Veterinary Vertex
Veterinary Vertex is a weekly podcast that takes you behind the scenes of the clinical and research discoveries published in the Journal of the American Veterinary Medical Association (JAVMA) and the American Journal of Veterinary Research (AJVR). Tune in to learn about cutting-edge veterinary research and gain in-depth insights you won’t find anywhere else. Come away with knowledge you can put to use in your own practice – along with a healthy dose of inspiration to remind you what you love about veterinary medicine.
Veterinary Vertex
Predictive Tools for Splenic Mass Etiology in Dogs
Discover the critical insights from Dr. Janet Grimes and Townes Hillier as they join us to unravel the complexities of splenic masses in dogs. Their extensive knowledge sheds light on the limitations and potential of predictive calculators like the HeLP score and T-STAT, providing a clearer understanding for veterinarians and pet owners making difficult treatment decisions for patients with splenic masses. Join us as we explore the intricacies of splenic mass diagnosis and the importance of clinical judgment as well as the need for more reliable predictive calculators.
JAVMA article: https://doi.org/10.2460/javma.24.01.0016
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Speaker 2:You're listening to Veterinary Vertex, a podcast of the AVMA Journals. In this episode we chat about calculators used to preoperatively determine the etiology of splenic masses in dogs with our guests Janet Grimes and Townes Hillier.
Speaker 3:Welcome to Veterinary Vertex. I'm Editor-in-Chief Lisa Fortier, and I'm joined by Associate Editor Sarah Wright. Today we have Janet and Townes joining us. Janet, welcome back, and Townes, thank you so much for taking time out of your busy schedule to be with us here today.
Speaker 4:Thank you so much for having us. We're very excited to chat with you all today. Yes, thank you for having us.
Speaker 2:All right, let's dive right in Towns. Your JAVMA article discusses how improved predictability is needed for calculators used to preoperatively determine the etiology of splenic masses in dogs. Please share with our listeners the background on this study.
Speaker 5:Yeah, of course.
Speaker 5:So, as most of us know, the diagnosis of splenic masses prior to surgery and histopathology is very challenging, because they can either be benign or malignant and have very different prognoses.
Speaker 5:So most veterinarians rely on the double two-thirds rule to inform owners of the prognosis of splenic masses.
Speaker 5:This rule basically implies that two-thirds of splenic masses are malignant and then two-thirds of those masses are hemangiosarcoma, and recent studies have actually found that this rule may not be as accurate as we previously thought, and so recently there have been two different calculators that have been developed to predict the etiology of splenic masses prior to surgery.
Speaker 5:So calculators are a great idea and would be an easy way for owners to get more clarity on the situation before deciding to move forward with treatment, and so one of the calculators that was recently developed is the hemangiosarcoma likelihood prediction, or HELP score, and so this model was developed for dogs with non-traumatic chemoabdomens from any organ, and this calculator uses patient body weight, total plasma protein, platelet count and thoracic radiograph findings to give each dog a score from either zero to greater than 55, which is considered the cumulative help score, and then, based off this number, they are then assigned into a risk of low, medium or high for hematomandiasarcoma and that is called the categorical help score. And the other calculator that was developed is the Tufts Splenic Tumor Assessment Tool, or TSTAT, and so this was developed to estimate the probability of malignancy in dogs with splenic lesions, with or without hemoperitoneum, and this calculator uses eight different variables from blood work and abdominal ultrasound to determine the probability of malignancy, and these animals are then assigned a percentage of one to 100% no-transcript.
Speaker 3:I'm an equine orthopedic surgeon so I was like, do people really use these calculators? That was the true genesis of the question, that's true.
Speaker 2:So, with that being said, Towns. What were some of the pivotal findings from this study?
Speaker 5:So both of these scores report an area under the curve, or AUC, which basically helps us compare different scoring systems. And so an AUC of 0.5 is like a coin flip, so 50-50 chance that it predicts the correct diagnosis, whereas a score of one is perfect accuracy, so it will predict the right diagnosis 100% of the time. And the AUC is then given a score of either poor, acceptable, excellent or outstanding. And so our study's purpose was to compare these scores. And so what we found is that the T-STAT had an AUC of 0.68 for this diagnosis of malignant lesions, which is actually considered poor performance, and this is less than what they had originally reported. But for the cumulative help score it had an AUC of 0.79. And then the categorical help score had an AUC of 0.73 for the diagnosis of hemangiosarcoma, which is considered acceptable performance, and this is very similar to the original study. We also found that the cumulative help score performed better than the categorical help score, which was possibly due to dogs, you know, at the different extremes of each categorical score being incorrectly categorized.
