Carcinomas

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Carcinomas




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Presentations text content in Carcinomas

Slide1

Carcinomas

Wendy Blount, DVM

Slide2

Carcinomas

Squamous cell carcinoma (canine & feline)

Transitional

c

ell carcinoma (canine)

Mammary Gland Tumor (canine & feline)

Perianal tumor (canine)

Anal sac tumors (

c

anine)

Thyroid Carcinoma

Meningioma

Slide3

Squamous Cell Carcinoma

Feline Squamous Cell carcinoma

Second most common tumor in the cat

Oral SCC behaves differently than skin SCC

Canine Squamous Cell Carcinoma

Similar behavior as SCC in cats, but not as common

Slide4

Squamous Cell Carcinoma

Feline Cutaneous Squamous Cell Carcinoma

Most frequently on the head

Pinnae, nose, eyelids

Caused by sun exposure to light colored skin

Progression over time

Solar dermatitis

– crusts and scabs

Actinic dermatitis

- plaques

SCC in situ

– noninvasive mass

Invasive SCC

– ulcerative, invasive mass

Slide5

Squamous Cell Carcinoma

Feline Cutaneous Squamous Cell Carcinoma

Solar dermatitis

Actinic dermatitis

Slide6

Squamous Cell Carcinoma

Feline Cutaneous Squamous Cell Carcinoma

SCC in situ

SCC

Slide7

Squamous Cell Carcinoma

Feline Cutaneous Squamous Cell Carcinoma

Cytology often not helpful

Very inflammatory

Dx

- histopathology

Staging not usually necessary, as metastasis is rare

Tx

– early lesions

Surgery, cryosurgery, Strontium radiotherapy, photodynamic therapy

immunomodulatory agent imiquimod (Aldara

TM

) as a topical cream

Slide8

Squamous Cell Carcinoma

Feline Cutaneous Squamous Cell Carcinoma

Tx

– advanced lesions

Difficult to treat

Removal of the nasal planum is possible, but disfiguring

Slide9

Squamous Cell Carcinoma

Feline Cutaneous Squamous Cell Carcinoma

Partial planectomy

Pinnectomy and planectomy

Slide10

Squamous Cell Carcinoma

Feline Cutaneous Squamous Cell Carcinoma

Untreat

e

d for too long

Slide11

Squamous Cell Carcinoma

Feline Oral Squamous Cell Carcinoma

Most common oral tumor in the cat

Gingiva, tongue/sublingual, tonsil

Much more aggressive than cutaneous SCC

Maxillary tumors can mimic tooth abscess

Surgery often not possible

Radiation sensitive, but high morbidity – mandatory feeding tube

Slide12

Squamous Cell Carcinoma

Feline Oral Squamous Cell Carcinoma

Chemotherapy not effective

NSAIDs are palliative

Median survival 44 days

+

NSAIDs

9% survival at one year

Survival more than a few months even with multimodal therapy is rare (

BJ Honeycat

)

Slide13

Slide14

Squamous Cell Carcinoma

Feline Lung Squamous Cell Carcinoma

Often presents as multiple nail bed tumors

Primary tumor is found on chest x-rays

Always take chest x-rays prior to amputating a possibly neoplastic nail bed in a cat

Animals with systemic neoplasia often do not do well under anesthesia

Amputation is palliative only

Slide15

Squamous Cell Carcinoma

Canine Digital Squamous Cell Carcinoma

Nail bed SCC can be primary in the dog

MSA, MCT and SCC are most common digital tumors in the dog

SCC more likely to show bony

lysis

than others

Toe amputation is often curative

LN aspiration and thoracic radiographs indicated prior to surgery

Slide16

Transitional Cell Carcinoma

Most common bladder tumor in the dog (90%)

Most common symptoms are hematuria and stranguria

Things that increase suspicion

Atypical transitional cells in the urine sediment

Mass in the bladder or urethra on imaging

Thickened urethra on rectal exam (

sheltie

)

Ruptured urethra on catheterization (

chihuahua

)

Slide17

Transitional Cell Carcinoma

Etiology

Exposure to older topical flea treatments, dips and lawn chemicals (28x)

Possibly cyclophosphamide therapy

Neutered > sexually intact (2.5x)

Scottish terriers 18-20x other dog breeds

Eating vegetables 3x a week is protective

Shelties, Westies, beagles 3-5x other breeds

Slide18

Transitional Cell Carcinoma

Dx

– histopath

Surgery, cystoscopy, traumatic bladder wash

Percutaneous aspiration can seed tumor cells and should be avoided

Take care to avoid seeding during surgery

Slide19

Transitional Cell Carcinoma

Tx

At one time, radiation therapy was recommended, as TCC is highly responsive

But resulting permanent incontinence was common

If at the apex, resection can produce long disease free interval (1-2 years) – (

Tess

)

