PETS WITH CANCER You Have Options

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PETS WITH CANCERYou Have Options

• Nancy R. Gustafson, DVM, MS, DACVR (Radiation
  Oncology)
• Regional Veterinary Referral Center
• Springfield, VA

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Common Cancers in Dogs

• Lymphoma
• Nasal Tumors
• Oral Tumors
• Brain Tumors
• Thyroid Carcinoma
• Thymoma

• Liver tumors
• Hemangiosarcoma
• Bladder/Prostate TCC
• Anal Sac/Perianal ACA
• Osteosarcoma
• Soft Tissue Sarcoma
• Mast Cell Tumors

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Treatments Available

• SURGERY
• Radiation Therapy
• Chemotherapy

• Experimental
• Metronomic
• Photodynamic
• Immunotherapy
• Brachytherapy

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Lymphoma

• Presentations
• Nasal Discharge/bleeding, swelling, breathing
  difficulties
• Multicentric Lymphadenopathy, generalized or
  confined to single node.
• Mediastinal Hypercalcemia most common. May
  present with pitting edema of the head, neck or
  forelimbs, respiratory distress, pleural
  effusion, regurgitation, vomiting
• GI Weight loss, anorexia, diarrhea,
  panhypoproteinemia, evidence of malabsorption
• Hepatosplenic LSA lack of peripheral
  lymphadenopathy in the face of spleen, liver, and
  bone marrow involvement extremely aggressive.

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Lymphoma

• Diagnosis Biopsy, fine needle aspirate of lymph
  node, fluid or tissue, bone marrow aspirate,
  blood test
• Staging Chest radiographs, abdominal ultrasound,
  flow cytometry or PARR

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Lymphoma

• Standard of Care
• Chemotherapy COPLA, COP, MOPP, Colorado, single
  agent Adriamycin or CCNU, others
• Radiation to nose, specific lymph nodes or half
  body fields as part of a combination protocol.

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Lymphoma

• Prognostic factors
• Stage (Location) (worst prognosis leukemia,
  diffuse cutaneous, diffuse alimentary,
  hepatosplenic)
• Substage (clinical illness)
• Previous steroid treatment
• Immunophenotype (B cell vs T cell)
• Hypercalcemia
• Response to treatment

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Lymphoma

• Expected outcome
• Remission versus survival times
• Depend on treatment chosen
• 6 months, 12 months, 15 months, longer
• Rarely a cure

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Nasal Tumors

• Adenocarcinoma, Lymphoma, Squamous Cell Carcinoma
  (SCC), chondrosarcoma, osteosarcoma, other
• Presentation Discharge (mucoid, blood),
  congestion, swelling, bulging eye

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Nasal Tumors

• Diagnostics Skull radiographs, nasal CT or MRI,
  Rhinoscopy (biopsy), staging with chest x-rays,
  CT or MRI, abdominal ultrasound and bone marrow
  aspirate if lymphoma.
• Treatment
• Standard of care is radiation therapy
• 15-20 daily treatments
• Chemotherapy as a sensitizer or if lymphoma
• Surgery if small and/or on outer bone

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Nasal Tumors

• Prognosis 1 year
• ACA 1 year
• SCC 8-12 months
• CSA 15 months
• LSA 1-2 years
• OSA 8-12 months
• Longer if surgery is an option

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Oral Tumors

• Epulides, Oral malignant melanoma, Squamous cell
  carcinoma, Plasma cell tumor, Lymphoma,
  Fibrosarcoma, Osteosarcoma
• Presentation mass (pigmented or pink)
• Diagnostics Biopsy, radiographs, CT or MRI,
  staging with chest x-rays and other tests
  depending on tumor type

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Oral Tumor

• Treatment
• Surgery sole treatment or debulking to make
  other treatments more effective
• Radiation in addition or as sole treatment
• Chemotherapy as radiation sensitizer or primary
• Vaccine therapy - OMM
• Prognosis 7.5 months to a cure
• Depends on tumor type, size, location and
  surgical outcome

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Brain Tumors

• Tumor types
• Meningioma, Pituitary, Lymphoma,
  Glioma/astrocytoma, Unknown
• Presentation
• Seizures, stumbling, walking as if drunk, staring
  in to space, circling, head pressing, change in
  mentation/behavior

