Everyone at Hope was so nice and compassionate. Strangers I met in the lobby consoled me. You knew everyone who stepped through Hope's doors loved animals.
Ilona and Bill
The ethics of veterinary practice, particularly oncology, is an interesting topic for numerous reasons and one that should be discussed more frequently and fervently. These ethical dilemmas are perhaps more frequent and challenging for surgical, medical, and radiation oncologists because of the nature of what we do on a daily basis but the relative lack of evidence to support what we do. I am relatively frequently presenting owners with surgical options which have either not been performed before or have been reported in non-peer reviewed list servs and forums; and medical and radiation oncologists will often recommend treatment protocols for diseases for which there are no published studies or there are published studies which show no survival benefit for these treatments. Moreover, we often neglect to consider the potential deleterious effects of these treatments and the impact that these can have on quality of life.
Owners are advocates for their pets and informed consent is necessary prior to starting any treatment. Informed consent is the process of obtaining permission from the patient or, for veterinarians, their owner(s) so that they have an opportunity to decide about their health care. In the medical profession, this definition originates from the legal and ethical rights of the patient and from the ethical duty of the physician to involve the patient in health care decisions.1 Informed consent, at least in theory, has transitioned from a paternalistic approach (whereby the doctor was the only one to make treatment decisions) to a more collaborative approach (whereby the doctor and patient discuss the pros and cons of the various treatment options and the patient decides the treatment option they prefer, with or without guidance from the doctor).1 Unlike our human counterparts, veterinarians are not obligated by legal precedence and our only obligation to our patients and their owners for informed consent is moral rather than legal.2
In “Owner Consent in Veterinary Medicine”, the American Veterinary Medical Association (AVMA) states that the “information received by them (the owner) has been understood, and that they are consenting to the recommended treatments or procedures”.2 This definition reflects the often used paternalistic approach used by many veterinarians whereby owners, despite being informed of the recommended treatment and its associated risks and costs, are not involved in the decision-making process other than to say “yes” or “no” to the recommended treatment. In contrast, the Royal College of Veterinary Surgeons (RCVS) in the United Kingdom (UK) states informed consent “can only be given by a client who has had the opportunity to consider a range of reasonable treatment options, with associated fees, and had the significance and main risks explained to them.”3 Similarly, the Code of Good Veterinary Practice of the Federation of Veterinarians of Europe states that the veterinarian must provide information of the “risks, the costs and benefits of the different and alternative diagnostic and therapeutic routes.”1 The essential difference between the definitions of informed consent between the AVMA and RCVS/Europe is that owners in the UK and Europe are collaborating with their veterinarian in making an informed decision (based on a discussion of the benefits, risks, and costs of a number of procedures and/or treatments) regarding their pet rather than the paternalistic approach favored by the AVMA.
How many of us collaborate with our clients and how many of us adopt the paternalistic approach? How many of us truly involve owners in the decision-making process for their pets by discussing a number of different treatment options, if available, and explaining the risks and benefits of each option and the evidence to support these options? More importantly, how many of us do this impartially and without inserting our own personal biases (unless requested)? Surgical oncologists are perhaps more fortunate than medical and radiation oncologists as we often have more published literature to be able to inform owners on the benefits, risks, and outcomes of surgical procedures. However, we are also bound, at least morally, to inform owners when we do not have studies to support the efficacy of proposed treatment options (for example, surgical re-excisions for narrowly excised tumors, chemotherapy for high-grade soft tissue sarcomas and non-metastatic apocrine gland anal sac adenocarcinomas, and radiation therapy for incompletely excised soft tissue sarcomas) and to discuss the reasons why these treatments may not have provided a beneficial effect on outcome (e.g., retrospective study, low case numbers, heterogenous groups, etc).
As an avid proponent of evidence-based medicine and collaborative informed consent, my two challenges to us all are:
1. If you are not already, do not use the paternalistic informed consent as defined by the AVMA but rather the collaborative informed consent as defined by the RCVS and the Federation of Veterinarians of Europe.
2. When we do not have published evidence for procedures/treatments and when we ignore published evidence in favor of our own opinions because of criticisms of the design and/or interpretation of these studies or disbelief of the results, then this should inspire us to search for this evidence for the benefit of our animals, owners, and profession.