Secondary UTI is common – treat PRN

Ureteral stents can restore urine flow

Urethral stents can relieve obstruction if urethral sphincter and continence can be preserved

Prepubic cystostomy tube can relieve obstruction

Slide20

Transitional Cell Carcinoma

Tx - NSAIDs

Mainstay of treatment is medical therapy

Not curative, but remission is achieved in 15-20% and stable disease is reached in 75% of dogs

Piroxicam only – median survival 195 days

0.3 mg/kg PO SID to QOD

Deramaxx only - median survival 323 days

3 mg/kg PO SID

Previcox similar success

Median survival surgery only is 109 days

Slide21

Transitional Cell Carcinoma

Tx - Chemo

Mitoxantrone and piroxicam (see chemo section for details)

35% remission with minimal toxicity

Median survival 291-350 days

Single agent vinblastine (see MCT notes)

36% remission

50% stable disease

Most of these had failed other therapies

Relatively more toxicity than mitoxantrone + piroxicam

Slide22

Transitional Cell Carcinoma

Tx - Chemo

Doxorubicin and cyclophosphamide

Median survival 259 days

Metronomic therapy

Chlorambucil 4 mg/m

2

PO SID

See Chemotherapy section for monitoring

29 of 31 dogs had failed prior TCC treatment

3% partial remission, 67% stable disease, 30% progressive disease

Median survival 221 days

Slide23

Transitional Cell Carcinoma

Px

Euthanasia often due to obstruction, metastasis or both

50% have metastasis at the time of death

Some will invade the sublumbar lymph nodes and then the spinal cord and present as acute posterior paralysis, often with urethral obstruction (

1 cat, 2 Rottweilers

)

Slide24

Transitional Cell Carcinoma

Slide25

Canine Mammary Gland Tumor

42% of tumors in all intact female dogs

Rare in dogs less than 5 years old

duration of exposure to ovarian hormones early in life determines the overall mammary cancer risk (Dorn et al, 1968).

0.5% if OHE prior to the first heat

8 if OHE prior to the 2

nd

heat

26% if OHE after the 2

nd

heat

tumor risk increases incrementally each year and plateaus around 11–13 (Schneider, 1970)

intact females are more likely to have an anaplastic tumor type, compared to dogs spayed early or late in life, prior to MGT (Ogilvie, 2006)

Slide26

Canine Mammary Gland Tumor

The effect of neutering on the risk of mammary tumours in dogs--a systematic review. J Small Anim Pract. June 2012;53(6):314-22. W Beauvais

1

; J M Cardwell; D C Brodbelt

Due to the limited evidence available and the risk of bias in the published results, the evidence that neutering reduces the risk of mammary neoplasia, and the evidence that age at neutering has an effect, are judged to be weak and are not a sound basis for firm recommendations.

Slide27

Canine Mammary Gland Tumor

Review article – not a clinical study at all

Conclusions:

9/13 were judged to have a high risk of bias, and though they all showed a connection between MGT and failure to spay, they were not considered as evidence.

The remaining four were classified as having a moderate risk of bias.

One study found an association between neutering and a reduced risk of mammary tumors.

Two studies found no evidence of an association.

One reported to have "some protective effect" of neutering on the risk of mammary tumors.

Slide28

Canine Mammary Gland Tumor

 

BMJ

. 2003 Dec 20;327(7429):1459-61.

Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of

randomised

controlled trials

.

Smith

GC1, Pell JP.

OBJECTIVES:

To

determine whether parachutes are effective in preventing major trauma related to gravitational challenge.

DESIGN

:

Systematic

review of

randomised

controlled trials.

RESULTS:

We

were unable to identify any

randomised

controlled trials of parachute intervention.

CONCLUSIONS

:

As

with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using

randomised

controlled trials. Advocates of evidence based medicine have

criticised

the adoption of interventions evaluated by using only observational data.

We

think that everyone might benefit if the most radical protagonists of evidence based medicine

organised

and participated in a double blind,

randomised

, placebo controlled, crossover trial of the parachute.

