Hemangiosarcoma Flashcards
malignant tumor arising from endothelial cell precursors
hemangiosarcoma
a malignant tumor of mesenchymal tissue
sarcoma
What is the most common site of hemangiosarcoma in dogs
Spleen
What kinds of dogs typically get hemangiosarcoma
middle- aged to older dogs
german shepherds, golden, and labrador retrievers, other large breed dogs
hemangiosarcoma is uncommon in cats but what sites are more common
Skin and SQ sites more common than visceral
The spleen is one of the most common sites for hemangiosarcoma in the dog, what are some other common places
-Heart (R atrium and auricle)
-Subcutaneous and IM sites
-Liver
-Skin
others (anywhere with blood vessels): retroperitoneal space, kidney, lung, bone, eye, oral (tongue), nasal cavity
What structure of the heart is most common for hemangiosarcoma
R auricle and atrium
What are the clinical signs of visceral hemangiosarcoma
often vague and non-specific clinical signs
-waxing. and waning lethargy/ inappetence
-neurologic/mentation changes
-GI signs
-acute collapse
-respiratory distress
-sudden death
can range from asymptomatic to sudden death
What are the PE findings of hemangiosarcoma when it occurs and ruptures on the spleen, liver, or heart
-Pale mucous membranes, prolonged CRT
-Weakness, dull mentation
-Tachycardia, poor pulse quality, arrhythmias
-Tachypnea, dyspnea
-Fluid wave, cranial abdominal mass
-Muffled heart sounds, pulsus paradoxus
masses that have not ruptured may only be found incidentally
hemangiosarcoma masss that have not ruptured may
only be found incidentally
dermal hemangiosarcoma is often induced by
the sun
with visceral hemangiosarcoma, what might you see on bloodwork *
CBC: leukocytosis, thrombocytopenic, regenerative or non-regenerative anemia
Chemistry: hypoproteinemia, elevated liver enzymes, azotemia
PT/PTT/FDG/d-dimers: 50% of dogs meet criteria for DIC
May need to blood type or cross match
What should you do if you suspect hemangiosarcoma
diagnostic abdominocentesis
-appearance of effusion? PCV of effusion? how does it compare to peripheral PCV? clot in red top tube?
do a pericardiocentessi if cardiac tamponade
get blood pressure, EKG, and provide IV fluids, supplemental O2
What abnormality on the EKG might be common in dogs with hemangiosarcoma
Ventricular arrhythmias common
electrical alternans
In dogs with hemangiosarcoma, why might you need to be more judicious with your use of fluids
you dont want to disrupt the clot
One a dog with hemangiosarcoma is stable, what should you do
1) Thoracic radiographs (3 views before surgery)
2) Abdominal ultrasound
3) Echocardiogram
if you have a non-traumatic hemo-abdomen, what do you need to do before going to surgery
3 view thoracic radiographs - if see pulmonary mets, then this could impact the prognosis
can also assess for pericardial effusion which can tell you prognosis
once a patient with hemangiosarcoma is stable, why is doing an abdominal ultrasound important
*to identify the source of hemorrhage (often spleen)
-Interpret staging with caution (dont overinterpret)
50% of liver lesions are detected with US
Only 50% of dogs with grossly abnormal livers at time of surgery have HSA mets (could be something else)
Omental mets hard to observe with US
What are the limitations of abdominal ultrasound in diagnosing hemangiosarcoma
-Interpret staging with caution (dont overinterpret)
50% of liver lesions are detected with US
Only 50% of dogs with grossly abnormal livers at time of surgery have HSA mets (could be something else)
Omental mets hard to observe with US
Once the patient is stable, what is the significance of using echocardiogram to diagnose hemangiosarcoma
Allows you to look for a R atrial / auricular mass
-more difficult to visualize if no pericardial effusion
-Pre-op staging; low likelihood of concurrent caridac mass with spenic mass (<10%)
What are your differentials for a splenic mass
Malignant: hemangiosarcoma, marginal zone lymphoma, splenic stromal sarcoma, histiocytic sarcoma, leiomyoma/leiomyosarcoma
Benign: Hematoma, extramedullary hematopoiesis (EMH), lymphoid hyperplasia
many of these can bleed
T/F: hemangiosarcoma is rare in humans
True
How are you going to start the bleeding of hemangiosarcoma
Exploratory lapartotomy and splenectomy
-or liver lobectomy or nephrectomy, depending on the source of bleeding
provide supportive care?