As oncologists, we are a collaborative group of like-minded specialists and clinicians and, as the Veterinary Society of Surgical Oncology has shown since its inception, it is possible to work together to develop large, multi-institutional studies to fill these gaps in our knowledge base and practice evidence-based rather than opinion-based medicine.
Passantino A, Quartarone V, Russo M. Informed consent in veterinary medicine: legal and medical perspectives in Italy. Open Journal of Animal Sciences 1:128-134, 201
Advances in Assessment of Tumor Margins
Assessment of surgical margins is a challenging task for the histology technician, pathologist, and submitting veterinarian. It is often difficult to communicate results of margin evaluations to a submitting veterinarian in a written report, or even by phone. This task is further complicated by the various techniques applied in different laboratories to assess margins. The purpose of this article is to familiarize the reader with advances we have made in margin evaluation, which include providing annotated images to our clients.
The most commonly used method to evaluate tumor samples is the cross-sectioning method, also known as the radial method or “halves and quarters” (Fig. 1). The specimen is bisected along its shortest axis. Then, each half of the tissue is bisected through its longest axis, creating quarter sections that demonstrate the mass in a different plane.
While we use this method for routine evaluation of submitted biopsies, this method is not favored for complete margin evaluations since it evaluates a very limited portion of the margin area and makes the erroneous assumption of symmetrical expansile growth of the tumor.
In human medicine neoplasms are sectioned like a “bread loaf” or a “pie” to have the most detailed information for each submission. Parallel slicing at regular intervals (complete bread loafing, serial sectioning) increases the percentage of margin area examined (Fig. 2). Since the distance between sections determines the quality of the margin evaluation, the cost of this approach limits its use in veterinary medicine.
A modified technique combines radial and parallel techniques (Fig. 3). This allows for evaluation of tissue immediately adjacent to the bulk of the tumor and evaluation of some distant margins of the tissue sample.
Tangential sections (shaved edge sections, “orange peel”) provide a complete assessment of surgical margins (Fig. 4). Multiple 2- to 3-mm sections are shaved off the edge of the sample and laid into cassettes with the cut surface down. Any tumor present in these sections is interpreted as incomplete excision. The disadvantage is that the distance of tumor to margins cannot be assessed. By combining cross-sectioning with tangential margin evaluation, we deliver the most complete margin assessment. While expensive, due to the large number of slides and time required for this method, it should be requested for all mast cell tumors, melanomas, mammary tumors, and other carcinomas to more accurately determine tumor extent. By inking the tumor margins the clinician can guide evaluation of certain regions and insure examination of the surgical margins.
Regardless of the method used to evaluate margins, the clinician needs to know to which margin the tumor extends in order to better direct additional resection or select advanced therapy, e.g. radiation. We therefore provide online photographs of tumors submitted for full margin evaluation that detail the exact position of each margin slide that was created by our technician (Figs. 2-5) This allows our pathologist to indicate in the biopsy report where neoplastic cells extend to the margin, and the clinician can view the photos and decide exactly where additional surgical resection or radiation may be needed.
Complete margin evaluations are not recommended for spindle cell sarcomas, as these neoplasms often infiltrate adjacent tissue via extension of thin tentacle-like processes. When such a tentacle is examined in cross section it can be very difficult to differentiate from reactive fibroblasts. Thus, histologic margin evaluation is not always definitive for these cases. Advanced imaging techniques, such as CT and MRI, are much more helpful in determining the extent of these neoplasms prior to surgical resection.
While complete margin evaluations are typically requested for cutaneous neoplasms, online digital photographs are also very useful for assessing margins of neoplasms in other organs and tissues, especially amputated toes, mandibles/maxillas, tails, lung lobes, liver lobes, and spleens. When neoplasms are present in these other “special” organs/tissues, we routinely assess proximal margins without an additional margin fee. A decalcification fee is applied for bony tissues. For example, for an amputated digit, the proximal margins are inked and we examine one soft tissue section taken through the mass (Fig. 5: A1) as well as sections representing the proximal skin margins (Fig. 5: A2 and A3). Then the toe is decalcified and a section is taken from the proximal bony margin (Fig. 5: A4). A longitudinal section through the length of the toe is also examined to assess for bone involvement (Fig. 5: A5).
