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Module 17 > Approach to Mammary Tumours > Flashcards

Approach to Mammary Tumours Flashcards

1
Q

what is the prognosis of mammary tumours in dogs

A

good or poor

~50% malignant

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2
Q

what is the prognosis of mammary tumours in cats

A

poor

90% malignant

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3
Q

what is the age of mammary tumours in dogs

A

7-13 years

malignant 9-11 y

benign 7-9y

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4
Q

what is the age of mammary tumours in cats

A

10-12y

9y siamese

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5
Q

what breeds are predisposed to mammary tumours

A

miniature and toy breeds

yorkie, poodles, dachsunds, spaniels

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6
Q

what cat breeds are predisposed to mammary tumours

A

oriental breeds (Siamese)

DSH

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7
Q

what are tumour suppressor genes

A

p53, PTEN, E-cadherin, B-catenin

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8
Q

what are oncogenes

A

ErbB2/HER2, COX2, PI3K/AKT/mTOR

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9
Q

what are familial genes for mammary tumours

A

36% of English springer spaniels in Sweden affected by CMT

BRAC1 and BRAC2 germline polymorphisms in in E spr sp associated with increased CMT risk

BRAC1 mutations and decreased expression also seen in other breeds

No evidence for BRAC1 or 2 mutations in cats

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10
Q

what are hormonal causes of mammary tumours

A

Reduced prevalence in countries in which spaying is culturally acceptable

Increased in Norway, Denmark, Mexico, Italy

Ovariohysterectomy in dogs reduces risk of malignant mammary tumours if done <2.5 years

Sexually intact cats have 7 fold higher risk of mammary tumours

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11
Q

how does obesity contribute to mammary tumours

A

Adipose tissue is a source of steroid hormones

Reduced risk in spayed female dogs if thin 9-12 months

Increased risk if obese at 1yr old

Increase risk if obese 1 year before diagnosis

More poorly differentiated (grade III) carcinoma in overweight/obese dogs

Increase aromatase and hormone receptors in obese dogs

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12
Q

how do previous tumours increase risk of mammary tumours

A

Previous mammary tumour increases the risk of second tumour (entire females)

22% of dogs with benign tumour develop another later

49% of dogs with malignant tumour develop another later

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13
Q

what are alternative considerations to consider when palpating a mammary lump (5)

A
  1. last season
  2. recently lactating
  3. painful/non painful
  4. diffuse gland enlargement
  5. rapid/slow growth
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14
Q

what are ddx in dogs

A

Mastitis

Duct ectasia (cysts)

Focal fibrosis

Lobular hyperplasia

Ductal hyperplasia

  • Epitheliosis
  • Papillomatosis

Gynecomastia

  • Sertoli cell tumour — male dogs!
  • Granulosa cell tumour — female dogs?
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15
Q

what are ddx in cats

A

Mastitis

Duct ectasia (cysts)

Focal fibrosis

Ductal hyperplasia

  • Epitheliosis
  • Papillomatosis

Lobular hyperplasia

  • Epithelial hyperplasia
  • Adenosine
  • Fibroadenomatous change (feline mammary hypertrophy) (fibroepithelial hyperplasia/hypertrophy)
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16
Q

when does fibroadenomatous hyperplasia occur in cats

A

Follows metestrus, pregnancy, exogenous progestins

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17
Q

what does fibroadenomatous hyperplasia look loke

A

One or multiple glands are swollen, painful, edematous, but no milk production

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18
Q

what are the clinical signs of fibroadenomatous hyperplasia in cats

A

anorexia

lethargy

tachycardia

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19
Q

how do you diagnose fibroadenomatous hyperplasia

A

Diagnosis on gross appearance and age — young animals

Check if pregnant with US

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20
Q

how do you treat fibroadenomatous hyperplasia

A

Stop exogenous progestins, use progesterone antagonist (Aglepristone), may require ovariohysterectomy

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21
Q

what are the histological types of mammary tumours

A
  1. stromal/connective tissue –> sarcoma
  2. ductal, luminal, myoepithelium –> adenocarcinoma
  3. fat cells –> lipoma
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22
Q

what are the features of mammary sarcomas

A

Highly aggressive — metastasis to bone, lungs etc (hematogenously)

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23
Q

which is the most common type of mammary sarcoma

A

Uncommon (2-3%)

