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Module 17 > Approach to Skin Tumours > Flashcards

Approach to Skin Tumours Flashcards

1
Q

what is the clinical approach to skin tumours and history considerations (6)

A
  1. age
  2. breed
  3. sex
  4. duration of lesion(s)
  5. progression of lesion(s)
  6. other clinical signs
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2
Q

how would you clinically examine skin tumours (5)

A
  1. site: depth
  2. site: locaiton
  3. size: measure
  4. ulceration
  5. mobility
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3
Q

how does the depth affect the approach to skin tumours

A

dermal, subcutaneous –> affects grading of mast cell tumours

deep soft tissues, bone (soft tissue sarcomas, osteosarcomas)

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4
Q

how does the location affect skin tumours

A

location can affect behaviour/malignancy for some tumour types (melanoma, mast cell tumours)

-mucocutaneous, back, digit

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5
Q

how are skin tumours diagnosed

A

cytology useful for some tumour types

histopathology for definitive diagnosis

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6
Q

what are ddx for skin tumours (4)

A
  1. hyperplastic conditions
  2. granulomatous conditions
  3. immune mediated conditions
  4. developmental lesions
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7
Q

how are skin tumours staged

A

TNM

T - primary lesion (extent)

N - local & regional node palpate, image, aspirate

M - distant metastasis, Xray, bloods

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8
Q

how are skin tumours treated

A

Local disease: surgery (radiotherapy)

Local & regional LN: surgery +/- radiotherapy

Multifocal/diffuse: chemotherapy

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9
Q

what are mutliple skin lesions

A

metastases from any malignant tumour

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10
Q

what are examples of multiple skin lesions (3)

A
  1. primary cutaneous lymphoma (T cell)
  2. disseminated mast cell tumours
  3. histiocytic skin conditions
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11
Q

what are examples of primary cutaneous lymphomas (2)

A
  1. primary cutaneous LSA - dermal/non-epitheliotropic
  2. mycosis fungoides - epitheliotropic (epiderma)
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12
Q

what are histiocytic skin conditions (2)

A
  1. reactive/immune mediated =
    - cutaneous histiocytosis
    - systemic histiocytosis
  2. malignant =
    - histiocytic sarcoma (malignant histiocytosis)
    - hemophagocytic histiocytic sarcoma
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13
Q

what are benign histiocytic skin conditions

A

cutaneous histiocytoma (solitary)

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14
Q

what is cutaneous histiocytosis

A

reactive histiocytosis

skin only

diffuse/nodular infiltration with myeloid interstitial dendritic cells of dermis and subcutis

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15
Q

what is systemic histiocytosis

A

reactive histiocytosis

skin, lymph nodes and other organs (BMD, rottweiler, retrievers)

diffuse/nodular infiltration with myeloid interstitial dendritic cells of dermis and subcutis

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16
Q

what are the clinical features of reactive histiocytosis

A

lesions wax and wane but over time slowly progressive

underlying disorder of immune regulation

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17
Q

how would you treat reactive histiocytosis

A

some may respond to immunosuppressive drugs (high dose corticosteroids, cyclosporine, tetracycline/niacinamide)

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18
Q

what lesion is shown here

A

reactive histiocytosis

cutaneous

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19
Q

what lesion is shown here

A

reactive histiocytosis

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20
Q

what is a histiocytic sarcoma

A

high grade sarcoma

localized and disseminated forms (malignant histiocytosis)

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21
Q

what breeds are predisposed to histiocytic sarcomas

A

BMD

flat coated retriever

rottweilers

golden retrievers

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22
Q

what are histiocytic sarcomas derived from

A

myeloid intersitital dendritic cell staining with CD1, CD11c, MHC II, CD18, Iba-1

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23
Q

what are solitary epithelial/epidermal skin tumours (3)

A
  1. papilloma
  2. basal cell tumour (trichoblastoma or solid cystic ductular sweat gland adenoma)
  3. squamous cell carcinoma
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24
Q

what are solitary adnexal/derma skin tumours (2)

A
  1. sebaceous and sweat gland adenoma/ACA
  2. hair follicle tumours (pilomatricoma/trichoepithelioma/trichoblastoma)
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25
Q

what are solitary mesenchymal/subcutaneous connective tissue skin tumours (2)

A
  1. fibrous tissue (fibroma/sarcoma)
  2. adipose tissue (lipoma/sarcoma)
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26
Q

what are melanocytic solitary skin tumours

A

melanoma

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27
Q

what are solitary mast cell skin tumours

A

mast cell tumours

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28
Q

what are other examples of solitary skin tumours

A

histiocytoma

plasmacytoma

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29
Q

what are papillomas in young dogs and cats

A

papilloma viral induced

often multiple should resolve spontaneously (more common in mouth in dogs)

