SA MED - ONCOLOGY Flashcards
1
Q
% of dogs that lived to 10+ years old died of cancer
A
45%
2
Q
Characteristics of malignant cell growth according to Hanahan and Weinberg
A
- self sufficiency in growth signals
- insensitivity to anti-growth signals
- evasion of apoptosis
- limitless replicative potential
- sustained angiogenesis
- tissue evasion and metastasis
3
Q
What is malignant transformation?
A
Mutation in DNA or epigenetic changes that alter the genetic code of a somatic cell, endowing it with limitless replicative potential or other growth or survival advantage
4
Q
Three stages of malignant transformation
A
- Initiation (initial, change, rapid)
- Promotion (more mutations or changes over years by initiating agent or normal hormones/GFs)
- Progression (more mutations toward malignant phenotype)
5
Q
Four types of changes that lead to aberrant differentiation (malignant transformation)
A
- Activation of oncogenes
- Inactivation of tumor suppressor genes (p53)
- Altered repair capacity of DNA
- Defective apoptosis
6
Q
Name for benign epithelial glandular tissue
A
Adenoma
7
Q
Name for malignant epithelial glandular tissue
A
Adenocarcinoma
8
Q
Name for benign connective tissue mass
A
Tissue type + OMA
Ex: fibroma
9
Q
Name for malignant connective tissue mass
A
Tissue type + SARCOMA
Ex: fibrosarcoma
10
Q
What is the name of the neoplastic growth curve?
A
Gompertzian growth
Best time to treat would have been before you could even palpate it
11
Q
Is cancer always painful?
A
No
12
Q
Does the presence of a mass diagnose cancer?
A
No - could be cyst, granuloma, abscess, etc.
Sample to know which!
13
Q
Cytologic criteria of malignancy
A
- anisokaryosis
- anisocytosis
- multiple, irregular, large nucleoli
- multinucleation
- mitotic figures
- altered nucleus-cytoplasm ratio
14
Q
Three basic cell types
A
Round cells
Mesenchymal cells
Epithelial cells
15
Q
On cytology you see cells sticking together, cell walls are visible. What type of tumor would this suggest?
A
Epithelial
aka city dwellers
16
Q
On cytology, you see lots of circular cells with round nuclei, not clumped together. What type of tumor would this suggest?
A
Round cell
Aka free spirits
17
Q
On cytology you see cells with indistinct borders, the cells are elongated and spindle shaped with elongated nucleus. Sample exfoliated poorly. What type of tumor do you suspect?
A
Mesenchymal
Aka small town
18
Q
Advantages of incisional biopsy (5)
A
Do not usually require anesthesia
Provides diagnosis to prepare for next step
Less likely to contaminate nearby clean tissue
To determine **what further staging tests may be needed* prior to removing the mass
Important when tx would be altered by knowing the tumor type or other characteristics
19
Q
Disadvantages to incisional biopsy (2)
A
Requires second procedure for treatment
Can be non-diagnostic or misleading on grade
20
Q
What must be known prior to excision biopsy?
A
Extent of the tumor
21
Q
What is liquid biopsy?
A
Detect metabolic marker or circulating tumor cells or pieces of tumor DNA that are circulating in the blood stream
22
Q
How is biologic behavior of tumors determined?
A
GRADE
Also histologic type, location, and other tumor-specific factors
23
Q
Do patients usually die from primary tumor or metastasis?
A
Metastasis
24
Q
Metastasis cascade (5)
A
- Cell detachment and vascular invasion
- Transport and survival in circulation (evasion of host defense mechanisms in blood or lymphatics)
- Aggregation with platelets and fibrin and arrest at new location
- Extravasation into the surrounding parenchyma
- Establishment of new growth
25
What pattern of metastasis do carcinomas have?
Lymphatic
Can still go to lungs, but go to regional LN first
26
What pattern of metastasis do sarcomas have?
Hematogenous
Check lungs/liver/LN involvement in sarcomas
Carriers a very poor prognosis
27
What pattern of metastasis do round cell tumors have?