Osteosarcoma (most common), chondrosarcoma, fibrosarcoma, hemangiosarcoma

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24
Q

what are the features of mammary lipomas

A

feels fatty, soft, mobile

benign

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25
Q

what are the type of benign epithelial tumours in dogs

A
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26
Q

what is the most common benign tumour in the dog

A

mixed mammary tumour

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27
Q

what is the appearance of mixed mammary tumours

A

circumscribed, non-fixed, hard, knobbly

cartilage/bone present histologically

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28
Q

what are malignant epithelial tumours in the dog

A
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29
Q

what are the features of solid mammary carcinomas

A

fixed

ulcerated

rapid growth

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30
Q

what are the features of anaplastic epithelial mammary carcinomas

A

ulcerated

dermal and lymphatic invasion

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31
Q

what are inflammatory carcinomas

A

Invasion of dermal lymphatics by tumour emboli causes local edema = definition

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32
Q

what are the types of inflammatory carcinomas

A

many different carcinoma types

(aggressive: undifferentiated, anaplastic)

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33
Q

do inflammatory carcinomas metastasis

A

yes

early to distant sites

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34
Q

what is the appearance of inflammatory carcinomas

A

erythema

firmness

warmth

pain

often no palpable mass

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35
Q

when do inflammatory carcinomas occur in the dog

A

Luteal phase/progestagens

Often concurrent cystic endometrial hyperplasia (CEH)

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36
Q

what are the ddx to inflammatory carcinomas

A

acute mastitits

dermatitis

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37
Q

why is it important to read detail of pathology reports

A

prognostic significance of tumour type

Complex carcinomas

Simple carcinomas

  • Tubulopapillary
  • Solid
  • Anaplastic

Sarcomas

38
Q

describe the histology of this tumour

A

well circumscribed

clear tubule formation

low mitotic rate

39
Q

describe the histology of this tumour

A

invasive

poor tubule formation

nuclear pleomorphism

high mitotic rate (>20/10HPF)

40
Q

what is the mammary tumour grading scheme based on

A

Mammary tumour grading scheme in addition to tumour subtypes, based on human scheme

Individual scores added to make total score

41
Q

describe the grading scheme for mammary tumours

A
42
Q

what additional pathological findings influence prognosis

A

Surrounding stromal invasion

Vascular or lymphatic invasion

Lymph node involvement

43
Q

what is the breakdown of bengin vs. malignant and what type in feline mammary tumours

A

10-20% benign = most are fibroadenomas

80-90% malignant = most simple carcinomas

44
Q

what grades are simple carcinomas usually

A

high grade

45
Q

are simple carcinomas hormone receptor positive or negative

A

negative

46
Q

how do you confirm the diagnosis of mammary masses

A

FNA

biopsy

47
Q

what are the problems with FNA of mammary masses

A

Problems with mixed/heterogenous tumours being unreliable/unrepresentative

48
Q

what can FNA rule out

A

May rule out non-mammary tumours (ex. MCT, lipoma, abscess)

49
Q

what additional information does biopsy provide

A

Biopsy will give ore information than FNA (tissue architecture, histological type and grade)

Often not necessary for small lesions since surgery technique depends on lymphatic drainage rather than histological type

If extensive/untreatable, may want to confirm diagnosis before palliative treatment

50
Q

how do you stage mammary tumours

A

TLN

51
Q

how do you stage the primary tumour (T)

A

Perform a thorough clinical examination

Palpate both chains and all glands (66% dogs have more than one tumour, 33% cats)

Palpate and measure primary tumours in cms (T)

52
Q

why is important to palpate and measure the primary tumour

A

Size relates to prognosis

Malignant significantly larger than benign

Solid/cystic?

Ulcerated?

Fixed to skin/underlying tissues?

53
Q

what is the staging system for T in dogs

A
54
Q

how does size of the mammary tumour relate to prognosis in dogs

A

Survival time is better if <3cm

22 months vs 14 months

Reduced recurrence if <3cm

Survival at 2 years is better if <5cm

Worse prognosis if >5cm

55
Q

what is the staging system for primary tumour in cats

A

WHO staging system

56
Q

how does size of primary tumour relate to prognosis in cats

A

Mass <3cm: median survival 21-24 months

Mass >3cm: median survival 4-12 months

NB: size is important independent of LN status

57
Q

what are the lymph nodes that you should palpate to stage for metastasis

A

N0, N1

axillary, inguinal

palpate –> enlarged, fixed

FNA, biopsy

58
Q

how do you measure if there is distasnt metastasis

A

xray chest, abdomen (medial iliac), skeleton?