Slide29

Canine Mammary Gland Tumor

70% have more than one tumor at the time of diagnosis

Mammary gland tumors can be epithelial, myoepithelial, mesenchymal or mixed

Complex MGT

– epithelial and myoepithelial

Mixed MGT

– epithelial and mesenchymal

Slide30

Canine Mammary Gland Tumor

MGT Stages

Stage I

– less than <3cm and localized

Stage II

– 3-5 cm and localized

Stage III

- >5cm and localized

Stage IV

– any size, metastasis to lymph node

Stage V

– any size, distant metastasis

Slide31

Canine Mammary Gland Tumor

MGT Staging

CBC – check for evidence of infection

Profile – hypercalcemia

Aspirate draining lymph node

Thoracic radiographs – 3 views

Abdominal US

Slide32

Canine Mammary Gland Tumor

MGT StagingCBC – check for evidence of infectionProfile – hypercalcemiaAspirate draining lymph nodeThoracic radiographs – 3 viewsAbdominal US

Slide33

Canine Mammary Gland Tumor

Surgery

As with all masses removed, label margins so they can be read out

Describe the location of the lesion

Mark one end of one direction (e.g., cranial or caudal) with one type suture

Mark one end of the plane 90

O

to above with another type suture, if necessary

Don’t forget to describe your labeling on the submission form

Slide34

Canine Mammary Gland Tumor

Surgery – OHE?

The majority of MGT of epithelial origin express estrogen receptors, suggesting that reproductive hormones may play a role in the pathogenesis

755 days median survival - dogs spayed at or within 2 years before MGT surgery

286 days median survival – dogs not spayed at MGT surgery

301 days median survival – dogs spayed more than 2 years prior to MGT surgery

It’s rare for MGT to develop more than 2 years after OHE

Slide35

Slide36

Canine Mammary Gland Tumor

Prognosis

50-60% of mammary gland tumors are benign

98% of tumors <1 cm are benign

50% of tumors >3cm are malignant

Malignant tumors develop from benign masses

Early removal is usually curative

Slide37

Canine Mammary Gland Tumor

Inflammatory Mammary Carcinoma

Acute onset of painful, extensive swelling of the mammary glands

Fine needle aspiration with a 25g needle can drip blood for days (DIC)

Rapidly progressive

Grave prognosis

Slide38

Perianal Tumors

“aka” hepatoid tumor

Most common in older intact male dogs

And females with testosterone producing adrenal tumors

Tumor site – perineum > tail, abdomen

Most often found without symptoms

Tenesmus can be caused by the lesion or submandibular lymphadenopathy (palpable rectally)

60-80% benign

Those that are malignant often behave as anal sac tumors

Slide39

Perianal Tumors

Staging prior to surgery

Abdominal rads and/or sonography to evaluate sublumbar lymph nodes

Large tumors >2cm and single tumors should be removed

If multiple small tumors or coalescing tumors, castrate first (if male)

Remove any tumors that do not resolve in 2-4 weeks

Unless males are castrated, new tumors will likely arise

Slide40

Anal Sac Carcinoma

Highly malignant

Locally invasive AND distant metastases

90% develop hypercalcemia

25-50% are hypercalcemic at diagnosis

50-94% have lymph node metastasis at the time of diagnosis

Slide41

Anal Sac Carcinoma

Presentation

Found on anal sac expression

Dyschezia, tenesmus, ribbon-like stools

Attention to the perineum, scooting

Perianal bleeding

PU-PD (hypercalcemia)

Hind limb weakness or posterior paralysis

May be bilateral – check the other side

Slide42

Anal Sac Carcinoma

Staging

Profile – hypercalcemia, azotemia

Abdominal rads and/or sonography

Sonography more sensitive than rectal palpation or rads for finding enlarged sublumbar LN

Thoracic radiographs – 3 views

Aspirate popliteal and inguinal lymph nodes

Sublumbar if large enough and you are comfortable doing this with ultrasound guidance

Slide43

Anal Sac Carcinoma

M

edian Survival – no treatment

7-9 months

masses larger than 3cm

Dogs with hypercalcemia and/or pulmonary metastasis

18-19 months

Masses smaller than 3cm

Dogs with normocalcemia and no lung mets

Slide44

Anal Sac Carcinoma

M

edian Survival

Surgery only

90% survival at 6 months (hypercalcemia often goes into remission, even if incomplete excision)

65% survival at one year

29% survival at 2 years

20% temporary fecal incontinence, some permanent

Wound infection and sepsis can occur

30% perioperative fatality when sublumbar lymph nodes are removed

Slide45

Anal Sac Carcinoma

M

edian Survival

Multi-modal therapy – surgery, radiation of nodes, doxorubicin/carboplatin

18-26 months median survival

86% survival at 6 months (similar to surgery alone)

69% survival at one year (same as surgery alone)

36% survival at 2 years (maybe more than surgery alone – 29%)

14% survival at 3 years

Median survival 22 months with radiation alone

15% rectal structure

Slide46

Thyroid Carcinoma - Dog

3-4% of tumors in dogs

90% are malignant

Boxers, Golden Retrievers and Beagles are at increased risk

Most common presentation is ventral cervical mass

Change in bark or breathing

Cough

Occasionally swelling or regurgitation

Hyperthyroidism is rare

Slide47

Thyroid Carcinoma - Dog

Diagnosis

Cytology

Vascular – may get blood only

often confirm endocrine origin, but it can be difficult to confirm malignancy

US guidance can target a solid spot for better results

Incisional biopsy can result in massive hemorrhage – not recommended

US can confirm mass is of thyroid origin

Slide48

Thyroid Carcinoma - Dog

Staging

Ultrasound – assess lymph nodes and local invasion

3 view thorax

Slide49

Thyroid Carcinoma - Dog

Treatment

Surgery

If freely moveable, surgery can result in a long disease free interval

If invasive, surgery can be difficult

Hemorrhage

Damage to recurrent laryngeal nerves (LP) or carotid aa.