Lymphatic and hematogenous
28
What is included on a pathology report?
Histologic diagnosis
Margins
Invasiveness
GRADE
29
What is a grade?
Attempt to predict which tumors will metastasize or carry a poorer prognosis
30
What is a mitotic index?
Number of cells in mitosis in ten high power (40X) fields
31
What is the TLM method of staging?
Determination of **what the tumor has actually done** to the patient at time of diagnosis
Includes: tumor, LNs, and metastasis via blood (always poor prognosis)
32
What does the TLM method of staging help? (4)
Aids in determining prognosis
Aids in forming a treatment plan
Aids in monitoring response to treatment
* Guides a good clinical workup
33
How to stage a tumor
1. PE and history (usually do bloodwork too)
2. Evaluate the tumor (measure size, take rads/US)
3. Evaluate LNs
4. Evaluate for metastasis
34
Compare CT vs MRI
CT
* best for bony masses
* best for screening for metastasis
MRI
* extremely good detail
* best for local soft tissue exams
35
T staging
N staging
M staging
T: primary tumor
N: lymph node evaluation
M: evaluate for metastasis
36
Tumor histology and grade tell you what?
Histology - where it goes
Grade - how far
37
What is cancer cachexia?
Profound state of malnutrition and weight loss despite adequate nutrition.
Has a clinical significance in humans - decreased QOL and survival time
Not really a problem in dogs
38
What is the mechanism of cancer cachexia?
Glucose is preferred substrate of cancer cells
Tumor cells do incomplete metabolism of glucose (get 2 ATP vs 36 ATP in normal cells)
Expends a lot of energy as the host must now do gluconeogenesis
Causes protein wasting, decreased immune function / wound healing
39
Treatment for cancer cachexia
Remember, mainly a problem in CATS
Provide 30-50% of non-protein calories as FAT
Provide 1.5-3X normal calories
Make sure energy is given via GI tract (oral)
40
What is one of the most common causes of hypercalcemia in cats/dogs?
Cancer:
- lymphoma
- anal sac apocrine gland adenocarcinoma
- multiple myeloma
- thymoma
- parathyroid gland adenomas
41
Mechanisms of hypercalcemia as a Paraneoplastic syndrome
Depends on tumor type
- PTHrp
- true hyperparathyroidism
- vitamin D like factors
- tumor production of osteoclast activating factor
- direct bone lysis
42
Treatment of hypercalcemia from paraneoplastic syndrome
Treat underlying disease once diagnosis is reached
- saline diuresis (0.9% NaCl IV)
- furosemide (inhibits Ca reabsorption at loop of Henle)
- Glucocorticoids (careful, only if you have DX first. If you give before dx, can mask lymphoma)
- bisphosphonates
43
What is the bisphosphonate that Dr. Fidel loves?
Zoledronate
44
MOA of Zoledronate
Bisphosphonate used to treat hypercalcemia
Directly inhibits bone resorption
Causes apoptosis of osteoclasts
Depository effect on bone reabsorption
45
Signs of hypoglycemia
Weakness, tremors, seizures
46
Treatment for hypoglycemia
Unlike hypercalcemia, ok to TX before diagnosis of cause is reached
- feed frequently, high protein better than high carb
- glucose solutions PO or IV (careful if insulinoma)
- glucocorticoids (cause an increase in hepatic gluconeogenesis)
47
Tx for insulinomas
- Remove tumor
- Streptozotocin (anti neoplastic agent w/ affinity for pancreatic islet cells)
- Toceranib
48
What types of tumors can cause polycythemia?
Those that cause ectopic EPO production
- renal tumors
- lymphosarcoma
- hepatic tumors
- nasal fibrosarcoma
49
Signs of polycythemia
Neuro: motor/sensory depression, dullness, lethargy, seizures
Hemorrhage: epistaxis, hyphema
50
Tx for polycythemia as a paraneoplastic syndrome
- Remove primary tumor
- Phlebotomy
- Hydroxyurea
51
You see hypertrophic osteopathy (lots of painful new bone growth along shafts of long bones), what should you do next?