When an entire lung or liver lobe is submitted with a neoplasm, the proximal margin is inked and at least one representative section that includes both the tumor and healthy tissue (radial section) is examined (Fig. 6: A3). One section is taken perpendicular to the grossly narrowest margin that includes the mass (radial section) (Fig. 6: A4). Then tangential sections from the surgical margin are taken by cutting off the inked edge and lying the resulting sections flat in a cassette inked side down (tangential sections) (Fig. 6: A5-A8).
Evaluation of Surgical Margins
As discussed above, surgical margins of tumor biopsies are evaluated on every routine biopsy in our laboratory. However, on routine samples the evaluation is limited to the extent of the neoplasm on 2 cross sections. A more complete margin evaluation is a complex process and has to be specifically requested for each biopsy submission. To avoid unnecessary costs for our clients and to provide detailed information on the extent of a neoplasm in a submitted section, we have revised a specific protocol explained within the following paragraphs. The following paragraphs and figures also illustrate how referring veterinarians can ink samples before submission, especially if there is a particular margin that is of strong concern.
Figure 7: To correctly identify surgical margins during the trimming process in the histology laboratory, it is necessary to paint (ink) the surgical margins. This can be done by the submitting veterinarian on unfixed samples or in our laboratory after the samples have been fixed. The procedure is simple and does not interfere with the microscopic evaluation. Besides ink, cotton swabs and wooden applicator sticks are all that is needed to perform this procedure. Courtesy of Veterinary Pathology.
Figure 8: Surgical margins of a biopsy are painted with a dye that adheres to the tissue and is visible under the microscope. There are many commercial dyes available, such as the one depicted from Cancer Diagnostics, Inc. Such kits contain multiple different colors (black, blue, green, red, yellow, etc.) for different aspects of mass orientation.
Figure 9: To save money, simple waterproof drawing ink can be purchased (Wal-Mart etc.) and such bottles will last several years.
Figure 10: The drawing ink can even be diluted with isopropyl alcohol (1:1). Isopropyl alcohol is also useful when submitting fixed tissue through the mail in winter months. The 10% neutral buffered formalin used for fixation of specimens is subject to freezing in very low temperatures. The addition of a small amount of isopropyl alcohol to the formalin specimen container (1 part alcohol to 10 parts formalin) will help to prevent damage to the tissue specimen related to freezing and thawing.
Figures 11 and 12: Biopsy margins can be painted on unfixed or fixed tissues. It is often an advantage for referring veterinarians to ink the margins on an unfixed tissue because they have performed the surgery and can best identify margins of concern. The mass should be placed on some absorptive material and needs to be blotted dry prior to painting the margins.
Figure 13: Different colors may be used to mark the cutaneous surface of a mass, which will help the histotechnician to correctly identify the orientation of the neoplasm. Such inking marks are superior to using sutures of different colors in identifying proximal and lateral margins of a mass. Courtesy of Veterinary Pathology.
Figure 14: Using a cotton swab facilitates even color distribution over the deep tissue margins. The referring veterinarians may decide to ink only margins of concern where they suspect incomplete removal. We will only evaluate the inked margins. Courtesy of Veterinary Pathology.
Figure 15: The biopsy margins of the mass may be inked with multiple colors too. Do not pour dye on the surface, but use the cotton swab or wooden applicator stick. A wooden applicator stick is especially helpful to ink the lateral margins by rolling it along these tissue margins. After inking the margins the dye should dry for 5-10 minutes prior to immersing the sample in formalin. Some dye will dissolve within the fixative, but this will not affect the evaluation. For large samples (thicker than 1-2 cm) incisions should be made into the mass to improve penetration of fixative. Courtesy of Veterinary Pathology.
Figure 16: After receiving the tissue, our technicians will palpate the section to determine where the mass/lesion comes closest to the surgical margins.
Figures 17 and 18: We will bisect the specimen vertically through the mass so the section extends through the margin closest to the identified mass and the center of the mass. A 2-6 mm full thickness plane/slab/piece will be cut from the cross section surface of the mass.
As previously illustrated in Figure 1, our laboratory uses the “Cross Method” (i.e. ½’s and ¼’s) as the standard trimming method for ellipse sections. The red line demonstrates the cross section of the mass and the associated closest specimen margin. The blue line demonstrates the quarter sections (1/4’s).