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30
Q

what are papillomas in old dogs often confused with

A

sebaceous adenoma

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31
Q

are basal cell tumours/carcinomas more common in dogs and cats

A

cats

less so in dogs

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32
Q

what are basal cell tumours/carcinomas reclassified as

A

trichoblastoma or solid cystic apocrine ductal adenoma

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33
Q

what is the signalment of basal cell tumours/carcinomas

A

middle age to old cats

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34
Q

what is the appearance of basal cell tumour/carcinomas

A

solitary, discrete, well circumscribed, can be pigmented

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35
Q

are basal cell tumour/carcinomas slow or fast growing and are they benign or malignant

A

slow growing

bengin

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36
Q

how are basal cell tumour/carcinoma

A

surgical cure with wide local excision

rarely metastasis

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37
Q

what are the causes of sqaumous cell carcinomas

A

chronic exposure to UV light in depigmented skin (white) areas

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38
Q

what is shown here

A

papilloma

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39
Q

what lesion is shown here

A

basal cell tumour/carcinoma

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40
Q

what is shown here

A

squamous cell carcinoma

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41
Q

how are SCC treated

A

locally invasive

metastasis via lymphatics but variable – often slow

treatment wide local surgical resection

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42
Q

what are the differences of squamous cell carcinomas in the nasal planum

A

cats: solar induced, superficial or invasive
dog: not solar induced, usually very invasive and aggressive

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43
Q

how is SCC of the nasal planum treated

A

surgical excision (nosectomy)

radiotherapy (external beam)

brachytherapy (strontium 90)

photodynamic therapy

electrochemotherapy

curettage and diathermy

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44
Q

what are the SCC of the foot in cats and dogs (4)

A
  1. ditial/interdigital SCC: aggressive
  2. subungual SCC
  3. syndrome of multiple SCC of digits (dogs 3% of SCC)
  4. syndrome of metastasis from lung carcinoma in cats (lung digit syndrome)
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45
Q

what breeds are predisposed to SCC of the digit

A

black coat large breeds

lab

standard poodle

schnauzer

rottweiler

gordon setter

flat coated retriever

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46
Q

what are the features of invasiveness of SCC of the digit

A

locally invasive

bone destruction (subungual less metastatic than digit SCC?)

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47
Q

how are SCC of the digit treated

A

amputation at metacarpophalangeal or proximal interphalangeal level

radiotherapy?

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48
Q

what are other digit tumours besides SCC (4)

A
  1. melanoma
  2. soft tissue sarcoma
  3. mast cell tumour
  4. osteosarcoma
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49
Q

what are benign adnexal sebaceous gland tumours

A

hyperplasia – warts, cysts, adenoma, epithelioma

most common skin tumour of old dogs

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50
Q

what breeds are prediposed to sebaceous gland tumours

A

cocker spaniel

poodle

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51
Q

what are hair follicle tumours (4)

A
  1. pilomatricoma
  2. trichoepithelioma
  3. trichoblastoma (prev called basal tumours)
  4. meibomian gland adenoma
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52
Q

what are malignant adnexal tumours (2)

A
  1. matrical carcinomas
  2. malignant sweat/sebaceous carcinomas
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53
Q

what are matrical carcinomas

A

adnexal malignant pilomatricoma/trichoepithelioma

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54
Q

how are adnexal tumours treated

A

very aggressive tumours

surgery/radiotherapy/chemo?

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55
Q

what is shown here

A

sweat gland adnexal carcinoma

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56
Q

where are peri-anal adenomas derived from

A

skin sebaceous gland

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57
Q

what is the signalment of peri anal adenomas usually

A

elderly male dogs

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58
Q

describe the appearance of peri anal adenomas

A

solitary, discrete, button like lesion in perianal skin

can get big and ulcerate

can also be found at base of tail, prepuce and midline

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59
Q

are peri anal adenomas benign or malignant

A

usually benign, hormonally dependent

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60
Q

how are peri anal adenomas treated

A

usually regress with castration but surgical excision may be needed

but sometimes can transform into adenocarcinoma

61
Q

what are malignant peri anal tumours (2)

A
  1. perianal adenocarcinoma (sebaceous glands)
  2. anal sac adenocarcinoma (apocrine gland)
62
Q

how are perianal adenocarcinoma treated

A

surgery or radiotherapy?

