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3. Cat & Dog > oncology 1 > Flashcards

oncology 1 Flashcards

1
Q

most common cancers for dogs

A
  1. mammary
  2. skin
  3. connective tissues
  4. testes
  5. melanoma & lymphoma tie
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2
Q

most common cancers for cats

A
  1. non-hodgkin’s lymphoma
  2. leukemia
  3. skin
  4. mammary
  5. Connective tissue
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3
Q

how common is cancer as a cause of death for cats and dogs?

A
  • 47% of dogs
  • 32% of cats
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4
Q

causes of cancer

A

 environment (up to 80‐90% of human cancers)
 diet
 chemicals (hormones)
 radiation
oncogenic viruses
> feline leukemia virus
> human papilloma virus
- genetic factors
- trauma

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5
Q

why is there an increasing prevalence of cancer in companion animals?

A

Due to increased life expectancy of pets (increased risk with age)
a) better nutrition
b) vaccination for infectious disease
c) preventative medicine
d) leash laws
e) human‐animal bond

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6
Q

Treatment of Cancer requires knowledge of :

A
  1. Biology of the disease/natural history of the tumour
  2. How to diagnose & stage
  3. Modalities of treatment
  4. Costs
  5. Expectations/prognosis
  6. Client Education
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7
Q

what type of Knowledge of the Biology / Natural History of the Tumour should we know for treatment plans?

A
  1. Common sites
  2. Malignancy potential
  3. Where to look for metastatic disease
  4. Distant effects (paraneoplastic disorders)
  5. Precancerous conditions
  6. Suggests the clinical workup necessary
  7. Suggests treatment response & prognosis
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8
Q

types of cancer, categorically

A

*Carcinoma
*Sarcoma
*Round cells
> Lymphoma, leukemia, MCT, ….

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9
Q

clinical presentations / classifications of cancer based on location and spread (stage)

A

*Local / regional
- local and systemic
*Systemic

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10
Q

are soft tissue sarcomas local or systemic?

A

local

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11
Q

4 questions of oncology

A
  1. what is it?
  2. where is it?
  3. how bad is it?
  4. what to do about it?
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12
Q

the cornerstone of cancer diagnosis - what is it?

A

biopsy

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13
Q

types of biopsy, and what type they are

A
  • fine needle aspirate (FNA): cytology
  • incisional: histology
  • excisional: histology
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14
Q

how to interpret biopsy results - what info do we need from pathologist?

A
  • neoplastic versus not neoplastic
    > e.g. inflammatory
  • malignant versus benign

The clinician has the right and the obligation to question the diagnosis if it is inconsistent with the clinical picture !!!

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15
Q

evaluation of malignant criteria all boils down to…

A

uniform or variable?

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16
Q

soft tissue sarcomas often present as what? diagnostic challenges?

A
  • One of the challenges can be associated with getting a diagnosis!
  • Often present as a subcutaneous mass that is slow growing
  • Less aggressive tumours are harder to diagnose - Can appear as anything
    > Soft and mobile
    > Firm and fixed
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17
Q

where on the body do we commonly see STS? what can we mistake them for? best chance for cure?

A
  • Very commonly seen on the limbs
  • easy to mistake for a lipoma on aspirate
  • Treat early (small) for best chance of cure
  • Lipomas are RARE on limbs
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18
Q

how to diagnose STS - what is the use of FNA? do STSs exfoliate well? what can we learn?

A
  • Fine needle aspirate & cytology
  • Often exfoliate poorly
  • malignant tumours exfoliate better (i.e. diagnosis on cytology can mean a worse tumour)
  • Ddx: sarcoma vs scar tissue (spindle
    cells)!
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19
Q

Is a FNA useful for diangosing MCT? lipoma? STS?

A
  • good for MCT
  • ok for lipoma
  • generally poor for STS
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20
Q

use of FNA & cytology for learning about behaviour, stage, and grade?

A
  • cytology can hint at behaviour but does not provide a grade!
  • can help direct your preoperative staging
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21
Q

STS Diagnosis: Incisional biopsy
- what is the goal? what technique should we use? considerations for surgery?

A
  • Goal: to achieve a diagnosis with minimal disruption of the mass
    > Provides more information about tumour behaviour (grade!)
    > Not necessary if diagnosis achieved from cytology
  • Want the smallest incision possible to get a diagnosis, stay within the boundaries of the mass
    > Make sure to go through the pseudocapsule … sarcoma tissue looks a bit like toothpaste!
    > Go deep to get through the pseudocapsule but DO NOT disrupt the fascial plane
  • Plan biopsy based on surgery … must remove biopsy tract later
  • (Rarely used for mast cell tumour [MCT])
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22
Q

STS Diagnosis: Excisional Biopsy
- goal? what we learn? when would we use this technique? when is this not reccomended? what are the risks? technique?