Check the chest/abdomen for mass
Connection between mass and new bone growth is unclear, but there is definitely a connection
52
Treatment for hypertrophic osteopathy
Tx/remove primary tumor
Corticosteroids
NSAIDs
Bisphosphonates
Vagotomy (rarely done; more of a human med thing)
53
What should always be on your differential list for fever of unknown origin?
Cancer
54
CBC abnormalities often seen in cancer patients
- Anemia (from blood loss, chronic inflammation, IMHA, BM suppression, chemotherapy etc)
- Leukocytosis (from chronic inflammation and granulopoietic factors)
- Thrombocytopenia (from all four mechanisms)
- Thrombocytosis (immune mediated)
55
Signs of hypergammaglobulinemia (3)
PU/PD
Neuro signs
Bleeding
56
DfDX for monoclonal gammopathy (3)
Plasma cell tumors
Lymphoma/leukemia
Ehrlichia
57
What paraneoplastic syndrome can a thymoma cause?
Myasthenia gravis
Produces anti ACh receptor antibodies
58
Which chemotherapy causes seizures and death in cats?
5-flurouracil
59
What tumor can cause alopecia and gross shiny skin on cats?
Pancreatic
60
Causes of cutaneous flushing
Pheochromocytoma
Mast cell tumor
61
Nodular dermatophytosis in GSDs is linked to what?
Renal cysts or cystadenocarcinomas
62
Which treatment modality cures the most patients?
Surgery
63
Why are second/subsequent surgeries more difficult if you don’t get clean margins during the first surgery?
B/c surgery alters vascularity, immune system, and tissue planes
This will allow recurring tumors to become more aggressive
64
How does radiation kill cells?
Deposits energy (ions) on/near DNA which breaks the DNA
When the cell tries to divide, it will die
This kills a constant proportion of cells, and doesn’t distinguished between normal/cancer cells
65
Limitations to radiation therapy
Surrounding normal tissue must tolerate radiation
Anesthesia requirements to give the radiation (b/c animal can’t move)
66
Four R’s of radiation therapy
Repair
Repopulation
Re-oxygenation
Redistribution
These four things help normal cells repopulate/kill more cancer cells (why we fractionate radiation dose)
67
What is fractionation of radiation therapy?
Helps kill tumor and save normal cells
It is basically a time period to allow reoxygenation/redistribution in the tumor, and repopulation and repair in the normal cells
Large total dose in small fractions
68
Is radiation better for smaller or larger tumors?
Smaller
69
Acute effects of radiation (up to three months post)
Hair loss
Most dermatitis (aloe Vera, aqua-horse)
Mucositis (flush mouth w/tea)
Intestine or bladder inflammation
Nervous tissue
Inflammation/edema
70
“Normal” late effects of radiation
(Can be years after treatment)
Alopecia
Hyperpigmentation
Cataracts
71
Bad/unacceptable late effects of radiation
Skin fibrosis
Bone necrosis
72
What is sterotactic radiation?
One (or very few) high dose(s) of radiation
73
Pros of stereotactic radiation (2)
May kill cells not rapidly dividing better than multiple lower doses
May damage blood supply better
74
Mechanism of chemotherapy
Act on rapidly dividing cells by interfering w/ DNA synthesis or cell division
Highly non-specific, targets macro difference (rapidly growing cells)
75
List the alkylating agents
Cyclophosphamide
Lomustine
Melphalan
Chlorambucil
76
List the antimetabolite chemo drugs
Methotrexate
Cystosine arabinoside
Espar
Rabacfosadine
Azothioprine
77
List the anti tumor abx chemo drugs
Doxorubicin
Mitoxantrone
Bleomycin
78
List the spindle cell poisons chemo drugs
Vincristine
Vinblastine
Taxol
Vinorelobine
79
List the platinum chemo drugs
Crisp Latin
Carboplatin
80
What is the only therapy for metastatic disease?
Chemotherapy
81
What types of tumor cells can chemo kill?