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Brain Tumors

• Diagnostics MRI, CSF tap, tests for infection or
  inflammation, other staging depending on
  suspected tumor type
• Treatment surgery, radiation, chemotherapy,
  steroids
• Prognosis 6 months to over 2 years, dependent
  upon tumor type and if surgery is an option

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Thyroid carcinoma

• Presentation Most common in middle aged and
  older dogs, cervical mass, coughing, difficulty
  breathing, listlessness, weight loss, vomiting,
  anorexia, facial edema, altered bark and
  excessive drinking/urinating if the thyroid tumor
  is functional (5-20 of tumors)
• Diagnostics Biopsy, CT or MRI of neck, staging
  (chest x-rays), echocardiogram and abdominal
  ultrasound if suspect ectopic tumor

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Thyroid Carcinoma

• Surgery Resection with complete removal (more
  likely with adenomas) or surgical debulking
  (allows for alleviation of clinical signs pending
  additional treatment).
• Chemotherapy Platinums, Adriamycin, COP
  protocol
• Radiation chemotherapy as a sensitizer
• I-131 for functional thyroid tumors??

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Thyroid Carcinoma

• Prognosis
• If mass is freely movable, no signs of
  metastasis, surgical resection with clean margins
  median survival is 2 years.
• Radiation following debulking surgery 1-2
  years
• Radiation alone - mean survival 11 months,
  significant decrease in tumor volume

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Thymoma

• Presentation Coughing, difficulty breathing
• Diagnostics Chest x-rays, aspirate/biopsy,
  ultrasound/CT/MRI
• Treatment Surgery, radiation, steroids
• Prognosis 1 year, longer with surgery plus
  radiation, shorter with steroids alone or if
  fluid in chest

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Liver tumors

• Presentation Vomiting, diarrhea, jaundice,
  collapse, incidental
• Types Hepatocellular carcinoma, hemangiosarcoma,
  metastatic
• Diagnostics Radiographs/ultrasound, aspirates
  (U/S guided), biopsy (U/S guided or surgical
  explore)
• Treatment Surgery, chemotherapy
• Prognosis curative or very poor

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Hemangiosarcoma

• Presentation
• Depends on location
• Collapse, abdominal pain, vomiting, diarrhea,
  jaundice, exercise intolerance
• Diagnostics Radiographs, abdominal U/S,
  echocardiogram
• Treatment Surgery, chemotherapy, radiation
  therapy
• Prognosis Poor

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Bladder/Prostate Tumors

• Presentation difficulty urinating, urinating
  small amounts frequently, apparent discomfort
  when urinating or defecating, bloody urine,
  persistent or recurrent UTIs.
• Diagnosis Presumed, urinalysis, radiographs
  (flat and contrast), cystoscopy, abdominal U/S,
  biopsy

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Bladder/Prostate TCC

• Treatment/Prognosis
• Chemotherapy Results inconsistent Mitoxantrone
  /- carboplatin, Cisplatin/Adriamycin,
  Adriamycin/Cyclophosphamide (median survival 259
  days), Carboplatin alone ineffective
• Piroxicam NSAID, daily, Median survival 181
  days
• Comfort measures as needed (catheterization)
• Surgical debulking/removal rarely an option
• Urethral stent with intra-arterial chemotherapy
• Radiation therapy palliative, emergencies

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Anal Sac Tumors

• Clinical signs occurs equally in both sexes. 
• Perianal mass Enlarged SLLNs (leading to
  defecation issues and painful arched lumbar
  spine) Elevated calcium (signs include
  increased drinking/urinating, decreased appetite,
  weight loss, vomiting and muscle weakness). 
• Diagnostics Aspirate/biopsy blood test, chest
  x-rays, abdominal U/S
• Treatment Aggressive surgical excision with
  radiation, possible lymph node removal /-
  chemotherapy
• Prognosis Mets at time of dx 6 mo.  No mets at
  time of dx 15.5 months.  Hypercalcemia has
  poorer long term survival.