A
  • Goal: confirmation of diagnosis when potentially a benign disease process
    > eg. granuloma
  • provides histopathology and grade
  • Not recommended if STS highly suspected
  • Major risk that you will disrupted local tissues making curative excision more difficult/ not possible
  • Occasionally performed for very small cutaneous masses if suspect benign (<1cm) > do not disrupt the fascial plane
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23
Q

Types of STS

A
  • Hemangiopericytoma** (NOT hemangiosarcoma)
  • Fibrosarcoma
  • Neurofibrosarcoma (peripheral nerve sheath tumour)
  • Liposarcoma
  • Rhabdomyosarcoma
  • Undifferentiated (anaplastic) sarcoma
  • others
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24
Q

basis of answering the question: where is it?

A

staging

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25
Q

clinical staging of tumours tells us what?

A
  1. defines the extent of the disease
  2. Aids in planning treatment
  3. Allows more accurate prognostication
  4. Assists in evaluation of therapy
  5. Allows communication between clinicians
  6. Nomenclature: ‘TNM’ System (WHO)
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26
Q

staging could require:

A
  • biochemical profile
  • urinalysis
  • CBC
  • thoracic radiographs (3 views)
  • abdominal radiographs or ultrasound
  • bone marrow aspirate / biopsy
  • CT / MRI / PET‐CT / bone scan
  • CSF tap
  • etc. (FeLV / FIV status)
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27
Q

metastatic risk of sts depends on:

A

Grade:
- Grade 1: 0‐10%
- Grade 2: 10-20%
- Grade 3: 40-50%

28
Q

minimum thoracic radiographs to stage STS? When not as useful?

A
  • minimum 2-views thoracic radiographs
    > low yield in low grade tumours
    > but useful for screening for other disease in older anmals
29
Q

what type of imaging to consider for staging if high grade?

A

consider CT thorax

30
Q

what do we often need for local staging to evaluate the mass & for planning surgery

A

often need advanced imaging (CT/MRI)

31
Q

what do we need to konw to answer the question: how bad is it?

A

Grade

32
Q

what info does grade tell us about marginal excisions? vs complete excisions?

A
  • Grade is a strong predictor of local recurrence with a marginal excision
  • complete excision is a strong predictor of local control
    > (ie. clean margins = decreased recurrence)
33
Q

how quickly will low grade tumors recurr, if they do?

A
  • Often with low grade tumours they can take months‐years to recur
34
Q

behaviour of STS of Mesenchymal or Connective Tissue Origin
- how locally aggressive? metastatic rate? how to control? how do they tend to metastasize?

A
  • Locally aggressive – somewhat grade dependent
  • Distant metastasis depends on grade but overall low metastatic rate
  • Grade I: 0-10%
  • Grade II: 10-20%
  • grade III: 40-50%
  • often a surgical disease local control is key
  • tend to metastasize hematogenously (ie.lungs)
35
Q

what treatment modalities can be used for cancer?

A
  • surgery
  • radiotherapy
  • traditional chemotherapy
  • precise therapy
  • immunotherapy
36
Q

treatment modalities for local disease?

A
  • Surgery
  • Radiation
37
Q

treatment modalities for systemic disease?

A
  • Chemotherapy
  • Radiation
  • immunotherapy
38
Q

mainstay of STS treatment? other options? what has limited efficacy?

A
  • surgery is the mainstay of treatment
  • if surgery alone not possible consider surgery + radiation therapy (RT)
  • chemotherapy has limited efficacy
39
Q

In most cases of cutaneous and SQ masses, what gives us best chance of cure?

A

surgical excision

40
Q

Planning for Surgical Excision
> what do we need?

A
  • GET A DIAGNOSIS!
    > The diagnosis will significantly affect your surgical approach and therefore it SHOULD be rare to remove a mass without a diagnosis
    > Cytology
    > Excisional biopsy
    > Incisional biopsy
41
Q

Types of surgical Excisions

A
  • Intracapsular
  • Marginal
  • Wide
  • Radical
42
Q

what is an intracapsular excision? Goal? pros and cons? limitations?

A
  • aka: intralesional, cytoreduction, debulking
  • Goal: decrease the amount of disease present, typically for palliation or lipoma
    > residual visible tumour at surgery site
  • Better to avoid and perform marginal excision whenever possible
  • local control is not possible with this technique if malignant disease
    > recurrence is a certainty
43
Q

marginal excision - goal? when is it typically used? follow up?

A
  • aka: excisional biopsy, minimal excision
  • Goal: Remove all visible tumour without requiring reconstruction or significant patient morbidity
    > Residual microscopic tumour cells at surgery site
  • Excision with minimal margins, no skin margin or fascial plane
  • Typically used in cases where curative intent surgery is not possible and follow up with radiation
44
Q

wide resection - goal? how do we perform, generally? what do we need for these surgeries?

A
  • aka: Curative intent * Goal: Surgical cure
  • Lateral & deep margins (ie fascial plane) to remove complete macroscopic and microscopic tumor
  • These surgeries take a lot of planning:
    > understanding of anatomy and fascial plane beneath tumor
    > may need advanced imaging (MRI, CT)
    > may need reconstruction for closure
45
Q

wide resection technique for STS

A
  • STS: aiming for 3 cm margins + 1 fascial plane deep
    > may not always be possible on limbs, but in these cases should consider referral for best chance
    > may need advanced imaging to determine extent of tumour
46
Q

wide resection for MCT - how much do we cut / what are our margins?