Can only kill tumors w/“liquid” growth (dividing) and genomic stability (if tumor mutates, drug is useless)
82
Limitations of chemo
- resistance
- drug delivery issues (ex: tumor in CNS)
- side effects to normal tissue (BAAG)
- Drug specific side effects in each class
83
Which chemo drugs affect the kidney?
Cisplatin
Doxorubicin (cats)
Lomustine
Monitor bloodwork for signs of kidney damage
84
Which chemo drug has side effects on the heart?
Doxorubicin
85
Which chemo drugs cause side effects in the bladder?
Cyclophosphamide (cystitis)
86
Which chemo drugs cause side effects in the pancreas?
Laparotomy
Doxorubicin
87
Which chemo drugs cause side effects in the nervous system?
Vincristine (peripheral neuropathy)
5-FU (seizures in cats)
88
Which chemo drugs cause side effects in the liver?
Lomustine
Monitor bloodwork
89
Which chemo drugs cause side effects in the lungs?
Cisplatin (will kill cats)
Bleomycin
Lomustine
Tanovea
90
Advantages to using multiple drugs in a chemo protocol (3)
You can use a lower dose of each drug, which means fewer side effects
Using multiple drugs decreases the risk of development of resistance
Single drugs are unlikely to cure bulky disease
91
What two types of tumors are the only ones that chemo alone can cure?
Lymphoma and germ cell tumors
TVTs also fit this category
92
What is adjuvant therapy?
Chemo combined with some other modality to reduce tumor burden
(Esp when you have a tumor that’s not rapidly dividing)
93
When is the greatest chance for cure with adjuvant chemo in combination with surgery? Before, during, or after surgery?
Shortly after surgery
94
Administration considerations in choosing a new chemo protocol
Practice factors, can you safely handle these drugs?
Client factors (can they come in weekly, biweekly, etc)
Patient (size, personality)
95
Chemotherapy:
Dose calculation usually based on what?
What kind of system to limit exposure?
BSA (m2)
Closed system
96
How to give quick IV chemo
Use lateral saphenous or cephalon vein (dogs)
Use medial saphenous in cats
97
How to give chemo slowly
Infusion - decreases cardiac toxicity
Be careful, severe tissue reaction if extravasated
Place catheter, wrap so vein is visible
Flush w/saline
98
When is cryotherapy successful?
Only when tumor is small and superficial
(Small SCC)
99
What is photodynamic therapy?
Combo of photosensitizing agent and light for superficial tumors (can’t diffuse any deeper)
100
What is electrocheotherapy?
Combo of:
Traditional chemo drugs (usually bleomycin)
Pulsed electricity to facilitate drug uptake
101
Define survival
Length of time post diagnosis an animal will live, usually quoted as a median
102
Define time to recurrence or relapse
End of treatment to tumor reappearance
103
Define time to tumor progression/recurrence
Same as time to recurrence* but tumor may have never actually gone away
* end of treatment to tumor reappearance
104
Define prognostic indicator
Anything that can be evaluated that predicts how patient may respond to treatment and for how long
105
New targets in cancer therapy
Signal transduction
Angiogenesis
Evasion of apoptosis
Immune tolerance
Cell cycle dysregulation
Tissue invasion and metastasis
106
How is signal transduction a target for cancer treatment?
Mutated signal proteins involved in signal transduction are often oncogenic and are present in most cancer types
107
Why is aberrant expression of growth receptors / mutated signal transduction proteins bad for the patient?
It will increase:
- potential for tumor proliferation, invasion, and metastasis
- angiogenesis
Also will shorten patient survival, cause poor response to chemo, and decrease patient prognosis
108
What is the main signal transduction molecule that is targeted in cancer treatment?