Figures 19 and 20: The inked margins are easy to recognize on the half section of the mass. Depending on the size of the mass, the half section may have to be split to fit into cassettes for further processing. Following embedding in paraffin and sectioning, the half sections of the mass will be placed on slides for microscopic evaluation (Fig.1). Courtesy of Veterinary Pathology.
Figures 21 and 22: Halves of the mass that have resulted from the cross section are vertically cut from the mass/lesion through the longest axis of the tissue and thin sections are placed into cassettes. These pieces demonstrate the mass in a different plane, and the association of the mass with surrounding normal long axis tissue margins
Figure 23: The number of slides necessary to identify whether the deep margins are clean is determined by the size of mass as illustrated. Evaluation of deep margins will be performed along the previously described half and quarter sections.
Figure 24: The half and quarter sections have been placed in cassettes for further processing.
Figures 25, 26 and 27: In addition to the deep margins, lateral margins will be evaluated. These margins are cut vertically to the cutaneous surface of the submitted section and trimmed into cassettes. Detailed evaluation of margins will only be performed following a written or oral request. The number of slides evaluating margins and the price for margin evaluation is based on the size of the excised tissue. As a general rule, sections smaller than 2 cm long will require 2 additional slides. A section of 2-4 cm length will require 6 additional slides, sections of 4-6 cm long need 9 additional slides and sections of 6-8 cm long will require 11 additional slides.
Figures 28 and 29: Inked tissue section margins (lateral margins: figure 24; deep margins: figure 25) are easily recognized on microscopic examination and will help the pathologist to determine complete surgical removal. Courtesy of Veterinary Pathology.
Matti Kiupel, Dr. vet. med. Dr. habil., PhD, Dipl ACVP
Kamstock DA, Ehrhart EJ, Getzy DM, Bacon NJ, Rassnick KM, Moroff SD, Liu SM, Straw RC, McKnight CA, Amorim RL, Bienzle D, Cassali GD, Cullen JM, Dennis MM, Esplin DG, Foster RA, Goldschmidt MH, Gruber AD, Hellmén E, Howerth EW, Labelle P, Lenz SD, Lipscomb TP, Locke E, McGill LD, Miller MA, Mouser PJ, O’Toole D, Pool RR, Powers BE, Ramos-Vara JA, Roccabianca P, Ross AD, Sailasuta A, Sarli G, Scase TJ, Schulman FY, Shoieb AM, Singh K, Sledge D, Smedley RC, Smith KC, Spangler WL, Steficek B, Stromberg PC, Valli VE, Yager J, Kiupel M; American College of Veterinary Pathologists’ Oncology Committee. Recommended guidelines for submission, trimming, margin evaluation, and reporting of tumor biopsy specimens in veterinary surgical pathology. Vet Pathol. 2011 Jan;48(1):19-31.
Klimberg VS, Harms S, Korourian S. Assessing margin status. Surg Oncol. 1999 Aug;8(2):77-84.
Mann FA, Pace LW. Marking margins of tumorectomies and excisional biopsies to facilitate histological assessment of excision completeness. Semin Vet Med Surg (Small Anim). 1993 Nov;8(4):279-83.
Wick MR, Mills SE. Evaluation of surgical margins in anatomic pathology: technical, conceptual, and clinical considerations. Semin Diagn Pathol. 2002 Nov;19(4):207-18.
Facing the holiday season for the first time following the loss of your beloved companion animal can be extremely challenging. The holidays represent a time for joy and reflection, but when you have lost your pet, you might feel unable to celebrate, because your lap or the space next to you is empty. Participating in traditional family activities is an ongoing reminder of what is missing from your life.
The following recommendations serve as a guide to help you through the holidays, while taking into consideration that grief is a unique and individual experience:
Acknowledge the Pain
Grieving the loss of a pet is agonizing at any time of the year and the holidays tend to intensify feelings of loneliness and sorrow. You may feel pressured to mask your true feelings, but pretending you are not brokenhearted will only delay you from moving in a forward direction. Ultimately, embracing the sadness can help with leading you out of the pain. Grief comes as a result of love and is a tribute to the remarkable relationship you shared with your companion animal.
