from your pathologists.

So I really want to remind you all of just how important you all are. So we should be up to our first poll question here. So what I'd like you all to do with this question is to, is to tell me how satisfied you feel in general with the, the quality of, of the biopsy reporting that, that you get back from your pathologist.

So here with respect to things like their, their ability to give you a definitive diagnosis or some useful comments or helpful information for, for guiding your patient management. Right guys, you're all members. You all know how this works.

So the polls live. Click on the answer that best suits you and it'll all be anonymous. Come through to me and then we will reveal the results.

So Yeah. Let's just give you another 5 or 10 seconds. I see most of you have already voted.

So that's fantastic. There's a couple more coming in. That's perfect.

All righty. 5 more seconds and then we're gonna close this. Right.

Let's close that. And Nicola, let me, oh, as soon as the computer lets me do it, share those results with you. Can you see that?

I can. OK, so. We're getting, oh wow, that's pretty good actually.

We're we're getting about 75% of people saying. That they're rating their pathologist is excellent or good. So that's actually a decent outcome.

I, it's, it's better than I had expected. I, I like to see that result. It's, it's very heartening, especially to see that most of you seem to be mostly happy with your pathologists, but maybe some of the things that I talk about tonight might, might help to, to improve that number even further and to, to get a better rating for future cases for most of you.

That's good. OK, thank you, Bruce. So I can still see the, the sharing poll results.

Is that still? It should disappear shortly. OK, can I just continue?

Yes, please do. OK, thank you. So we all know how important it is to, to get an accurate diagnosis or to get some helpful comments from your biopsy report because this really is what kind of guides your treatment.

But I think that one of the biggest barriers to achieving this is communication, and this tends to be really magnified in, in general practise, just because we're all in, in different buildings. So usually, you've got three separate organisations, if you like, that are involved in the whole biopsy process. So the whole thing starts off at your practise when you, you take your biopsy, the biopsy gets passed on to whatever delivery service you're using, and then it finally reaches the pathology lab.

And each of these three stages, there are multiple steps, and multiple people involved. So this obviously means that there are many points in that whole process where errors or misinterpretations of some kind can accidentally or unintentionally be introduced. Now, obviously, you guys have no control over what goes on in the pathology lab, and neither of us has any control over what happens when that specimen is on its way to the lab.

So, my main aim today is to highlight some of the things that you personally can do to help to maximise the, the accuracy and the usefulness of, of those biopsy reports that come back to you from your pathologist. And I've broken these down into, into 5 main areas. So we're going to focus on communicating with your pathologist, making some decisions about your biopsy, collecting your specimens.

Preparing them for transport to the lab and then ultimately putting together your submission form. So let's start off with the communication side of things, our first section, and we should have our second poll question here, OK. So what I want you to do now is to let me know whether you have ever called your pathologist in the past about either a biopsy procedure that you were planning to do or about a biopsy report that you, you've received.

Right, guys, Paul is live and just get clicking on those answers for us, please. Have you ever called your pathologist with questions about either an upcoming biopsy procedure or a biopsy report that you've received? Quite simply, yes, no, or wait, what?

I'm allowed to call and speak to a pathologist. Nicola, can you see that pole up? I can't.

OK. Nobody's voting. So I think we've got a technical issue somewhere.

Let me just try and relaunch this again. Bear with me a second. Right.

Does that come up now? Yes, I can see it. Thank you.

Right, we're getting some votes. Technical issues that wouldn't launch, so. Right.

Excellent. Everybody's voting nice and fast this time. Couple of stragglers still sitting on the fence.

Yes, no, wait. Come on guys, it's anonymous. Give us an answer.

Right, 5 more seconds and then we will end that. OK, here we go. And let's share that.

Can you see that, Nicola? I can't. OK, well, I'm really impressed.

We've got 86% of you all saying that yes, you've, you've called your, your pathologist about biopsies. So that's, that's brilliant actually. I, I, I like knowing that the majority have, have made use of the communication zone for sure.

I'm definitely hoping that my talk tonight will, will convince the remainder of you to, to harass your pathologist though, because we, we absolutely need to be harassed at times. So never feel bad about harassing us. I do my best to keep up with technology here.

It seems to be failing me. There we go. So it can be really useful to, to call your pathologist at times, either before you do a procedure or after it, and obviously for, for different reasons.

Now, before you do a biopsy, that there's no doubt that I think for many cases that you'll deal with in general practise. You'll likely have no need to do this because most of your cases will seem relatively straightforward, and you'll deal with them without any issues. But every so often, I know that you'll have cases that are not so routine.

They might have lots of moving parts to consider. Maybe you've got a patient. With multiple skin masses or, or some weird complex medical GI case or maybe a not so routine splenectomy to deal with.

Maybe a client has even asked you to do a basic postmortem exam and you haven't done one before, so you just want some advice from a pathologist. These are just a few examples of when speaking to your pathologist upfront can really help you plan for that procedure. It can certainly make sure That you actually collect the right specimens and submit them appropriately.

It can also let you tell the pathologist exactly what they're going to be receiving. And I think most importantly, it can let you tell them exactly what you need from them in return. Now, it can also be useful to call the pathologist after you've received your report.

And here we have just a few examples of why you might be unsure what to do next because the result you get back isn't very clear cut, or maybe it's a bit of a shock that that diagnosis you get might seem a little bit unexpected or it may not fit the clinical picture that you've been seeing, or maybe it's just an oddball case and, and you feel like some case discussion would be helpful. Overall, good communication with your pathologist can often bring some real clarity to, to certain situations and, and it can definitely reduce the, the risk of, of errors and, and misinterpretations on both sides. I think it's, it's always good to remember that veterinary care is, is truly a team sport, as I like to say, and the more members of that team that we can engage in any particular case, the better the outcome for the patient usually.

And I feel that your pathologist is definitely someone to have in your contact list or on your phone and in your email account for sure. Now, what are a couple of strategies that you might think of using to help improve the likelihood that you'll maybe get to speak to a pathologist? Well, firstly, whenever possible, make that call to the lab as far in advance of your procedure as you possibly can.