Hypocalcemia if all parathyroids damaged or removed

Slide50

Thyroid Carcinoma - Dog

Treatment

External Beam Radiation

For unresectable masses

80% stable disease at 1 year, 72% at 3 years

For residual disease after surgery

Chemotherapy

Single agent carboplatin or mitoxantrone

Or alternate

Every 3 weeks, 4-6 treatments

Outcome is unknown

Slide51

Thyroid Carcinoma - Cat

Most present with hyperthyroidism

Diagnosis made by thyroid nuclear scan

Or histopath after thyroidectomy

Cytology may be diagnostic

Treatment

Higher dose of I131 – may need to be repeated

Surgery if no evidence of metastasis on nuclear scan

Chemotherapy remains unexplored

Slide52

Meningioma

Most common brain tumor in geriatric dogs and cats

Dolichocephalic breeds predisposed

10% of non-lymphoma neoplasias in cats are meningiomas

Multiple meningiomas are not uncommon in cats

Despite being “not malignant,” usually eventually result in death if not removed

Slide53

Meningioma

Clinical Signs

Subtle changes in behavior over time

Patients adapts to gradual increase in intracranial pressure

Acute onset of severe neurologic signs not unusual – Cerebral signs most common

Cluster seizures, changes in behavior

Contralateral blindness, ipsilateral circling, looking to that side, pacing

Stupor, head pressing, getting stuck in corners

CP deficits worse in the rear, UMN ataxia

Slide54

Meningioma

Clinical Signs

Cranial nerve signs if in the brain stem

Spinal reflex deficits if in the spinal cord

LMN 2 dermatomes caudal to the lesion

UMN below the lesion

Remember cats can have more than one

Slide55

Slide56

Meningioma

Diagnosis

Radiographs are rarely helpful

Occasionally the tumor is mineralized

CSF tap rules out infectious and inflammatory diseases

Increased CSF pressure can result in herniation

Hyperventilate with 10 breaths prior to stick

Give mannitol if high CSF pressure is suspected

Pacing, altered consciousness, dysphoria

Increased protein, increased mononuclear cells

Unusal to see neoplastic cells on sediment

Slide57

Meningioma

Diagnosis

MRI gives more information than CT

Contrast may be required

Isolated meningeal tumors presumed to be meningiomas until histopath says otherwise

Biopsy prior to surgery not generally recommended

Slide58

Meningioma

Treatment

Surgery often curative

But expensive

Frontal lobe tumors do well

Brain stem surgeries carry high morbidity

Radiation without surgery can give long term palliation

Palliative Medications

Glucocorticoids

anticonvulsants

Slide59

Carcinomas

Client Handouts

Squamous Cell Carcinoma

Transitional

C

ell Carcinoma

Mammary Gland Tumor – Canine

Mammary Gland Tumor – Feline

Thyroid Carcinoma

Meningioma

Slide60

Acknowledgements

Jane M. Dobson, MA, BVetMed, DVetMed, DECVIM-CA&Onc, MRCVS

Department of Veterinary Medicine, University of Cambridge, Cambridge, UK

Deborah W. Knapp, DVM, DACVIM (Oncology)

Purdue University, West Lafayette, IN, USA

Karin Ulrikke Sorenmo, DVM, DACVIM, DECVIM-CA (Oncology)

Veterinary Hospital of the University of Pennsylvania

Philadelphia, PA, USA

Slide61

Acknowledgements

Erik Teske, DVM, PhD, Dip ECVIM-CA

Clinical Sciences, Companion Animals

Utrecht University, THE NETHERLANDS

Katherine Skorupski, DVM, DACVIM (Oncology)

Assistant Professor of Clinical Medical Oncology

University of California, Davis

Greg Ogilvie, DVM, DACVIM (Oncology)

Director, Angel Care Cancer Center, California

Slide62

Acknowledgements

Laura Blackwood, BVMS (Hons), PhD, MVM, CertVR, DECVIM-CA (Oncology), MRCVS, RCVS

Small Animal Teaching Hospital, University of Liverpool, Leahurst, Neston, UK

Richard A. LeCouteur, BVSc, PhD, Diplomate ACVIM (Neurology), DECVN

University of California

Davis, California, USA


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