surgery + chemo (carboplatin or mitoxantrone or TKI palladia)

63
Q

what age are canine cutaneous histiocytomas commonly seen

A

young dogs <5 years

50% in dogs <2 years

64
Q

where are canine cutaneous histiocytomas typically seen

A

head, limbs, feet and trunk

65
Q

are canine cutaneous histiocytomas malignant or benign

A

rapidly growing intradermal lesion but benign

66
Q

what are canine cutaneous histiocytomas derived from

A

langerhans cell derived

67
Q

how are canine cutaneous histiocytomas treated

A

will regress if left alone

surgery curative

68
Q

what breeds of dogs are cutaneous melanocytic tumours seen in

A

scotties

boston terrier

airedale

cocker spaniel

69
Q

describe the apperance of cutaneous melanocytic tumours

A

solitary, dermal, dark mass

can be amelanotic, ulcerated especially if malignant

70
Q

are cutaneous melanocytic tumours typically benign or malignant

A

85% are slow growing and benign

71
Q

how are cutaneous melanocytic tumours treated

A

wide surgical excision curative

72
Q

what is the prognosis of cutaneous melanocytic tumours

A

good prognosis

73
Q

which melanocytic tumours have good prognosis

A

cutaneous

74
Q

which melanocytic tumours have a bad prognosis

A

mucocutaneous (oral, anal) and digital (not eyelid)

75
Q

what lesion is shown here

A

peri anal adenoma (hepatoid)

76
Q

what is shown here

A

perianal adenocarcinoma

77
Q

what is shown here

A

anal sac adenocarcinoma

78
Q

what is shown here

A

canine cutaneous histiocytoma

79
Q

what is shown here

A

cutaneous melanocytic tumour

80
Q

what is shown here

A

mucocutaneous melanocytic tumour

oral melanoma

81
Q

describe the rate of metastasis of mucocutaneous melanocytic tumours

A

rapid

82
Q

how are oral melanomas treated

A

wide excision or radiotherapy give good local control

metastasis –> no chemo works well (carboplatin/TKI?)

DNA vaccine – oncept for minimal residual disease

83
Q

what type of MCT are most common in the dog

A

skin

84
Q

what are type of MCT are most common in the cat

A

visceral

85
Q

what is the appearance of MCT in the dog

A

skin

often solitary tumours but can be multiple

86
Q

what is the appearance of visceral MCT in the cat

A
  1. splenomegaly
  2. hepatomegaly
  3. mesenteric lymphadenopathy
  4. GI mass
  5. BM/blood
  6. often preceeded by primary skin undifferentated MCT (dog)
87
Q

what is the signalment of skin MCT in the dog

A

middle aged to older dogs

occasionally seen in puppies

no sex predisposition

88
Q

what breed of dog are predisposed to skin MCT (6)

A
  1. boxers*
  2. staff BTs
  3. labs*
  4. golden retrievers*
  5. weimeraners
  6. pugs

*often multiple unrelated tumours

89
Q

what are MCT very variable with respect to (3)

A
  1. apperance
  2. behaviour/metastasis (LNs/abdominal organs)
  3. response to treatment
90
Q

what are proliferation markers of MCTs (4)

A
  1. mitotic index
  2. Ki67
  3. AnNOR count
  4. cKIT
91
Q

what are mitotic index markers used in MCT

A

of mitoses/10 HPF

>5 mitoses/10HPF has worse prognosis

92
Q

what is Ki67 marker of proliferation of MCT

A

nuclear stain for cells in cell cycle

>1.8% of positive nuclei/total mast cells in field has worse prognosis/decreased survival

93
Q

what is AgNOR count in MCT proliferation marker

A

nuclear silver stain and PCNA (proliferating cell nuclear antigen)

both increased in proliferating cells and associated with worse prognosis but not independent of grade

94
Q

what is cKIT MCT marker

A

cell surface growth factor receptor with TK enzyme

mutated in 15-40% mast cell tumours – worse prognosis

mutation detected by PCR test

mutation may mean better response to TKI treatment

protein can be visualized in MCT by IHC, pattern of expression associated with prognosis

95
Q

what is KIT1 pattern of expression in an MCT mean

A

membranous –> seen with normal cells or low grade MCT

96
Q

what is KIT2 pattern of expression in an MCT mean

A

focal cytoplasmic: aberrant –> worse prognosis

97
Q

what is KIT3 pattern of expression in an MCT mean

A

diffuse cytoplasmic –> aberrant

worse prognosis

often high grade tumours

98
Q

what do mast cell tumour granules contain

A
  1. histamine
  2. heparin
  3. vasoactive amines
99
Q

when do mast cell tumours degranulate

A

either spontaneously or due to trauma

100
Q

what is shown here

A

mast cell tumour

with granules

101
Q

what local effects does degranulation of MCT cause (3)