It may not be easy for you to speak with the pathologist. Maybe you don't have the direct office line, you might have to go through the lab's main reception phone. So, There may also be specific times in each day when the pathologists either make or take their calls.

So this gives you a bit of a buffer of time, just in case you do have to wait for a call back or maybe you have to order some special fixative solutions or containers and things like that. Now, another way to raise the odds of, of speaking to a pathologist at some point when you actually need one in the future is to befriend one. And I'm not talking about going full stalker mode here, but one way that you can do this is just to gradually develop some kind of a decent rapport with the Pathologists at your lab, some of the bigger pathology labs, and, and this especially happens over here in the US, they may give you the option to select a couple of pathologists to try and deal with as many of your cases as as often as possible, although it's no guarantee that you'll get these particular pathologists.

But this often Applies to certain types of cases. So often things like GI cases or skin cases, for example, just because some pathologists may choose to, to focus on certain types of pathology. So if this happens to be an option, if you can select one or two pathologists to, to have in your pool, if you like, then that can be helpful because you can build a rapport in this way.

As you work with each other over the, the cases that you submit. And this can all be further enhanced if you do happen to call the lab every now and then to discuss cases or to pass along a quick hey thanks message if, if say, somebody helped you with a, a last-minute case on a Friday night or something like that. I'm sure that if you think of the report that you have with your clients, you can likely relate to the kinds of things that, that make you either dread or look forward to returning your call from some of them.

And you can just apply those same kinds of principles in, in how you relate to your pathologist to. Now, another way to befriend a pathologist is to get to know them in person. And this can happen at, at various events.

Now, this could be pathology CPD events, for example. Now, I, I do imagine that many of you are sitting there now thinking that you'd rather pull out your own teeth than go to a pathology CPD event. But this is really a, a great way to, to get to know your pathologists if your lab is local.

Some corporate labs sometimes run these kinds of events, occasionally, even in regions away from where they're based. So do check their websites just in case they do happen to offer something in your area. And if they don't, you can even feel free to, to check in with them and, and ask if they might be interested in, in hosting something in your area.

I think if you have any pathologists locally, even if they're not ones who you use, you could even invite them to your practise to give a talk, ask one of them to come along and, and to tell them about, and tell you guys about how they like, their submissions to be, to be submitted for their lab has preferences for different submissions or, or maybe you might want them to give you a talk on the pathology of an and condition of your choice, and things like that. No, I mean, I have to say I can always be very easily bribed with coffee to, to go and give talks at practises, but I realised that I'm probably a little bit far away to be of much help to you folks. But you know, I think if all else fails and you still have a tough time getting to speak directly with a pathologist at your lab, do reach out to the wider pathology community.

I do realise that, that sometimes vets do have trouble getting to speak to their pathologists. I've heard these stories, but I promise that there are plenty of us out here who really are happy to, to help you with questions whenever we can. And there are many people in that pool to consider.

So you might want to consider checking in with your old profs from vet school, or maybe you currently work in a city that has a vet school. If that's the case, do make good use of their experts. And if any of your friends or your classmates from vet school happen to be pathologists or pathology residents, then speak to them, use them too.

And finally, there's always social media. I only actively use Twitter, but whatever platform you use, I bet you'll find pathologists there, and social media is a great way to, to kind of crowdsource, and to get some information and, and answers and, and sometimes to get those answers quite quickly. So never underestimate the power of, of social media.

OK, so here's our 3rd poll question. So what I'd like to know now is for those of you who have tried to call your pathologists, let me know how easy it's been to get to speak to them. So think of those calls that you've made during normal business hours.

So if you've called on a Friday night at 7 o'clock, just ignore those kinds of calls. Just think of the ones that you've made during regular business hours during the week. Right, Mikela, these votes are coming in quite quickly to start with.

So hopefully, we should have those answers for you shortly. Come on, guys. You know how to do this.

You know, it's completely anonymous. Simple answers. First one, I can usually speak to someone immediately or very quickly.

Second one, I usually receive a call back within 2 to 3 hours. 4 the third one is I usually receive a call back within 24 hours. Next one is, I, it's a lottery, and then I just give up.

Can't give up. Let's go. Let's have some votes here, guys.

We've only got 50% of people that have voted so far. That's just Couple of stragglers coming in now. Come on guys.

OK, we can't give you any more time. I'm afraid not everybody has voted this time, Nicola, but let's reveal these answers for you quickly. Well, it makes sense that not everybody will vote because I bet not everybody has tried to call their pathologists like we've found before, so.

Well, that's a good point. I'll forgive them this time. So there's your results.

46% will receive a call back within 2 to 3 hours. 31% can usually speak to somebody immediately or very quickly, and 23% get a call back within 24 hours. So I can't see the results, but I've just jotted them down on paper here.

So we've got 14, 179. Most people who have called or at least getting to speak to somebody within 24 hours, so. That's, I, I'm pretty content with that.

I'm definitely happy that in general, you're, you're getting to, to speak to somebody within, within 24 hours at least. It would obviously be nicer if you could get to speak to somebody within a couple of hours. It's a bit of a deficiency on our part as pathologists, I feel if we can't get back very quickly to the vets in practise to help with, with queries, but I'm glad that at least most of you guys are, are at least getting some Word back from your pathologists within 24 hours at the most.

So let's just move on to, to biopsy decision making now. This is our 2nd of the 5 areas. So obviously, many of your biopsy procedures will be quite straightforward for you, and you won't have questions about them, especially when we're thinking of things like a single skin mass, for example, in an accessible location.

But for those cases that do pose some extra questions for you, these are obviously where it's really good to try and speak to your pathologist beforehand. But in general, some of these decision-making questions that you might have, they may relate to the kind of diagnostic technique that you need to use. And here we have a couple of main considerations to think about.