Receptor tyrosine kinases (RTKs)
- These are the main mediators that transmit extracellular signals into the cell
- Control cellular differentiation and proliferation
109
How to RTKs fit into cancer development (3)
Constitutive RTK signaling causes dysregulated cell growth and cancer:
This can be from
- over expression of RTK proteins
- functional alterations from mutation that cause a gain of function
- abnormal stimulation that increases RTK activation
110
Primary targeted families of RTKs (3)
EGFR-HER-2
C-KIT (to tx MCTs)
VEGFRs (receptor involved in angiogenesis)
111
What are the two drugs that are RTK inhibitors
Toceranib phosphate
Masitinib (not available in US anymore)
112
What to remember to tell owner about RTK inhibitors
Once you start these drugs, must continue giving them for life (or until they stop working)
113
What species can you use RTK inhibitor in?
Dogs/cats
Too expensive in horses/other LAs
114
Why does tumor endothelium represent a valuable target for cancer therapy?
B/C it is molecularly distinct from normal vasculature, and the tumor growth is dependent on vascular growth
115
Two categories of drugs that target tumor blood vessels
1. Biological: Ab/peptides that deliver toxins/pro apoptotic effects to tumor endothelium
2. Small molecules: agents that exploit differences between tumor and normal endothelium, induce severe vascular dysfunction
116
What drugs are in the biologic category of drugs that target tumor blood vessels?
Avastin (Ab directed at human VEGF)
None for vet use exist yet :(
117
What drugs are in the small molecule category of drugs that target tumor blood vessels?
Toceranib (VEGF is an offsite target, this is an RTK inhibitor)
Thalidomide (illegal to use in US)
118
What are vet strategies to target tumor blood vessels?
Metronomic chemo:
Low, daily dosing of chemo drugs (theory is stops endothelial cells from multiplying)
Toceranib:
RTK inhibitor that directly inhibits VEGF signaling
119
Why is apoptosis important for tumor growth?
Evasion of apoptosis is necessary for tumor growth
120
How do tumors avoid the immune system
Likely via a variety of mechanisms, but above all they are recognized as self so the body won’t attack
121
Types of immune therapy to treat cancer
1. Active, nonspecific, immune stimulation
2. Active specific - tumor vaccine
3. Passive - Ab admin
4. Target/destroy T reg cells
122
Examples of active, nonspecific immune stimulation to treat cancer
- intact bacteria
- chemical agents like COX2 inhibitors, fenbendazole, cimetidine
- vitamins/minerals
- IL2, IFNa
Basically anything that will cause immune activation
123
Two goals of tumor vaccine
Activate T cells (increases MHC on cell surface)
Activate APCs
124
What passive (Ab) therapy exists in vetmed to treat cancer?
What is passive immunotherapy?
None yet
Antibodies
125
What types of drugs target T regulatory cells (cancer increases T regs which is a problem, prevent immune destruction of cancer)?
Metronomic chemo
Cimetidine
126
When is COX2 induced? (5)
Inflammatory states
Growth factors
Mitogenic substances
Oncogenes
Hypoxia
127
What is the primary culprit in COX2 and cancer?
PGE2
128
What does PGE2 do in cancer? (5)
Converts pro-carcinogens to carcinogens
Stimulates tumor cell growth
Prevents apoptosis
Promotes angiogenesis
Suppresses immune system
129
What is a good NSAID to treat cancer with?
Piroxicam
Even better when combined with chemo
130
Hat is the main tumor type that NSAIDs help treat?
Carcinomas
131
> 90% of hemolymphatic neoplasias are what?
Lymphoma
132
Are most k9 lymphomas B or T cell?
B cell
133
How to diagnose B vs T cell lymphoma
Cytology:
- flow cytometry
- immunocytochemistry
- PARR assay
Histopatholgy:
- immunohistochemistry
134
Stage I lymphoma
Single node or organ like the spleen
135
Stage II lymphoma
Group of nodes on one side of diaphragm
136
Stage III lymphoma
Generalized lymphadenomegaly
137
Stage IV lymphoma
Spleen or liver involvement
138
Stage V lymphoma
BM, CNS, or other organs involved
139
A vs B lymphoma
Add the letter to the stage number
A = no symptoms
B = symptoms/feels sick
140
Tests to stage lymphoma
CBC/Chem/UA (blood smear)
Thoracic rads
Image abdomen: U/S more sensitive and specific than rads
BM aspirate
141
Is staging important for lymphoma?