A

erythema

wheal formation

darier’s sign

102
Q

what is shown here

A

MCT degranulation local effects

103
Q

what is hyperhistaminemia and what causes it

A

degranulation of MCT

paraneoplastic syndrome –> systemic effects

104
Q

what systemic effects does hyperhistaminemia cause

A

acts on H2 receptors in gastric parietal cells, leading to

  1. increased acidity and motility
  2. vomiting, anorexia, melana
  3. gastirc ulceration

plasma histamine increased but plasma gastrin decreased by negative feedback loop from acid

105
Q

how is hyperhistaminemia treated (5)

A
  1. supportive therapy – fluids
  2. H2 antagonists (cimetidine, ranitidine, famotidine)
  3. gastric protectants (sucralfate antepsin)
  4. proton pump inhibitor (omeprazole)
  5. remove/treat mast cell tumour to remove source of histamine
106
Q

what biological effects can MCT have (3)

A
  1. hypotension: histamine + vasoacitve substances
  2. coagulation problems (check before surgery!): localized hemorrhage
  3. delayed wound healing: proteolytic enzymes + vasoactive amines
107
Q

which MCT cause biological effects?

A

low grade: may have local effects

high grade: more likely to have systemic effects

high serum histamine reported with all grades

108
Q

how would you approach an MCT

A

do FNA to confirm diagnosis or biopsy

109
Q

how do you treat clinical stage I MCT (solitary mass and no sentinel LN metastasis)

A

Surgical excision only — wide local excision or

Marginal excision and radiation

Radiation alone if not amenable to surgery at all

110
Q

how do you treat clinical stage II MCT (solitary mass + sentinel LN metastasis)

A

Surgical excision of mass and LN

Marginal excision +/- radiation and LN excision/radiation

Metastasis to LN implies higher grade so chemotherapy as well

111
Q

what will help you decide if chemotherapy is indicated in MCT

A

histopathology and the grade of the tumour

112
Q

how would you treat low grade/grade I + low grade/grade II MCT

A

Wide local excision should have been sufficient to remove all tumour cells

Check histological margins are adequate — if incomplete, consider repeat surgery or if not possible use radiation

If radiation not available, consider chemotherapy/TKIs for local control but only if signs of malignancy

-PNS signs/bruising, sentinel LN involved, high mitotic rate (>5 per 10hpf is worse), high Ki67 index (>1.8 may be worse prognosis), cKit mutation/staining pattern

113
Q

how would you treat high grade/grade II + high grade/grade III MCT

A

Wide local excision or radical excision will have been needed to remove primary tumour (cytoreductive surgery and radiotherapy if good surgical margins not achieved)

Adjunctive chemotherapy will always be needed because of high risk metastasis (whether detectable or not on staging)

Treatment for paraneoplastic signs if presents

Chemotherapy alone for unresectable gross disease (TKIs licensed for gross disease)

114
Q

when is chemo indicated to treat MCT

A

Only indicated for management of high grade malignant/metastatic tumours

Usually adjunctive to surgery

115
Q

what is the response of MCT to chemo

A

esponse of gross disease to MTD chemotherapy:

47% vinblastine + prednisolone

44% lomustine

116
Q

what chemotherapy is used to treat MCT

A

2 week Vinblastine/prednisolone protocol

Vinblastine 2mg/m^2 IV q 1 week x 4 doses, q2 weeks x 4 doses

Prednisolone 1mg/kg PO daily for 2 weeks, 0.5 mg/kg daily for 10 weeks

OR

OR single agent Lomustine

Lomustine at 60-90mg/m^2 PO q3 weeks for 4-6 doses

OR single agent TK inhibitor (treat cytotoxins)

Masitinib (Masivet): 10-12.5 mg/kg daily

Toceranib (Palladia): 2.5-3.0 mg/kg EOD

117
Q

what is the signalment of feline MCT

A

most common skin tumour in cat

older cats (mean age 11 years)

118
Q

what breeds of cats are predisposed to MCT

A

siamese (burmese, russian blue, ragdoll) predisposed

119
Q

what are the typical features of feline skin MCT

A

usually solitary and benign

small percentage are malignant and aggressive

120
Q

what would indicate a poorer prognosis of feline skin MCT

A

> 5 masses

121
Q

how are skin MCT treated

A

surgery curative

122
Q

what are the most common histological types of MCT in the cat

A

mastocytic: most common

atypical

123
Q

what are the types of mastocytic MCT in felines

A

compact (well differentiated)

or

diffuse (poorly differentiated)