So firstly, you'll need to ask yourself whether taking a biopsy is the right way to go. And then secondly, you'll need to think about what type of biopsy procedure is best to use. Now, these decisions are important because they, they do influence the usefulness of, of your biopsy specimen, and therefore, the usefulness of the report that you get back from your pathologist.

So let's take a quick superficial look at these two areas. So when you're wondering if biopsy is the right place to start, one question that you might have is, do I start with a biopsy or might cytology be a good place to start? Often, in many cases, you might be guided by, by cost.

You might understandably choose to avoid cytology just because you don't want the owner to have that extra cost if it turns out to be an inconclusive cytology, and you then still have to send the biopsy in. But, but cytology can definitely be a useful first step in, in many cases. And just to highlight a few examples of what I mean about this.

I think that if you have a, a, a pretty decent grasp of, of basic cytology, and if you have a functional microscope in your practise, then cytology can be a really quick and cheap way to get some information that can instantly help you plan how to manage tumours, for example. And I think it's, it's also especially Useful for those skin cases that you feel might be parasite induced just because it's, it's quite easy to do a skin scrape and check the mites, for example, these old critters are quite easy to identify on a slide. And if you can find things like mites, this is a great first step at no cost or minimal cost to the owner.

Now, there may also be some cases when the owner wants you to avoid biopsy initially, even if you feel it's the right step, they, they might prefer something less invasive to begin with. So in these cases, I would recommend sending the slide out for a clinical pathologist to evaluate just Obviously, you can feel free to examine slides yourself, but I would definitely get the clinical pathologist to, to examine them for you and give you the most definitive answer that you can get in those instances. But there are many cases when going straight for biopsy is absolutely the, the right step to take.

And I think here it's a, it's a good time to remind ourselves of the difference between pathology evaluation based on a biopsy, so histopathology and evaluation based on cytology, because in some cases, knowing this difference can really help to, to guide you. As you choose between biopsy or cytology as the technique of choice. So one analogy that I really kind of like to use to, to help students as they get to grips with the differences between cytology and biopsy is, is this, it's my jigsaw analogy.

So let's say we have a, a big jigsaw puzzle like this one here. And if we give someone a handful of random pieces, the most that they can tell us about the jigsaw is what they see on those particular pieces. They can't really comment on the big picture of the jigsaw and how it's all organised.

And it's the same story with cytology. We can only get a few images, a few snapshots of, of those clumps of cells that we take from the lesion. Now, on the other hand, if we put that jigsaw puzzle together and take a complete layer of it, then the person can tell us far more about that jigsaw puzzle.

They can now tell us about how all the individual pieces relate to each other, about the overall structure of the picture. And this is really what histopathology allows us to do. So just remembering this difference can sometimes help to, to guide you as you choose between biopsy and cytology in some of your cases.

So when might we consider going straight to biopsy? Well, again, this is not a complete list by any stretch of the imagination, but biopsy is usually a better choice for, for tumours when you want to know anything about tumour grade, for example, so things like mast cell tumours, or when you want to know anything about prognostic information about the, about a tumour. Also, oftentimes we, we definitely need the, the bigger architectural picture so we can differentiate between different types of, of mammary masses, for example.

So here I'm thinking about differentiating between benign mammary tumours, malignant ones, or mammary hyperplasia, just because looking at, a few clumps of cells via cytology doesn't always help us in some of these cases. I'd also usually go straight to biopsy for any lesion that looks somewhat atypical. So here, you might be thinking about things that have strangely irregular outlines or things that have asymmetry of pigments or asymmetry of configuration.

Also, for those lesions that pop up that initially seem typical for something, but then they might start to behave strangely for whatever you initially thought they were. Similarly for long-standing chronic lesions of any kind, including ulcers, that you can't easily explain away. And I think that as long as the animal is healthy enough for anaesthesia, that if you happen to need general anaesthesia for, for the biopsy if you're not using local anaesthesia, then it's wise to consider biopsy for Any lesion that might be either making the owner push you for biopsy, or that might be keeping you awake at night for whatever the reason, because I feel that in, in both of these types of cases, biopsy just has a greater chance of, of giving you a definitive diagnosis and, and much more quickly than if you start off with cytology and, and then move on later to, to biopsy.

Don't forget too that sometimes you might want to submit something else along with your biopsy, and just a couple of very basic examples of, of what I mean here. For tumours, for example, let's say the owner wants to remove a mass regardless, then if you want to, you can submit both cytology and biopsy specimens for that tumour. You can ask the lab to, to process the cytology first just because it's cheaper and only run the biopsy if it's necessary.

So maybe if the, the cytology is inconclusive, for example. And in some cases, diagnosis might even benefit from, from having multiple types of specimens submitted. For example, maybe you have a lesion that may benefit from having microbiology and biopsy submitted.

Here, I'm especially thinking of, of certain skin diseases. So for cases that maybe present like pyoderma or for those chronic non-healing wounds, for example. Now, there are also situations when we pathologists know that biopsy might be of somewhat low yield for you.

And this is again where speaking to your pathologist upfront can sometimes be really helpful so that you can get advice that is tailored to the specific case that you're dealing with. For example, for those bone core biopsies that you might sometimes need. Unless you're really experienced collecting these, you know, unless you're doing them quite frequently in practise, I'd always recommend referring them so a specialist can collect them for you.

This will increase the, the odds of, of getting deep enough into the bone to, to actually capture a diagnostic specimen off. And we pathologists just receive specimens that have been collected from the superficial reactive bone, and these are non-diagnostic, unfortunately. So in these cases, unless you're used to collecting these samples, I would just save yourselves the grief and, and get a specialist to collect them for you.

True biopsies of, of kidneys. Now, these are, are rarely indicated in general practise, to be honest. For most non-neoplastic kidney diseases, the, the severity of the, of the histopathologic lesion that we tend to see will vary throughout the different areas of the kidney.

So taking these truecu biopsies often doesn't reflect the, the whole story across the whole kidney. So it just tends to be more reliable to, to monitor these patients in the more traditional way that you're accustomed to doing it in practise, using lab values, so like serum biochemistry, you're in specific gravity, your analysis and whatnot. And the same goes for two biopsies of, of livers that look cirrhotic.