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Perianal Tumors

• Presentation Usually in males. Either solitary
  or multiple masses.  Usually adenomas and not
  usually invasive.Treatment wide surgical
  excision, surgical debulking and RT
• Prognosis potentially curative tumors gt 5cm
  diam decreased survival time and increased
  chance of recurrence  Mets at time of dx 7
  months.

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Bone Tumors

• Types Osteosarcoma, Chondrosarcoma, Synovial
  cell sarcoma, metastasis (carcinoma)
• Osteosarcoma 80 of all bone tumors
• Presentation Most common in giant and large
  breeds.
• Extremity - lameness/pain, mass or swelling,
  fracture, does not cross joint
• Rib swelling, short rapid breathing
• Skull, mouth or nasal area mass, seizures,
  pain, bleeding from the nose and or mouth, or
  facial deformity
• Vertebra difficulty walking, pain, hindlimb
  weakness

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Bone Tumors

• Diagnosis Radiographs- typical appearance of
  bone, Biopsy- risks vs. benefits, Clinical
  Staging survey and thoracic radiographs, nuclear
  scintigraphy
• Treatment Definitive versus palliative therapy
• Definitive Amputation/limb spare plus
  chemotherapy Platinum, Adriamycin
• Palliative Oral medications, radiation therapy,
  pamidronate, combination is best

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Bone Tumors

• Osteosarcoma
• Prognosis Definitive 1 year Palliative 2-6
  months
• Metronomic therapy May slow growth of lung
  metastasis
• Axial Tumors less prone to metastasis, but more
  difficult to control locally. Surgical excision
  is key, followed by radiation if incomplete
  surgical margins, or chemotherapy. Rib tumors
  after rib resection 3.3 months, Mandibulectomy
  71 at 1 year. Prognosis varies greatly on
  location and local tumor control.

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Bone Tumors

• Chondrosarcoma
• Amputation alone usually curative
• Metastatic tumors
• Usually lesions in multiple bones making surgery
  inappropriate
• Palliative therapy

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Soft Tissue Sarcoma

• Types PNST, HPCT, FSA, myxosarcoma, others
• Diagnostics aspirate/biopsy, chest x-rays,
  local imaging (CT/MRI)

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Soft Tissue Sarcomas

• Treatment
• surgery alone
• surgery and radiation (pre- or post- operative)
• experimental options (radiation plus local
  hyperthermia, metronomic therapy)
• chemotherapy as radiation sensitizers or for high
  grade tumor to prevent mets, but hasnt been
  shown to increase survival time

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Soft Tissue Sarcomas

• Prognosis
• factors - completeness of surgery, treatment
  decision and grade
• Potentially curative
• Oral Fibrosarcoma histologically low-grade,
  biologically high-grade tumors tend to grow
  quite large and invade deeper structures,
  including bone.  Prognosis is based on size of
  tumor and degree of infiltrative growth

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Mast Cell Tumor

• Presentation - mass in or under the skin, can
  metastasize to the lymph node, spleen and liver,
  commonly will shrink/swell. 
• Well differentiated skin MCT tends to be 1-4cm in
  diameter, is slow growing, red and the overlying
  hair may be lost.
• Undifferentiated MCT tends to be rapidly growing,
  ulcerated lesions that cause irritation and
  become large in size.  Surrounding tissue may
  become inflamed and edematous.
• MCTs are often misdiagnosed as a lipoma.
• Vomiting, diarrhea and melena.
• Diagnostics Aspirate or biopsy, staging for
  metastasis (abdominal U/S to assess spleen, liver
  and LN, chest x-rays to assess LN)

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Mast Cell Tumor

• Treatment
• Standard of care Surgery alone can achieve a
  good outcome with wide surgical margins.
• Surgical excision /- radiation therapy tends to
  be successful when surgery can not achieve clean
  margins
• Amputation may be the best form of treatment to
  obtain margins.
• Radiation therapy chemotherapy
• Palladia

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Mast Cell Tumor

• Prognosis
• Dependent upon grade, size, location, choice of
  treatment
• Grade 1 and 2 have a long term survival after
  surgery /- radiation Potentially curable
• Grade 3 (55-96 chance of metastasis) Less than
  1 year (with surgery) because of local recurrence
  or metastasis. Addition of chemotherapy might
  extend survival time