Speaker 3:Janet, you're starting to get a reputation a bit of like a myth buster when it comes to hemoabdomen splenic masses. What sparked your research interest in this area?
Speaker 4:So I really became interested in splenic masses during my surgery residency. It was the focus of my master's project and it really has become a true passion of mine, and so I think part of it is the challenge right. So we don't know what these are prior to surgery, and it's a huge challenge for the owner and the veterinarian having to try to counsel this owner as to you know what the best next steps are, and so it's. It is such a dichotomy. As Towns mentioned, you know, it could be hemangiosarcoma, which is a devastating tumor with short survival times, even with multimodal treatment. But on the flip side, the dog could be cured, and we don't get to say cure a ton when we're dealing with masses. So it is really difficult. And so I got really interested in research to try to help solve that challenge, to try to figure out how do we figure out what the etiology is before surgery, and so I think it's really fascinating, and then there's just so much potential to help clients and their dogs and the veterinarians having to help make these decisions.
Speaker 3:Yeah huge, huge problem and if you can keep going until we figure it out and again I said earlier, welcome back to the podcast and thank you for submitting this manuscript, as well as your others, to JAVMA. Why did you choose to submit this manuscript to JAVMA?
Speaker 4:Yeah, so one of the main reasons is splenic masses are so common and I really wanted to make sure we were able to disseminate this information to as many veterinarians as possible. And so JAVMA is, you know, one of the most widely read journals, reaches not only specialists but also the primary care practitioners, who are seeing infinitely more of these than we are, and so I knew if we were published with Javma, that we would reach that huge audience. And, just as a plug for y'all, I've really appreciated the changes y'all have made. It's a really quick, quick process from submission to publication and the review process is, you know, the reviewers tend to be friendly and really I think they, you know, of course help improve the manuscript with their questions as well, but it's been a really smooth process and I know we can get the information out there quickly.
Speaker 3:Yeah, thank you. We have a fabulous team. Our current time from submission to publication is less than 100 days, with double reviews. So we're really proud of the team and the authors have really responded and provided us with really clinically important manuscripts, like you have. So we're grateful for that. Townes, sarah asked you earlier what were some of the pivotal findings of your manuscript, but always when we write manuscripts, articles, we're surprised by some findings. What was the most surprising finding from your study?
Speaker 5:All right. So the most surprising finding for us was that the HELPS score categorized dogs with hemangiosarcoma very evenly between risk categories, so about a third of dogs were in each category, so either low, medium or high risk, and it was actually better at classifying dogs with benign masses, and so 76% of those dogs with benign masses were classified as low risk. And so we believe that one factor that may have affected this score is the platelet count, and so the assigned score for platelet count is very similar for the different degrees of thrombocytopenia, and low platelet count has also been found to have a high positive predictive value for hemangiosarcoma, but a relatively low negative predictive value, and so this is likely because a low platelet count more represents severe hemorrhage rather than a specific diagnosis, and so dogs with hemangiosarcoma are more likely to have hemorrhage than dogs with other diagnoses. So while use of a platelet count may be accurately classify some dogs, it is still a nonspecific marker.
Speaker 2:I think that's really good information for clinicians because it's so easy, you know, just to get a quick platelet count and then have, like you know, a technician do a manual count right, just to make sure. So important not to rely on that too heavily. And for those of you just joining us, we're discussing calculators used to preoperatively determine the etiology of splenic masses in dogs, with our guests Janet Grimes and Towns Hillier. So, towns, how did your advanced training prepare you to write this manuscript?
Speaker 5:So prior to this study, I didn't have much experience with research and this is actually one of my first studies that will be published, I think. To get experience and be prepared to write a manuscript it takes really great mentorship and I was lucky enough to have a great mentor like Dr Grimes, who has so much experience, as you guys have already said, in research, and she really helped me write this manuscript.