So those kind of knobbly bobbly livers that you might see on ultrasound or you might even be able to feel in some cases. Like with the, the story in the kidney, it's kind of hard to get a representative true-cut sample of these lesions. Plus, at your end, these end-stage livers also have a bigger risk of excessive bleeding when you're taking the biopsy samples.

And for us as pathologists, the, the histopath changes that we tend to see are often very non-specific, and they don't tell us any more than we already know from the clinical picture. Chronic inflammatory skin cases that have been heavily treated. So this is something that I know you can all relate to, I'm sure, but sadly, in many skin diseases, the more chronic the lesions, the less specific and the less useful the histologic changes tend to be.

So for a lot of these skin diseases that you'll be dealing with, it's typically better to biopsy them sooner rather than later on after you've thrown lots of different rounds of treatment at them. And for cases of, of chronic stomatitis or, or gingivitis, for example, one of the problems that we run into as pathologists is that the oral mucosa is kind of boring. It's somewhat limited in how it actually responds to injury.

So we, we often see the same kind of histopathology reactions for many underlying conditions, whether we've got viral disease that has initiated something or trauma, for example. Now, a biopsy can help to rule out things like underlying cancers in these areas. So obviously here we're talking about things like squamous cell carcinomas or epitheliotropic lymphomas, for example, even those eosinophilic granulomas that that our cats get, but otherwise for those generic cases of stomatitis and gingivitis, it's often unlikely to provide any real useful prognostic or therapeutic information for you.

Chronic supparative rhinitis too. Now, I know you've had these cases as well, and, and they're also really frustrating to deal with. And similarly on histopathology, we often see only relatively mild and, and somewhat non-specific changes.

So again, it doesn't often help to, to give you a definitive diagnosis and, and let you know what kicked off the whole process in the first place. Although again, it can help to rule out some things, it can be useful to, to pick up things like fungal rhinitis or nasal carcinoma, for example. Now, to be clear, I want to clarify that I'm not saying don't ever take a biopsy in any of these situations, but I think it's just good if you're all aware of the, the limitations that they pose, just so that you and, and clients have kind of realistic expectations of what biopsy can, can bring for you.

OK, so let's say you've decided on taking a biopsy. So now you're going to be considering the best approach to collecting that biopsy. And, and for us in our business, we mostly use one of these 5 different biopsy techniques.

Now, again, in most cases, you will make your decisions without much thought. I know that, but it's always helpful just to remember that all these different techniques have their own uses and their own limitations. And in some cases, you might be left pondering between, say, just a couple of different options.

And in these instances, it's important to pick the right one because that choice could mean the difference between a non-diagnostic and, and a diagnostic biopsy sample. So we'll just hit a few superficial highlights of, of these different types. We're all familiar with punch biopsies.

I'm sure of that because we, we use them quite commonly to evaluate our skin disease cases. Now, in general, these punches don't always capture much of the deeper layers of the skin, like the paniculus layer, for example. So they tend to be best to evaluate lesions that are in the most superficial layers of skin.

They're not great for properly assessing disease that might be in those deeper areas. But we do use them a lot to, to collect from different areas of, of different non-neoplastic skin conditions, especially, and they're really useful in these cases to, to help us evaluate diseases that might have inflammatory or infectious or endocrine origins, but they can also be a good way to collect superficial tumours or those superficial skin nodules that you might sometimes find. And even to collect, a fresh tissue specimen, if for instance, you might need to do a microbial culture for some of your skin cases.

What about excisional and incisional biopsies? Well, these are great because they allow us as pathologists to see a nice broad geographic overview of, of tissue organisation, and they're great for, for checking out those lesions that are in the deeper layers of tissue. They're also good to let us appreciate things like tumour invasion into vessels or into the surrounding adjacent tissues.

Even to assess the, the relative amounts of, of normal and abnormal tissue. These are all the kinds of things that, that can be critical to evaluating prognosis of your lesions. Obviously, most of the time, we, we're gonna be taking excisional biopsies and, and these tend to be our gold standard.

They're really ideal whenever we're dealing with those isolated lesions that that lend themselves to being fully excised, but they're also a great way to capture those lesions that might be either arising in or extending to the deeper skin layers. And they're also a good way of collecting skin ulcers too, as long as the size of the ulcer allows this to happen. Incisional biopsies.

So this approach also provides a decent volume of tissue for your pathologist. So it's, it's another good way of giving them enough tissue for, for a good evaluation, but it carries a bit of a higher risk of wound site complications at your end, and it sometimes leads To put tumour sampling as well through no one's fault, just because you're having to kind of randomly select a portion to biopsy. So you might just be unlucky in what you happen to capture.

So overall, it's not our preferred approach, but sometimes it's, it's necessary and it can, it can be really useful. For those tumours like complex or large or invasive skin tumours or even tumours that happen to be in awkward locations like this, poor cat in, in the, in the image on the slide that has squamous cell carcinoma of the tongue and you obviously can't remove the whole tongue. In these kinds of cases where you get these complex tumours or things in awkward locations, taking a small sample through incisional biopsy can give you that diagnosis and, and a bit of a prognosis up front.

And, and I think this can sometimes help you to kind of make better plans for how you manage that patient moving forward. And it also gives you the, the chance to, to balance the owner's expectations around these complex cases. It's better to know.

What you're dealing with upfront, I think, rather than diving blindly into a really difficult surgery and, and then submitting the biopsy and just discovering that you've got this tumour with a, a really terrible prognosis. These tissue core biopsies, you know, your, your true-cut biopsies. So this technique allows you to use these specialised needles to collect these strips or, or cause of tissue from different sites within a mass.

It typically has a relatively low complication rate, but you have to remember that these needles capture only really tiny histologic samples. So save this option for when you feel that the pathologist will need some appreciation of tissue architecture, but when you also expect that the histologic changes are going to be widespread enough in the tissue or in the lesion. But because remember that these samples only really give us a kind of a keyhole view of the lesion.