Not really; owners may request
Need to consider cost of staging; can they still afford treatment after paying for staging tests?
142
Prognosis of k9 lymphoma
- Extremely sensitive to chemo, but usually not curable
- 90% will achieve remission with chemo
- Avg survival is one year; worse prognosis with higher grade/stage of tumor
143
What worsens the prognosis of k9 lymphoma? (7)
- Substage b (likely T cells and hypercalcemic)
- Stage > III
- Hypercalcemic
- Icteric (liver likely failing)
- Hypoproteinemic (liver failure)
- T cell lymphoma
- Prior prolonged treatment with glucocorticoids
144
5 most common drugs to treat K9 lymphoma (and their classes)
Prednisone (corticosteroid)
Vincristine (mitotic spindle interrupter)
Cyclophosphamide (alkylation)
Doxorubicin (antitumor abx)
Elspar (L-aspariginase — enzyme metabolite) for relapse
145
What to do at relapse of K9 lymphoma
- Start same protocol over if more than six months from induction
- switch to a new protocol with new drugs (esp if T cell)
- use a rescue protocol
146
When can you do radiation therapy or surgery for lymphoma?
Surgery
If sure only single node or organ (ex: spleen)
Radiation
Local treatment only if you’re sure no lymphoma elsewhere (ex: nasal LSA in cats)
147
Feline lymphosarcoma (LSA) may be related to:
- young
- old
- environment
Young FeLV —> mediastinal
Older FeLV —> GI or abdominal
Second hand smoke
148
High grade vs low grade lymphoma in cats
Small cell (more chronic) —> low grade
Large cell —> high grade
149
Tx of high grade lymphoma in cats
Same as dogs, but cats get more side effects
If single node (grade I) can do radiation
150
Prognosis for feline lymphoma
Worse than dogs, but more unpredictable
151
What is leukemia?
Proliferation of neoplastic hematopoietic cells in the bone marrow
Relatively rare
152
Signs of leukemia
Weakness, depression, anorexia
Fever
Bleeding
Signs of hypercalcemia
Can be asymptomatic
Usually discovered on bloodwork
153
Which is worse prognosis: acute or chronic leukemia?
Acute
154
What is acute leukemia?
How to diagnose?
Presence of blasts and very high numbers
Worse prognosis
Flow cytometery or cytochemical stains to determine cell origin
155
What is chronic leukemia?
Over abundance of one mature cell type in high numbers
Most commonly lymphocytic
156
What is aleukemic leukemia?
No abnormal cells in the peripheral blood (proliferation in the bone marrow)
157
Best to worst prognosis for leukemia
Chronic lymphocytic leukemia (best)
Acute lymphocytic leukemia
Acute non-lymphocytic leukemia (worst)
158
Plasma cell tumors
- cell type
- prognosis
mature B cells
can be localized and benign
Local therapy is adequate :)
159
Multiple myeloma
- what is it
- prognosis
- 2 suspicious signs
- metaplastic plasma cell tumors
- can be managed (1.5y)
- punched out lesions in bones
- hypergammaglobulinemia
160
MCT signalment in dogs
Any age dogs, older cats, Boxers, Bostons, Labs, Schnauzer, Beagle
No gender
161
How do MCTs usually present in dogs
- most commonly
- less likely
- “special” sign
External skin masses
Primary internal mass is rare
Darier’s sign: puff up, red
162
How do MCTs usually present in cats?
Equal incidence of external and internal tumors
So primary complaint is not always a skin mass
163
What is in the granules in MCTs?
Histamine, heparin, other bio active molecules that cause systemic signs
164
Paraneoplastic syndromes from MCT (6)
GI ulcers
Impaired local healing
Coagulopathy
Urticaria
Eosin / basophilia
Rare: hypotensive shock
165
What is required to grade a MCT?
Histopathology
166
How are MCTs graded?