Speaker 2:Yeah, it's great to hear. And just putting in a plug, for our journal awards, which are available to students and house officers that have published in JAVMAR or AJVR, the deadline for our manuscripts published in 2024 will be in March of 2025. So, for anyone listening, feel free to submit a nomination. They are rolling until that date for this year's manuscripts. And now this next set of questions is really important for our listeners Townes. What is one piece of information the veterinarian should know before discussing calculators used to preoperatively determine the etiology of splenic masses in dogs with the client?
Speaker 5:So I think the most important thing is to keep in mind that they still need to rely on their clinical judgment and the full clinical picture for each patient. These calculators, you know, may be able to help you with your conversation with the owner, but they aren't always accurate, as we've kind of found in this study.
Speaker 2:Yeah, I think that's good information to have, always important to remember that you are one of the best tools in your toolkit, so good to keep that in mind. And then Janet, on the other side of the relationship, what's one thing clients should consider around? Calculators used to preoperatively determine the etiology of splenic masses in dogs.
Speaker 4:So I think it's pretty similar to what Town said for the veterinarians. I think clients should know there's more to the diagnosis than just the score, and so the scores are also reliant upon the data put into the calculator. So if your veterinarian's asking for an ultrasound or for more blood work, it may be to help them, help you, make that diagnosis and or, you know, make that prediction of what they think the diagnosis will be. But still, I think it's important to remember that, even if the score indicates a high likelihood of hemangiosarcoma or malignancy, there's still a chance the tumor's benign and, conversely, if you go into it thinking, oh, everything pointed to benign disease, with the calculators, histopathology may still return with hemangiosarcoma as a diagnosis, and so I think it's really helpful to have these in the toolkit, because it is a difficult situation.
Speaker 4:It makes the decision. You know it's a very hard decision to make, and so I think they could be useful to help. You know, sway a client who's really on the fence but you can't put. You know all your stake in that. You know it's not perfectly accurate, and so I think for me this really emphasizes that we need to do more work to find a calculator that's going to have perfect accuracy or some sort of biomarker to help diagnose that disease process accurately before surgery. And so if they ever have an opportunity to be part of that research, you know I hope they would jump at the chance to help future dogs and owners with that condition.
Speaker 3:So important, you know, and I hear lots more manuscripts coming our way, so we look forward to your next steps, yours and Towns, on trying to figure out this dilemma that's so important for our profession and our pets. Yeah, absolutely. As we start to wind down a little bit, we try to ask a little more of a personal fun fact. So, townes, for you, what is your favorite animal fact?
Speaker 5:So one of my favorite animals is otters, and so otters actually hold hands while sleeping so they don't float away from each other, which I think is really cute.
Speaker 3:So that's adorable. Yeah, we haven't gotten that one before, janet, a little bit different for you. When you do a puzzle, do you start with the inside or the exterior border pieces?
Speaker 4:So I always start with the edge pieces and then, once I've got those, I sort the inside pieces by color. So I try to do everything in a methodical way, which may not surprise you, given my profession as a surgeon.
Speaker 3:Yeah, I would say that's true. That's a predictor of surgeons.
Speaker 2:Yeah, definitely our most common answer. I think too, and, towns, you might appreciate this. I have a bunch of otter prints in my office. One is a hand-drawn picture from one of our marine mammal trainers from a previous fellowship that I did, and I also have some nose prints and little paw prints too, which are cute. But thank you both, jana and Towns, we really appreciate you being here today and sharing the knowledge from your manuscript, too, with our listeners.
Speaker 4:Well, thank you so much for having us. We really appreciate you giving us the opportunity to share more about our work.
Speaker 5:Yes, thank you so much. It's been nice talking to you guys.
Speaker 2:And to our listeners. You can read Janet and Towne's article and print Javma or online using your favorite search engine. I'm Sarah Wright with Lisa Fortier. We want to thank each of you for joining us on this episode of the Veterinary Vertex podcast. We love sharing cutting edge veterinary research with you and we want to hear from you. Be sure to leave us a rating and review on Apple Podcasts or whatever platform you listen to.