So they might not highlight the, the variability and, and the degree of histologic aggressiveness in a tumour, for example. And they're also not great for those different lesions that might be kind of patchy or random in, in how they're distributed in a tissue. So here I'm thinking about things like tumour metastasis or, or bacterial lesions like pyelonephritis, for example.

Our final example to have a quick look at here today is the endoscopic biopsy approach. So one advantage of endoscopy over laparotomy is that you guys get to see the mucosal surface as you do your examination. So this means you can target your sample collection to areas that you think look abnormal.

And another advantage is that you can take multiple biopsies relatively quickly using this technique. On the downside, it's somewhat limited to the most cranial and the most causal regions of the GI tract, and it also typically only allows you to collect samples of mucosal tissue. Sometimes you get to capture a bit of submucosa as well, but in general, it's just really the mucosal tissue that you get to pinch off.

So those lesions that might be deeper in the wall of the GI tract tend to be missed with this technique, and they're the ones where you'll need to go to the laparotomy to, to capture those. So our 3rd of our 5 sections, we're going to focus on specimen collection. So here we'll take a brief overview of three key areas.

One relates to the selection of areas of your lesions to collect. The second relates to handling the specimens that you collect, and then the third relates to to marking your specimens if you need to do so. So when it comes to selecting your lesions, there's no standard guideline for this unfortunately, because as you all know, different lesions and, and different conditions can look different in different animals.

But again, for most cases, this will be a straightforward selection process for you. You probably will do it without even thinking about it, but it's for those challenging cases when you might want to think about calling your pathologist beforehand, just to, to speak to how you might best want to approach these kinds of cases. But I'll highlight, I'll highlight just a few things to, to guide you when it comes to collecting samples from areas like the skin, and GI tract.

So a few Very general points about biopsies for skin disease. In general, don't forget to biopsy your lesions sooner rather than later, just because for most of these cases, the more specific, the more informative changes that we see on biopsy often tend to arise relatively early on in the evolution of the disease as it starts to develop in the skin. And the more time that passes by, the more chronic the changes are that set in, and these are often the, the more non-specific changes that can look very similar in different diseases.

Also make sure that you've, you've stopped corticosteroid therapy whenever possible. Obviously, unless of course you've got a patient receiving corticosteroids for some life-saving indication or if they really can't cope with their skin disease without them. And if you do happen to take biopsies from a patient that is still receiving steroids, just let us know on the submission form.

For general skin disease cases, so I'm talking about your non-neoplastic cases here, don't scrub or prep the skin like you would normally for surgery just because things like crusts and exudates are often what I like to call them. The engine room of, of histopath findings. We often find very important diagnostic lesions here.

So if you're very judicious about scrubbing that skin, you often inadvertently remove those lesions that we need to make your diagnosis. And if you happen to be dealing with a large skin lesion or a really patchy condition that might have different appearances in different regions, make sure you take several punch biopsies in these cases. Don't just send one punch from something like this.

Take as many as you can, you know, within reason. So let's say you have a case where you've got maybe 2 or 3 different appearances of the skin. Aim for, say, 2 to 4 punch biopsies if possible.

When you've got these different skin diseases, collect lesions that look to be primary lesions, so things that look to be the main type of, of origin of the skin disease. So here I'm thinking about things like nodules or papules or pustules or vesicles, those kinds of things. And if you see secondary changes that seem to be a, a common feature, collect some of those too.

So here I'm thinking about things like, like crusts or scales or ulcers or erosions or, or patches of hair loss. Collect some of those for your pathologist as well. It's also always good to include a bit of normal skin as well, and you can do this by either just collecting one punch from normal skin, or you can collect, you know, two or more, say, of your punches at the intersection between normal and abnormal looking skin.

This just gives your pathologist, a bit of a benchmark so that he or she knows what normal looks like for this animal. And if you're dealing with a skin ulcer kind of condition that is too big to remove completely, make sure that you avoid collecting from just the centre of those lesions. Take some biopsies at the periphery, especially in these, in these lesions, maybe at the interface again between normal and diseased tissue.

Because if you only capture that, central portion that's ulcerated, then usually the most that we can tell you is that, yes, it's ulcerated. So definitely capture the, the, the more normal looking skin as well at the, at the intersection between normal and, and diseased tissue in these cases. For your GI specimens.

So let's say you're doing a laparotomy. Realistically, you're probably only gonna to collect 123 biopsies in these cases just because of, of the location where you are. So, If you happen to see visible lesions at laparotomy, that's great because they will guide you in choosing the location to biopsy.

But in cases when you don't see gross lesions at laparotomy, and you're having to randomly select a region or two to biopsy based purely on the clinical signs that you're seeing, then make sure that the samples you collect are decent for thickness. Ones, because the mucosa in these cases might be the, the engine room of, of those lesions. So you need to make sure that your, your sample is a decent full thickness one that will capture the mucosa.

So here I'm especially thinking about your medical GI cases where you're, you're looking at things like, trying to evaluate inflammatory bowel disease or intestinal lymphomas, things like that. Because often the, the mucosa will be where all the reaction is. For endoscopy, I assume that most of you will probably refer these cases, but if you do happen to do your own endoscopy, make sure that you collect multiple samples.

You can typically collect at least 6 samples from each region that you, that you scope. So, first of all, target any of the abnormal looking areas of mucosa. And if you don't happen to see any abnormal looking mucosa, just select randomly from different areas within each region that you're scoping.

And if you happen to be dealing with a case where you suspect upper GI disease, don't confine your endoscopic search to just the stomach and duodenum, even though that sounds logical for an upper GI case. Collect a little bit from the ilium too, if you're able to access it, because strangely, In these upper GI cases, we often see helpful diagnostic changes in the ilium as well, even though it doesn't seem like it would be the logical area to find them. So don't forget the ileum if you can't access it.