Treasure the Memories
While your pet’s physical presence is gone, the love, memories, and lessons learned will always be with you. Do not be afraid to remember the favorable times with your pet, as this can be a source of comfort while experiencing extreme heartache. Reflecting upon and taking an inventory of the gifts you received from your faithful companion animal sparks the healing process. One way to honor the relationship between you and your pet is to acknowledge how your life has been changed for the better.
Revise Holiday Traditions
For many individuals, companion animals are a vital part of the holiday celebrations and it is almost impossible to comprehend the fact they will not be here this year. Recognizing the holidays will be different without your pet and planning ahead for the change may make it less overwhelming. While there is a great value in upholding holiday traditions, it might not feel right to participate in the familiar festivities after the loss of a pet. Grief provides the opportunity to pause and reexamine past traditions and create new rituals if the need arises. The goal is to make the holidays work for you in less than ideal circumstances.
Connect with Children
The holidays can definitely be hard for children, because they are experiencing sadness due to the loss, but at the same time feel the excitement of the impending celebration. Communicate with children to let them know it is okay to have fun without feeling guilty. With regard to modifying holiday traditions, keep in mind children depend on the familiarity of annual rituals, since it provides them with a sense of security. Before finalizing the holiday plans, listen to what is important to your children and try to incorporate their hopes and wishes into the celebration.
Establish a New Ritual
When a daily routine was centered on the relationship with a pet, the death can also be profoundly disruptive to one’s sense of home, safety, purpose, and identity. Find a way to include your departed pet into a new tradition by keeping his/her memory alive during the holiday season and beyond. In the matter of forming a new ritual, consider writing a gratitude list of the noteworthy experiences you enjoyed with your pet, lighting a remembrance candle at the holiday dinner, decorating a tree ornament with your pet’s picture, creating a picture book or video, and sharing wonderful stories about your companion animal with family and friends. Remember the love that you shared and make a difference in your pet’s honor by giving back, in terms of volunteering or donating at a local animal shelter.
Engage in Social Support
The need for support may be the greatest in the midst of the holiday season. Be honest with how you are truly feeling with the people you love and give them the opportunity to be there for you. After the loss of a companion animal, reaching out to family and friends can be a daunting task. If you know someone who is grieving over the loss of a pet, do not wait for an invitation for help, but show up and lend support by being present.
Practice Self Care
Navigating through the first holiday season following the loss of a pet can feel incredibly confusing and problematic. Grieving is an exhausting process and the pain invades all parts of your life, which is why it is essential for your mind and body to take a hiatus from dealing with the complicated thoughts and emotions. Plan an activity to bring a moment of comfort and joy that will allow you to take a much-needed break. Schedule the holiday around supportive family and friends, but balance it with quiet time as well. Try to streamline your life as much as possible in relation to the holiday preparations. Most importantly, be kind to yourself and realize your pain is entirely appropriate.
The first holiday season after the passing of a family pet is generally the most difficult. While there is not an easy solution to alleviate the heartache, you can manage the holidays better by taking charge of the season. Introducing new traditions to honor your pet’s memory may cause some tears along the way, but it can also provide healing as you strive to make it through the holidays.
My wish for you this holiday season is that you find peace in your heart and hope in new beginnings.
Losing a pet can impact the entire family, but it can be especially painful for children, since it is typically their first encounter with death. The relationship a child has with a companion animal determines the level of grief he or she will experience with the loss. Understanding the bond shared between children and their pets is the first major step in assisting them through the loss. Children require support and guidance to comprehend the loss and move forward in the grieving process while continuing to honor their pet’s memory.
Helping Children Cope with a Pet’s Illness
- Discussions should be tailored to the child.
- Be straightforward and honest in all instances.
- Do not hide a pet’s condition from children.
- Carefully plan to include all family members and discuss all options.
- Decisions about family pets should not be made in haste.
- Children should be allowed to ask questions.
How to Prepare Children for Euthanasia
- Create an environment where a child feels safe to ask questions.
- Define euthanasia in the simplest of terms: a good death.
- Emphasize how euthanasia is a selfless and loving act of courage.
- Help children understand the need for euthanasia.
- Educate children what will occur before, during, and afterward.