On a three tiered system
- pathologist may use a 2 level grading scheme
- oncologists like having both systems
167
Grade 1 MCT facts including prognosis
Well differentiated, superficial
Prognosis: nearly always good
168
Grade 2 MCT facts including prognosis
Well to medium differentiation, SQ involvement
Prognosis: variable
169
Grade 3 MCT facts including prognosis
Poorly differentiated
Prognosis almost always poor
170
What marker about MCTs is important to oncologists?
Mitotic index
171
What is the cutoff for mitotic index to tell you the MCT is less likely to recur or met?
Less than 5 mitoses/10 hpf
172
How to stage MCTs (all grades)
Depends on grade and owner desire
For all three grades:
- LN check (+/- imaging)
- basic database, Buffy coat smear
173
How to stage Grade 3 and most Grade 2 MCTs
In addition to LN check and basic database:
Abdominal U/S +/- liver/spleen aspirates
174
How to stage Grade 3 and high grade Grade 2 MCTs
In addition to last flash card, also add on a BM aspirate
175
You have a low grade/stage MCT, surgically approachable. What is your treatment plan?
Surgery with 3 cm margins is gold standard
176
You have a low grade/stage MCT, not surgically approachable. What is your treatment plan?
Electrochemotherapy
Radiation therapy - if the tumor is dividing otherwise doesn’t work
177
You have an intermediate grade MCT. What is your treatment plan?
Surgery for local disease
If Mets are found or if mitotic index greater than five, chemotherapy may also be needed
178
What treatment is needed for high grade, any stage MCTs?
Chemotherapy
179
Symptomatic therapy for MCTs
Basically, these block the effects of the granules:
- H1 blocker, diphenhydramine to prevent bronchoconstriction/vasodilation
- H2 blockers (famotidine, cimetidine etc) to prevent GI ulcers
- Prednisone
180
What specific chemo drugs are used to treat MCTs
Vinblastine, Lomustine, and Prednisone (WSU protocol)
Sometimes just Vinblastine and pred
Hydroxyurea
181
What to know about tyrosine kinase inhibitors as treatment for MCTs
- Can use Toceranib or Masitinib (not in US)
- 50% chance for response
- toxicity an issue
- once a pet is put on these, MUST STAY ON FOR LIFE
182
What are some other therapies for MCTs?
Tiglanol tigalate injection
- it basically causes local tissue necrosis at site of injection, including the MCT
- 89% were “cured”
- only do in locations were necrosis is acceptable
183
You see a feline skin MCT. What can you tell an owner?
Most are benign; can cure with surgery
184
What are the two aggressive forms of MCTs in cats
1. Splenic/visceral (often involve LNs as well)
2. Gastrointestinal
185
How will a cat with an aggressive internal form of MCT often present?
Vomiting due to increased histamine from granule release
186
What diagnostics might you do to diagnose a feline mast cell tumor?
- abdominal aspirate (common intestinal mass)
- Buffy coat smear or CBC (often circulating mast cells)
187
TX for feline internal MCT
- Corticosteroids, H1/H2 blockers
- remove tumor from spleen/intestine
188
Prognosis for feline internal MCTs
Splenic/visceral form: prolonged, > 3 years
GI: median 1.5 years
189
What is the most common dog breed that gets histiocytic sarcomas?
Flat Coat Retriever
190
How will biopsy reports for histiocytic sarcomas often read?
“Round cell sarcoma, histiocytic tumor possible”
191
Cell of origin for histiocytic sarcomas
Macrophages or dendritic APCs
192
Presentation of histiocytic sarcomas
Can by anywhere but often associated with muscle groups/joints; quite painful
193
Seeing _____ on a cytology highly suggests histiocytic sarcoma
Giant multi-uncleared cell
194
How to stage a histiocytic sarcoma
Check draining lymph nodes
Check lungs
Abdomen: look at liver and spleen
195
Tx for histiocytic sarcomas (3 options)
Surgery: if in removable spot, minimal morbidity, with NO metastatic disease found (amputate, then Lomustine)
Radiation: palliative care, also combo w/ Lomustine
Chemo: Lomustine can be only treatment or combined with above two
196
Prognosis for histiocytic sarcomas
Rarely curable but will initially respond to tx even if metastatic disease is present
197
What chemo drug is used to treat histiocytic sarcomas?