How are you going to get the definitive diagnosis of hemangiosarcoma
Exploratory laparotomy and splenectomy with histopathology
*Cytology often unrewarding (RBCs only), caution with cystic or cavitated masses
If a dog is presenting for non-traumatic hemoabdomen then what percent of these are from hemangiosarcoma
65-75% are hemangiosarcoma
73% are malignant
If a dog has a splenic mass that is incidental, what amount are hemangiosarcoma
30% are malignant with 1/2 being hemangiosarcoma
“also called splenic nodules”
if not bleeding then the chances of it being hemangiosarcoma is lower
hemangiosarcoma is more common in dogs that are what body size
> 20 kgs
If a patient has a higher ___________ ratio and _________ percentage of body weight then it is more likely to be benign
if a patient has a higher Mass to Splenic Volume (MSV) ratio and splenic weight as a percentage of body weight (SWPBW) then it is more likely to be benign
What is the treatment of hemangiosarcoma
1) Surgery - mainstay of treatment, but may be challenging with some locations (cardiac), may be the only therapy needed for dermal HSA
2) Radiation therapy - for incompletely excised tumors (often SQ or IM)
Palliation- cardiac, SQ, or IM tumors (gross disease)
3) Chemotherapy- post operatively to delay onset of metastasis, (Doxorubicin based chemotherapy protocols)
What might be the only therapy needed for dermal hemangiosarcoma
surgical excision
radiation therapy for hemangiosarcoma is indicated when
for incompletely excised tumors (often SQ or IM)
Palliation- cardiac, SQ, or IM tumors (gross disease)
Why do you do exploratory laparotomy and splenectomy for hemangiosarcoma
1) Remove source of bleeding
2) Biopsy abnormal lesions - liver, omentum (remember only about 50% of abnormal lesions in liver are consistent with metastasis on histo path)
3) Biopsy of normal liver - low yield to ID occult mets
What is the perioperative mortality rate of splenectomy for hemangiosarcoma
8% (doesnt include patients euthanized intra-op for suspected metastatic disease
What are the major complications of splenectomy for hemangiosarcoma tx
1) Hemorrhage
2) Thromboemoblic events - pulmonary thromboembolism, portal system thrombus
3) DIC
4) Cardiac arrythmias (VPCs)- do continuous ECG 12-36 h post-op
5) Intra-abdominal / incisional tumor seeding
What stage of hemangiosarcoma is when it ruptures
Stage 2
What stage of hemangiosarcoma is when there are mets
Stage 3
What prolongs the survival of HSA
chemotherapy
surgery alone (weeks to 3 months)
Stage I Sxand Chemo = 9 months
Stage II Sxand Chemo = 6 months
Stage III Sx and chemo = 3 months
hemangiosarcoma chemotherapy protocols generally consist of
Doxorubicin given once every 2-3 weeks for 5-6 treatments
can combine w other agents 2
You should be cautious with Doxorubicin in what patients
1) Breeds predisposed to DCM
2) Breeds at risk of MDR-1 mutations
Why is hemangiosarcoma such a poor prognosis
1) High metastatic cancer
2) Common sites: lungs, liver, peritoneum, omentum, brain (most common tumor to spread there)
can go anywhere
What is the most common tumor to spread to the brain
hemangiosarcoma
After the spleen, what is the 2nd most common site of hemangiosarcoma
R atrium or auricle
How do you treat cardiac hemangiosarcoma
surgery excision of mass possible in some cases (not commonly performed and pericardiectomy not beneficial)
1) Radiation therapy- palliative or sterotactic (may decrease bleeding episodes)
2) Doxorubicin- MST = 4 months
What does Dermal / Cutaneous HSA look like
often small, blood blister like masses
on poorly haired areas-ventral abdomen
may be solar induced
What breeds are predisposed to dermal / cutaneous hemangiosarcoma
Whippets
American Staffordshire
Terrier / Pitbulls
Italian Greyhounds
Beagle
Dalmation
likely solar induced
How do you cure Dermal/ Cutaneous HSA
Surgery - often curative
MST = 18months to >4 years
What are the better prognostic factors of dermal / cutaneous HSA
1) Predisposed breeds
2) Ventral abdominal location
3) Actinic changes on histo (ie solar induced)
4) High recurrence rates, but prolonged survivals
no effect on progosis is multiple masses
What are worse prognosis factors for dermal / cutaneous HSa
1) Non-predisposed breeds
2) SQ invasion
3) Increased risk for metastasis and shorter survival
no effect on progosis is multiple masses
T/F: multiple dermal / cutaneous HSA masses is a worse prognosis
False - no effect on prognosis
What does the coriolus versicolor mushroom do
known as turkey tail mushroom
-contains polysaccharopeptide (PSP)
possible inhibition of cancer cell growth through cell cycle inhibition, immunomodulation and gene modulation
expensive - side effects = nausea, diarrhea
WHat do you need to diagnose hemangiosarcoma *
Histopathology
the liklihood of HSA for dogs presenting with non-traumatic hemoabdomen is high but not 100%
likelihood of HSA for incidentally found splenic mass is much lower
T/F: Visceral hemangiosarcoma is an aggressive cancer with a low metastatic rate
False - it is aggressive AND it has a high metastatic rate
How do you achieve the best outcomes of visceral hemangiosarcoma *
multimodal therapy
1) Surgery + Chemotherapy +/- radiation therapy (depending on site of tumor)
*Splenic HSA has some unique complications secondary to surgery
*Long term prognosis is poor even with aggressive therapy
exception is dermal HSA- surgical excision is sufficient for most cases
T/F: for dermal HSA, surgical excision is sufficient for most cases
True