I, I know it can be difficult to, to get to the ileum sometimes. Tissue handling. So this is an important thing to think about because if you make one accidental wrong move, that tissue sample that you work so hard to collect could suddenly become non-diagnostic.

So do make sure that you handle those specimens really carefully. Just treat them the same way that you would treat those tissues during surgery. Just a few key things to remember here.

Avoid crushing your specimens at all, especially with instruments of any kind, and especially avoid ratooth forceps whenever possible. Definitely don't use forceps on the actual lesion itself. If you are handling your specimen with forceps, make sure that you use the forceps only on the very peripheral unimportant edges of that whole specimen.

Avoid grasping any area of the tissue that you might want the pathologist to look at. So here I'm thinking about the actual lesion itself, or surgical margins at the, at the very periphery of the sample you've collected. When you grasp or, or crush tissue in any way, it traumatises it and we see the trauma on the, on the biopsies and, and the, the kind of trauma that you create, unfortunately removes a lot of the lesions in many cases.

And you also want to avoid using electrocauteery on these important areas for just the same reason because electrocautery can, can wipe out the, the anatomy, the, the microanatomy that we see on biopsies. And just generally don't let anybody manhandle your specimens, handle them as little as possible, so don't pass them around the clinic for your colleagues and students to play with. Don't squeeze them or, or crush them in your hands, for example.

And if you have an intestinal specimen with bowel contents in it, so let's say you've done a, a, a resection and anastomosis, you can place that intestinal specimen under the tap and just let some water very gently flush out the contents so that You can clean it up a little bit before you plunk it and fall in. Do avoid rubbing the mucosa with your fingers because this can slough off the mucosa along with any interesting lesions that might be in there. So just be very cautious about, about touching the mucosa.

The 3rd area Here relates to marking your specimens. And my biggest piece of advice here is that if you need your biopsy report to help you figure out the difference between different biopsies that you're submitting from different locations, or if you need to know what's happening in certain specific areas of a lesion that you're submitting, then make sure that you clearly identify these things so your pathologist can report them accurately for you. Don't rely on, on small differences in, in size or appearance, for example, of, of samples as a way to expect the pathologist to be able to differentiate between them at the lab side of things, because, for one, the pathologist won't see them.

When they arrive, that the samples will go straight to the lab and the technicians will prepare them. And secondly, the tissue really shrinks and distorts and undergoes all kinds of weird colour changes after it's been fixed in formalin. And these changes can have a really great impact on how the tissue actually looks when it reaches the lab compared with how it looked when you removed it.

So how can you mark your different specimens or, or different areas of tissue of interest? Well, you can just use different containers if necessary. This is a nice foolproof way to separate things from different regions.

But you can obviously save on formalin and save on containers by submitting multiple lesions together as long as you make sure that you tag different specimens, if it's important for you to know what what belongs where. And one way you can tag your specimens is to use sutures. This can help you mark samples from different locations on the skin, for example, or just to highlight.

On lesion that you want the pathologist to, to especially look at maybe things like a surgical margin, for example, or, or just an area that looks odd visibly to you when you remove the lesion. So you can use different numbers of sutures, for example, or even just different colours of suture material to, to tag your different specimens or to, to tag specific areas of one lesion and just make sure that you describe what they all refer to on the submission form. So for example, you might say something like, there's 1 suture at the cranial margin and 2 at the caudal margin, or the cranial margin has a white suture attached and the caudal margin has a purple one.

Do avoid naming the actual type of suture material that you've used, that the lab techs who received these samples, they likely won't won't know the, the different materials that you're using, and some of your pathologists either won't know what they are or won't remember them either. Surgical ink is another great way to, to mark certain areas of interest on a biopsy, maybe using different colours to, to indicate different areas of interest, like surgical margins. And again, just tell us what the colours relate to when you write your submission forms out.

These little screen cassettes, I've put a couple of pictures on the bottom left there. They're also a great way to separate out tiny specimens from different regions when you submit them. All you have to do is use a pencil to, to label these cassettes.

And don't forget that photos of lesions can also be useful accessories. Just let us know how we can get to see them, if they're available, and, just don't use them on their own as a way to distinguish between things for us. Just a quick word of warning to avoid using any sharps to, to tag your specimens.

They can obviously be hazardous for technicians who won't be expecting them when they open these containers, and they can also damage your tissue as well, and we definitely don't want your tissue to be damaged. So our 4th section is preparing your specimen for transport. So I'm gonna highlight some things here about the, the fixative, the containers, and also about packaging things up for transport to the lab, because these are all steps, no matter how boring they seem, but these are all steps that can affect your specimen too.

So on the fixative side, 99% of the time, all your biopsies will go into formalin. It'll be 10% neutral buffered formalin, and your lab can provide that for you, or you can buy your own stock solution through your suppliers. We do have other fixatives in pathology labs that we sometimes use often for some special tissues like eyeballs, for example.

So do check with your lab if you have any questions about special submissions, but in general, If you're caught short on a weekend or an evening surgery or something, it's highly unlikely that you'll do any harm if you just use formalin for for 99.9% of the, of the surgical biopsy specimens that, that you take in practise. So don't hesitate to, to put your biopsy specimens in formalin.

Don't forget too, though, that if you happen to want other tests performing on the same lesion, just make sure that you are submitting the right sample in the right way for the specific test that you need, because not everything ends up being interchangeable or salvageable in the lab. If you need multiple tests performing, you might need to provide multiple separate samples to, to achieve this. So we can't do a culture on following fixed tissue, for example, I've, I've had those tissues submitted to me in the past.

So the bottom line is, if you're unsure about anything, do you speak to your lab ahead of time if possible. And when you do happen to submit multiple different sample types, try and keep your unfixed tissues, so things like your cytology or micros specimens, keep them all away from your formal and fixed tissues in the big container, just because even formalin fumes can, can damage those those unfixed specimens that you submit. So just keep everything separated as much as you can.