A
  • MCT: Proportional margins + 1 fascial plane deep
  • if mass <5mm: take 5mm margin + fascial plane
  • if mass 5mm - 1cm: take 1cm margin + fascial plane
  • if mass 1‐2 cm: take 2cm margin + fascial plane
  • if mass >2 cm: take 3cm margin + fascial plane
47
Q

how do we mark margins for wide excision? what should we plan out? what do we do with deep margin and why?

A
  • Identify margins with sterile marker
  • Clip wide and plan any potential reconstruction/ flaps necessary
  • Suture deep margin to skin during
    excision to avoid shifting of tissues
    during formalin fixation
48
Q

radical resection goal

A
  • Goal: Completely remove the
    tumour & surrounding tissue =
    no place for recurrence to occur
    > amputation
    >typically reserved fo cases where cytoreduction not possible
49
Q

should we always submit a sample of removed tissue? what should we include?

A
  • If it’s worth taking off, it’s worth submitting!
  • Always build histopathology into your estimate
  • be descriptive
  • Make sure your pathologist knows exactly where the sample came from, what was your goal of surgery, & specifically identify any margins you are concerned about
50
Q

what will histo report tell us?

A
  • Diagnosis and certainty (from pathologist)
  • Grade (or why not!)
    > mitotic index
    > anisokaryosis and other criteria of malignancy
    > necrosis
  • margins
51
Q

How to interpret margins

A
  • Should be interpreted in light of your surgery
    > ie what did you see clinically
  • all dirty margins are not created equally = did you cut through the tumor or did you think you were cutting clean!
  • clean = no tumot cells contact the margins
  • dirty = tumor cells contact the margins
  • clean but close ??
    > pathology recut in areas where < 2mm?
52
Q

danger of unplanned excision - tumor removal without diagnosis

A
  • danger of disrupting fascial planes, increasing the diameter of the definitive resection, increasing rink that definitive resection will not be successful (curative)
53
Q

I just did an unplanned excision: What now?

A
  • Advanced imaging for residual tumour
  • Scar resection if possible or radiation therapy
  • curative intent radiation therapy to scar
  • Active surveillance (high chance of local recurrence but could take time depending how HOW dirty)
54
Q

how is radiation therapy used?

A
  • Increasing availability
  • Often combined with other modalities
  • control vs cure
55
Q

use of radiation therapy for STS? pain? price? time? stress?

A
  • Excellent treatment modality for
    local control of STS after marginal excision
  • potentially painful
  • expensive
  • Time consuming > 4-5 week course of daily fractionated radiation
  • stressful for the patient
56
Q

STS curative methods

A
  • plan for curative intent wide resection with no radiation
    OR
  • plan for a positive margin: marginal excision followed by radiation therapy
57
Q

STS radiation therapy is best for what type of disease? what are the response rates?

A
  • Microscopic disease is better
  • Macroscopic (gross disease)
    > 70% response rate for 6-8 months
  • Microscopic with curative RT
    > 85-90% curre
  • microscopic with palliative RT
    > 70% 2-3 years local control
58
Q

when should we use radiation therapy after STS surgical removal?

A
  • Use in cases of marginal excision, especially if grade II or III
  • Another method of local control that can be combined with an
    inadequate excision
59
Q

what is the use of chemotherapy for STS? when is it not reccomended vs recomended? what does it do? schedule optiosn?

A
  • Grade I or II – not recommended
  • Grade III – controversial but recommended by some medical oncologists
  • systemic treatment of micrometastatic disease
  • full course chemotherapy (MTD)
  • Metronomic (low dose continuous) chemotherapy
60
Q

Full course chemotherapy (MTD) drug options

A
  • Doxorubicin
  • Mitoxantrone
  • Carboplatinum
61
Q

Metronomic Chemotherapy - reduces or eliminates what? cost? tolerance?

A
  • Reduction or Elimination of the Break Period
    > dose reduced accordingly
  • Low cost, easy to give, well tolerated
    > Alkylators: cyclophosphamide, chlorambucil, lomustine (CCNU)
  • Formal clinical evaluation is currently lacking
62
Q

metronomic chemotherapy mechanisms

A
  • Direct tumour cell kill
  • Angiogenesis
    > Indirect
    > Direct
  • Immunologic
  • Stromal? Other?
63
Q

Take home message
Soft tissue sarcoma Diagnosis

A
  • Cytology can be suspicious for STS but not diagnostic
    > combined with advance imaging (CT or MRI) can be enough to plan surgery
  • biopsy is required to make a final diagnosis
    > excisional: only if can do another surgery if confirm STS to get clean margins
    > incisional: better, as gives diagnosis prior to surgery planning
64
Q

STS palliative intent treatment

A

Intralesional or marginal resection +/-
metronomic chemo

65
Q

STS curative intent - wide or radical
resection not
possible

A

Marginal excision +RT

66
Q

STS curative intent, wide or radical resection not possible

A

Dirty margins:
- RT +/- metronomic chemo

Clean margins
- potential cure, monitor for recurrence

3. Cat & Dog (33 decks)

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