US abdomen

scintigraphy

59
Q

how would you clinically stage for metastasis

A

CT

more details of lungs of metastatic nodules

good for bone metastasis (expasile lyitc lesion on scapula)

60
Q

why are bloods important in mammary tumour staging

A

To evaluate general healthy if old or very severe disease (stage III, IV)

Coagulopathies — uncommon except inflammatory carcinoma in dogs (21%)

FeLV/FIV status if considering chemotherapy

Increased acute phase proteins — in large, ulcerated or metastatic tumours

Hypercalcemia — uncommon

61
Q

what is the main treatment of mammary tumours

A

surgery

role of chemo and endocrine therapy unproven

62
Q

what is the normal mammary gland LN drainage in dogs

A
63
Q

what is neoplastic mammary gland LN drainage in dogs

A
64
Q

what is neoplastic mammary gland LN drainage in cats

A
65
Q

what surgery is used to treat mammary neoplasia (4)

A
  1. nodulectomy/lumpectomy
  2. simple mammectomy (whole gland removal)
  3. partial/regional masetcomy (gland plus other adjacent glands which drain from it)
  4. radical masectomy (mammary strip)
66
Q

when is a nodulectomy/lumpectomy indicated

A

Considered more as a biopsy procedure

Unfixed lesions <0.5cm

67
Q

when is a simple mammectomy indicated

A

Centrally positioned lesions

Fixed or unfixed 0.5-1.0cm

68
Q

when is a partial/regional masectomy indicated

A

Use to recommended for most lesions in dog

Can’t be certain of lymphatic drainage in neoplasia

58% dogs develop new tumour after regional mastectomy

69
Q

when is a radical mastectomy indicated

A

Use for multiple lesions

May reduce new tumour formation in ipsilateral glands in dogs

Very low risk of contralateral new tumours

No survival benefit in dogs compared to regional mastectomy

70
Q

what are the issues with a radical mastectomy

A

Can be technically difficult

Excessive tension/discomfort

Increased risk of dehiscence

71
Q

what is the surgery of choice in cats

A

radical mastectomy

72
Q

when is a radical mastectomy indicated in cats

A

Use for multiple or single lesions

Bilateral surgery vs unilateral improves survival times

73
Q

how is a radical mastectomy done in cats

A

Usually staged operations with 2 weeks recovery in between to reduce complications

But increased risk of dehiscence and complications with bilateral

74
Q

what is done after surgery

A

submit for histopathology

Definitive diagnosis

Evidence of lymphatic spread

Check surgical margins

Further/bilateral surgery?

Removal of LNs?

75
Q

what LNs might need to be removed

A

Inguinal excised with gland 4 (cat) or 5 (dog)

Axillary — remove if enlarged/positive for metastasis or for staging purposes

Sentinel lymph node mapping?

76
Q

should you spay at the same time

A

Benign tumours: reduce risk of growth of further being tumours by 50%

Will prevent pyometra

Prevents the need for progestins

Malignant tumours:

Most studies show NO effect on time to metastasis (TTM) or overall survival time (OST)

Better to do mammary strips

But new data on ER/PR status and serum estrogen levels at the time of surgery

77
Q

should chemotherapy be used

A

Needed for aggressive carcinomas but not very effective

Most evidence supports some efficacy for doxorubicin

78
Q

how does doxorubicin work in cats

A

Some effect on cell lines in vitro

Some effect on gross disease

Some effect on median survival time

As adjuvant to surgery but no significant difference when concurrent control group used

79
Q

what chemo might work for dogs

A

Cyclophosphamide with 5-Fluorouracil in dogs?

NB 5FU toxic in cats

80
Q

what chemos are useful for carcinomas

A

Mitoxantrone?

Carboplatin?

Gemcitabine?

Targeted therapy (TKI) may be antiangiogenic too

Toceranib (Palladia)

81
Q

what dose of toceranib (Palladia) would be used

A

10mg M, W, F or 7mg EOD

GI signs, weight loss, neutropenia

82
Q

what other therapies are used to treat mammary tumours

A
  1. herceptin
  2. anti estrogens
  3. cox2 inhibitors (NSAIDs)
  4. anti angiogenic therapy
83
Q

what is herceptin

A

blocks EGFR2/HER2 antagonist

increased expression in dog and cat carcinomas but drug not tried

84
Q

what are anti estrogens

A

tamoxifen/aromatase inhibitor

85
Q

why are cox2 inhibitors used

A

Increased COX2 expression in aggressive carcinomas and associated with poor prognosis

86
Q

what are anti angiogenic therapies used

A

Thalidomide

87
Q

what are prognostic factors in the dog

A

50:50 malignant:benign

Histological type

  • Tubular, papillary - good, solid, anaplastic = poor

Histological grade

  • Well differentiated = good, undifferentiated = poor

Tumour size

  • <3cm diameter = good
  • >5cm = poor

Tumour clinical stage

Spay status

  • Not spayed (more likely ER positive) = good
88
Q

what are prognostic factors in cats

A

80:20 malignant:benign

Histological grade

  • Well differentiated = good but rare!

Tumour size

  • <2cm diameter = good
  • >3cm = poor

Tumour clinical stage

  • Stage 1 = good
  • Stage IV = bad

Extent of surgery: aggressive surgery is best in cats to prevent recurrence —> bilateral mammary strip down to a clean fascial plane

89
Q

what is the modified WHO staging in dogs

A
90
Q

what is the modified WHO staging in cats

A

Module 17 (31 decks)

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