On the container side, whenever possible, use the containers that your lab provides for you. But if you get caught short or you need to use some kind of alternative, just make sure that it's breakproof and leakproof and that it has a nice secure lid. Do avoid using those tablet containers that you all have kicking around the practise that have those pop on, pop-off lids that they're not great for the safely containing formalin, especially for transport.

And the container's neck should always be wider than the specimen that you're trying to put in it. Although that fresh tissue sample that you take at surgery is nice and squishy and flexible, formal and fixed tissue is knot, it becomes really rigid. And, and very difficult to, to manipulate out through a too narrow opening.

So ideally, your specimen should be able to, to drop into the open container unhindered without you trying to force it in or encourage it in in any shape or form. Otherwise, you sadly risk your tissue being damaged and sometimes made non-diagnostic if the techs in the lab have to kind of forcibly remove them from the container. Remember too that the container you use has to be big enough to cope with the amount of formalin that your specimen needs.

Remember that the volume of formalin needs to be at least 10 times that of the volume of the tissue that you want to fix. It's really important. If you have very small samples like those endoscopic biopsies or even just little flat samples that you may have collected, say, from the bladder or the gallbladder, for example, remember that you can just put these in these little screen cassettes and just label the cassette with pencil and then just put the whole cassette into the form.

Container. It's a, it's a nice way to separate out these tiny specimens. And remember too, that when you label your regular containers, do make sure that you label the actual body of the container, not just the lids.

This is where things often go wrong, unfortunately, the lids can Accidentally get swapped or misplaced in labs when the technicians are preparing all these samples at the same time. So by you labelling the body of your container, it's a huge help and it really reduces the risk of error and it reduces the risk of, of you receiving a biopsy report for, for somebody else's animal. Now, transport is an important step for, for a couple of main reasons.

Firstly, because we're dealing with animal tissues and hazardous materials. So you need to make sure that you're, you're following regulations from everybody involved and this, the, the courier service. So the mailing service that you use to deliver your specimens may have their own regulations, and the lab may also have some regulations for how they like things to be transported to them.

So just make sure that you are abiding with their regulations. And secondly, you have to remember that missteps at this stage can also affect your diagnostic return, especially when samples get lost or damaged in transport, just because they, they haven't been properly packaged. Don't forget that this transport stage is, is that wildcard in the whole process, like I mentioned at the start, because neither you at the practise, nor the pathologists in the lab have any real direct control over what is happening in this kind of no man's land in the middle while the specimen is being delivered.

So it's really important that you can package everything properly for transport, just to help reduce the risk of, of tissue damage and loss. And one useful thing that you can do is to protect your formal and container against leakage in transit. So secure that lid, make sure it's nice and tight, but not so tight that you need superhuman powers in the lab to be able to open the container.

And you can also surround that container. With absorbent material, so things like paper towel or gauze or even cotton wool can be useful. And then double bag this whole thing in a couple of sealed plastic bags.

This is a great way to help contain any leakage during transport and leakage happens more commonly than you can probably imagine, to be honest. Again, don't put any shops in in your specimens when you're transporting them. You can also put your submission form in the plastic bag too, that will help to protect that from any formal and leaks.

I've, I've lost count of the number of very sad looking soggy forms that I've seen over the past 20 years or so. If you happen to be sending slides to a clinical pathologist, ask your lab if they'll give you some of these special plastic cases, these slide cases that I put on the top right and one of the little images there. These are, these are great for protecting your slides in, in transport.

They'll stop them breaking. You can even buy some online. They, they're relatively cheap and they're great to have kicking around the practise for, for special occasions like this.

And again, just make sure that you pack your, your fresh and your phone and fix tissues separately to protect them all. Those Styrofoam boxes that you often get a lot of your supplies in for the practise, they, they work really well inside a larger cardboard box, for example, just as a way to kind of separate out different submissions like your biopsies or your micros specimens or your cytologies and whatnot. Just keeps that formalin away from all those unfixed specimens.

OK, our final section, the submission form, we should be heading for our 4th and final poll question now. So here what I'd like you all to tell me is, when you submit a biopsy specimen, tell me how much clinical information you usually provide on the form. Right, guys, so I hope you can see that.

Nicola, can you see that? No, I can't. OK.

What I'm gonna do is we're having some technical issues with the polls tonight, folks, bear with me. I'm just gonna end this poll and then relaunch it and hopefully then you can see it. Has that shown up?

I can see it, yes. OK. Oh, and we're getting some votes coming through.

Folks, I really apologise for the technical problems we are having with the, the polls tonight. I have already reported it, so hopefully, it will be sorted out before the next webinar. It's just irritating that it doesn't launch and then that you can't see the results.

So if, if I end this one, Nicola, and you can't see the results, just give me a shout and I will try and, and, redo it so that they show up again. In the meantime, people are voting very nicely and Yeah, we've got got some more people voting this time than we had last time. So that's absolutely great.

5 more seconds guys, and then I'm going to end this poll. Righty, right. Let's end this and share those results.

Can you see that? Yes, I can. Excellent.

That's brilliant. OK, so I love you guys. 79% are telling me that you like to try and encapsulate the, the relevant history and treatment and, and diagnostics.

Given a comprehensive review of your cases like this on your forms is, is definitely the, the best way. To, to aim to send in your submissions, but I'd obviously love to see if we can get this number up to 100% of all of you in the future, and get all of you submitting a nice comprehensive review in this way. And the good news is that it's a really easy fix for, for you at your practise side.

She got more technology, OK. I'm just having my own technical issues here. OK, so we're on our final section here, this submission form.

This is a really vital part of the process. It's, it's really important that you should consider the submission form, like your referral letter to the pathologist, that it really provides the pathologist with a window into your case. So you need to include all the usual animal and owner information that we're all accustomed to, to dealing with in our profession, along with the, the key descriptive pieces of information about the specimens that you're submitting.

And do double check that everything on the submission form definitely matches what is in the containers, and that this all squares up with what is in the animal's medical records too. This is an area where things sometimes get accidentally mixed up, especially from our side of things where the form will tell us that there's something in the container, but it's not in there when we open it up and try and look for it. So it's definitely a good place to, to double check before you actually send those specimens off to the lab.