- Explain the pet will die peacefully, without feeling hurt or scared.
- Avoid the common phrase, “put to sleep.”
- Communicate about the physical changes that occur after death.
- Younger children require a clear explanation of death.
Should a Child be Present When a Pet is Euthanized?
- Children are all unique and a parent knows the child best.
- The recommended age for a child is 10 years of age or older.
- If old enough, the child should be given the choice to attend.
- Children who do not wish to witness, may want to view the body.
- Having a final goodbye can help create a sense of closure.
Speaking Truthfully about a Sudden Loss of a Pet
- Communicate with the child as soon as possible.
- Select a quiet and familiar setting to avoid distractions.
- Focus on the facts using simplistic language.
- Listen carefully and remain silent while the child processes the news.
- Openly discuss feelings, which will prompt a child to share as well.
- Allow the child to express as much grief he or she is experiencing.
- Respond to emotions with comfort and reassurance.
- Be patient and supportive throughout the entire process.
How to Explain Cremation and Burial to a Child
- Keep the discussion at a level that matches the child’s understanding.
- Follow the child’s lead as you answer questions about cremation.
- Avoid using the words fire or burned in the details.
- Make it clear that the deceased pet is not hurt in the process.
- Describe how the pet will be sealed in a box and placed in the ground.
- Be prepared to answer questions on this topic at a later time.
The Healing Power of a Ritual
- Holding a ceremony for a pet can be an important step in beginning to heal:
- Reinforces the reality of the death.
- Acknowledges the loss within the family.
- Provides support from family and friends.
- Offers the opportunity to express feelings of grief.
- Encourages the sharing of memories that celebrate the life of the companion animal.
- Serves as a means to provide closure after the loss.
Helping a Child to Honor and Preserve a Pet’s Memory
- Design a special gravestone
- Create a paw print and save a lock of hair
- Frame a portrait
- Assemble a scrapbook or collage with photographs
- Write a poem or short story about a pet.
- Plant a tree.
- Make a donation in your companion animal’s name
- Volunteer at an animal shelter.
Understanding Grief and Loss from a Child’s Perspective
- The death of a pet is often a child’s first encounter with death.
- For most children, pet loss can be a deeply painful experience.
- As children mature, their knowledge base of death expands.
- Many children develop differently and it is crucial to follow their lead.
- Adults should be nurturing and empathetic regarding loss.
Supporting a Child after the Loss of a Companion Animal
- Recognize that pet death is a significant loss for children.
- Emotional responses to a pet’s death will vary depending on the relationship.
- Be available to listen and answer questions with care.
- Assure children they are not responsible for the pet’s death.
- Encourage the child to express his or her feelings and share memories.
- Permit the child to talk about what it is like without his or her pet.
- Realize a child’s reaction may be more intense with a sudden death.
- Enlist positive reinforcements by notifying relatives, friends, and teachers.
- Provide ongoing support weeks and months following the loss of the pet.
Suggested Readings for Children and Families
- Jasper’s Day – Marjorie Blain Parker
- The Day Tiger Rose Said Goodbye – Jane Yolen
- Dog Heaven – Cynthia Rylant
- Cat Heaven – Cynthia Rylant
- The 10th Best Thing About Barney – Judith Viorst
- A Special Place for Charlee: A Child’s Companion Through Pet Loss – Debby Morehead
- The Fall of Freddie the Leaf: A Story of Life for All Ages – Leo Buscaglia
- I Will Always Love You – Hans Wilhelm
- When a Pet Dies – Fred Rogers
- Children and Pet Loss: A Guide for Helping – Marty Tousley
- When Your Pet Dies: A Guide to Mourning, Remembering, and Healing – Alan Wolfelt
When to Adopt Another Pet
- Involving the entire family in the decision to adopt a pet is vital.
- Adopting a pet too quickly might deny the child’s right to mourn.
- Children may take longer moving through the grieving process.
- The decision to adopt another pet does not represent disloyalty.
- Remember, the previous companion animal cannot be replaced.
- Let the next pet choose you.
- Do not expect the pet to become an instant member of the family.
For further guidance and information, please contact Jennifer Durn, MSW, LSW by phone (610) 296-2099 or email jdurn@HopeVS.com