124
Q

what breed are atypical MCT seen in

A

young siamese <4 years

125
Q

how are feline MCT graded

A

no grading system recognized

126
Q

what are histological prognostic indicators of feline MCTs (4)

A
  1. mitotic index may be important (>3.5 HPF has poor prognosis)
  2. mitotic index stronger predictor than Ki67
  3. multinucleated giant cells – poor prognosis
  4. mutated cKIT in 2/3 cases
127
Q

what is the behaviour of soft tissue sarcomas primary masses (4)

A
  1. all are locally infiltrative and invasive (usually subcutaneous)
  2. beware of pseudocapsule (compression zone)
  3. sarcomas DO NOT shell out –> surgery must be radical
  4. possibly can do cytoreductive resection and XRT
128
Q

what are the causes of feline injection site sarcomas

A

rabies

FeLV injection sites

aluminium adjuvant associated?

129
Q

what are the features of feline injection site sarcomas

A

very infiltrative and intermediate/high grade

130
Q

how are feline injection site sarcomas treated

A

use advanced imaging to ensure complete excision

surgery +/- radiotherapy for primary tumour

chemotherapy for metastasis

131
Q

how do soft tissue sarcomas usually metastasize

A

Via hematogenous route usually (15% overall)

Variable % depending on type and grade

132
Q

how do low grade soft tissue sarcomas metastasize and how are they treated

A

low risk of metastasis

no chemo needed

133
Q

what are examples of low grade soft tissue sarcomas

A

Peripheral nerve sheath tumour (PNST)

hemangiopericytoma

134
Q

how do intermediate soft tissue sarcomas metastasize and how are they treated

A

moderate risk of metastasis

possibly treated with chemo

135
Q

what are examples of intermediate grade soft tissue sarcomas

A

Fibrosarcoma, myxosarcoma

136
Q

how do high grade soft tissue sarcomas metastasize and how are they treated

A

high risk

chemo needed

137
Q

what are examples of high grade soft tissue sarcomas

A

Hemangiosarcoma, FISS, Histiocytic sarcoma

138
Q

how is chemo used to treat sarcomas

A

as an adjunct to surgery for high grade tumours

High risk of metastasis

139
Q

what chemotherapy is used to treat sarcomas

A

Doxorubicin based protocol for most sarcomas (ex. HSA) (need care in cats ex. FISS)

Lomustine for histiocytic sarcomas

140
Q

what age are hemangiosarcomas seen in

A

older dogs and cats (rare)

141
Q

what breeds are predisposed to hemangiosarcomas (3)

A

GSD

lab

g retriever

142
Q

what are the sites of hemangiosarcomas (5)

A
  1. spleen
  2. right atrium
  3. pericardium
  4. muscle
  5. subcutis
143
Q

how do hemangiosarcomas metastasize

A

via blood, transabdominal seeding (lymph nodes often negative)

144
Q

how do hemangiosarcomas present (4)

A
  1. Superficial/soft tissue mass or hematoma
  2. Splenic rupture: hemorrhagic, collapse, abdominal distention, pale mms
  3. Cardiac signs: muffled heart sounds, arrhythmias, right sided heart failure
  4. Regenerative anemia (blood loss, microangiopathic hemolysis), thrombocytopenia, neutrophilia, DIC
145
Q

how are hemangiosarcomas treated (2)

A
  1. Primary tumour: surgical excision of subcutaneous mass (radical excision/amputation), splenectomy, pericardiectomy
  2. Metastasis: Adjunctive chemotherapy (doxorubicin, VAC protocol, metronomic therapy)
146
Q

what is the MST of splenic hemangiosarcomas

A

Surgery alone 1-3 months

Surgery and chemotherapy 5-7 month

147
Q

what is the MST of intramuscular hemangiosarcomas

A

6-9 months with chemo

148
Q

what is the MST of skin hemangiosarcomas

A

Has better prognosis (surgery alone)

Dermal: 26-33 months (UV induced, thin coated dogs like whippets, pit bulls)

Subcutaneous: 7-10 months (39-40 mo in 1 study with adjuvant doxorubicin)

149
Q

what is the MST of cardiac hemangiosarcomas

A

3-4 months with doxorubicin vs 12 days with no treatment

Module 17 (31 decks)

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