The relevant clinical history on your forms, this is really vital. A lot of vets often forget that some of the most important data that you can provide us with to help to maximise the diagnostic outcomes is the patient's history. I really can't stress enough how, how critical this can be in many of your cases.

Providing a really good history is, is so important because we pathologists, we obviously Haven't had the luxury of, of seeing your patients, so we definitely need your expert opinions in this area. So don't leave the section blank, always, always give us your review. But on the flip side, do try and avoid simply attaching several years' worth of of photocopied medical history.

Sadly, we just don't have the time to read it all, but you can feel free to to type out. The relevant information from the case report. So maybe if you want to type out or copy one page of case information that does encapsulate the, the, this particular case and attach that, that's absolutely fine.

And if you feel you don't have enough space on the actual in the boxes on the form or on the back of the form to, to cover everything that you need. Also let us know if you have photos of the, of the lesions. Let us know how we can get copies of them, because this can be a great thing for us to be able to, to look at how the clinical lesions look to you visibly and compare them with, with the histologic things that we're seeing.

And also, don't forget to include things like any relevant treatment for this particular case or other relevant diagnostic findings that you might have. Giving us your, your kind of clinical working diagnosis that is in your head, or even a differential diagnosis list can, can be really helpful as we start to examine these biopsies, because if the histopath changes don't happen to point to anything specific, Us having all this information can be really helpful, so that we can at least rule in or rule out certain things for you. Because by doing this, you really give us your, your expert personal insight into the case.

You can think of it in in this kind of a way. If you happen to be challenged by a case and you don't give us much information about it, and that case ends up having just non-specific changes on, on histopath on the biopsy, then this often leads to us just describing these non-specific lesions for you in the report, and that makes for a very unrewarding report for you when you get no definitive diagnosis and no helpful information. However, on the flip side, in that same situation, if you happen to share a decent amount of, of history with us, it can really serve as a kind of a skeleton on which we can build your report.

So based on all your clinical suspicions and the treatments that you've used and other relevant history, we can then address some of the things that you talk about or the questions you might have. Sometimes we might be able to say that, yes, unfortunately, the lesions are quite non-specific, but they definitely don't look consistent with Disease X or there's no evidence of neoplasia. So in this way, we can kind of help to rule out some things moving forward for you.

All the information you give us can, can help us to help you narrow down that list of, of considerations just to help you better target the the rest of your workup. So now, as we come to the end, I, I hope that I have highlighted just a handful of of important areas for you to, to think about at your side of the surgical biopsy process. They're all things that, that do happen to us in, you know, as, as, as pathologists, but they're all things that can help to improve the usefulness of your biopsy reports and hopefully help ultimately to, to flip them from looking something like this.

In cases where we don't get much expert input from you to something like this, when we do get some great input from you, I think it's, it's really important to remember that the whole diagnostic process in general is a, a real team effort between you and your pathologist. So the more that you can give them, the more that they can give you in return, and, and certainly many problems can be prevented when, when samples do get submitted correctly. And if you and your pathologist have good communication, remember that we pathologists, we, we're not just diagnosticians or or science geeks.

We're all vets and, and many of us have also worked in, in general practise. And I can promise that I totally remember what it's like to be in the situation of, of managing challenging cases and often very challenging owners. We're also educators in many instances where we're definitely helpers, so please think of us as part of your team because we are always happy to, to help brainstorm if you want on those complex or oddball cases.

So please don't ever hesitate to, to reach out to us for help because we do want to solve your cases. So that's it, folks. Thank you all for hanging on.

I, I hope some of you are still awake and I'd also like to give a quick thanks to my good friend, Doctor Brian Law, who very kindly shared and took lots of his great photos for me. For this presentation. So thanks, Brian.

I really appreciate it. Thank you, everyone. I, I hope this has given you some helpful reminders of things that, that might be useful for you for your future cases.

Nicola, that was absolutely beyond useful. It was so good to get the pathologist input on it and to understand some of the little nuances. And I can tell you that, on the attendee counter that I had not one person left.

So everybody was hanging on every word that you were saying. It, it's just, it's so funny, as you say, you know, we, we know it from our side, but we don't always think of it from your side. Exactly.

And you know, these are, these are complex situations. You guys in practise are just hellish busy most of the time. You probably don't even have time to go to the loo a lot of days.

So it's, it's very common. To, to not even think about things that, that might be happening in the lab or, or, or whatnot. So I'm not surprised at all that that these things often get lost in translation.

You know they're things that we all know about from, from vet school days, but they're not things that we all keep in our, in our brains naturally because our brains are only so, so, you know, so big, mine's only very small and I can't keep, I can't keep a lot of information. There at any one time. So the, the only enough parking spaces to, to keep in the stuff that I need on a day to day basis.

So you and me both, I always say my brain is still working on one of the old 286s. They're not like the kids are today. So, but I did have to smile to myself when you were talking about, writing or typing.

And I thought, oh, I think there's many pathologists that looked at my horrible scribble and went, God, I wish he had typed it instead of writing. And vice versa as well. I think if we had to write out your reports for you, you'd have the same problem too.

I'm sorry that my, my dog is in the background a little orchestra here. I apologise for warned me beforehand and waited till the end. I'd say, time to go.

Nicholas, thank you so much for, for being on, on the webinar vet with us. . It, it really is great.

And if we were in an auditorium, as Anthony likes to say, there would be a thunderous round of applause. So thank you for sharing and allowing us to understand the pathologist aspect. It's really great.

Well, thank you, Bruce, and thanks to everybody at Webinar vet and, and thanks to all of you guys for, for very generously listening in for the past hour and however long it was. I, I appreciate it very much. That's great.

Folks, from my side, it's once again, thank you for attending and we'll see you on another webinar, to fill my controller in the background, thank you for all your help and good night, everybody. Good night, folks.