Lomustine
PO so GP can give
198
What is a histiocytoma:
- cell
- behavior
- appearance
Langerhans cell proliferation
Spontaneously will regress, or can remove if owner wants
Looks like a dermal nodule on a young dog; often on limbs
199
What is histiocytic sarcoma - hemophagocytic form:
- breed
- most likely cell
- common sign
A different form of histiocytic sarcoma (malignant histiocytic is) common in Bernese Mountain dogs but can occur in other breeds
Phagocytic macrophages
Cancerous cells; like to destroy RBCs, so present with SEVERE ANEMIA
No treatment at this time
200
What type of tumor is a histiocytic sarcoma
Round cell tumor
201
What is more important in soft tissue sarcomas, type or grade?
Tumor grade more important
202
Signalment for ST sarcomas
Larger, older dogs but any age/breed can get
Usually present with mass but often have internal mass but often have internal mass as well
203
Biologic behavior of ST sarcomas
Locally aggressive, invasive, poor margins
Grade should be predictive
Mitotic index is important prognostic indicator
204
What do the mitotic indexes in ST sarcomas mean?
0-10 grade I likely won’t met
10-19 grade II
> 20 grade III
205
How to diagnose ST sarcoma
Incisional biopsy is best choice b/c w/excisional biopsy you risk not getting margins, these are expansive weird shaped tumors so need to make a plan before surgery
206
How to stage a ST sarcoma
Measure the tumor: rads rarely enough, often need US/CT/MRI
Check LNs
Check lungs for Mets (use CT not rads if high grade tumor)
207
Margins for surgical removal of ST sarcoma
3 cm
Submit all the tissue for histopath
208
Tx for ST sarcomas - overview
- surgery clean is gold standard
- radiation: best if disease is minimal or dealing with bad margins then you have no choice
- chemo: often not needed b/c don’t often met
- metronomic chemo: especially if you don’t get clean margins
209
Metronomic chemo to treat ST sarcomas
Especially helpful if you didn’t get clean surgical margins
Use low dose alkylatiors (cyclophosphamide, Chlorambucil) plus an NSAID
210
Chemo as treatment for ST sarcoma
Often not needed, can be used if there is minimal disease present
VAC (vincristine, doxorubicin, and cyclophosphamide)
211
Tx for low grade ST sarcoma (most common type)
Surgery alone can be curative if done right
Bad margins: follow up with radiation and/or metronomic chemo
212
Tx for high grade ST sarcoma
High potential for metastasis
Surgery
+/- radiation
+/- chemo (less likely needed)
213
What to remember about feline ST sarcomas
Worse than dog sarcomas
Associated with vaccines
214
Rule of 1-2-3 for feline ST sarcomas (vax associated sarcomas)
Remove mass at vax site when:
Still growing at one month
> 2 cm
Still present 3 months post vax
215
Biologic behavior of feline ST sarcomas and how this dictates staging
Locally extremely aggressive, 10-25% will met
Advanced imaging almost always required
216
Tx for ST sarcoma in a cat
A bad surgery (dirty margins) will kill the cat
You really should refer these to a surgeon
- surgery with 5 cm margins
- radiation: really not needed if you got good margins
- chemo: not documented to extend survival but may help shrink the tumor
- metronomic chemo: cats don’t like being pilled SID so not really a good idea
217
Prevention of feline ST sarcomas
- Be cautious with vax program
- NEVER use killed virus vax in cat which has had VAS (including family members of the cat)
- vax low on limbs or in abdominal fat pouch
- always record vax location and lot number, company will pay
218
80% of primary bone tumors are ____
Osteosarcoma
219
Signalment of osteosarcoma
- mid/older dogs; also now seeing some at 18-24 months of age
- large/giant breeds
- males > females
- Neutered > intact at least in Rotties
220
Where are the tumors in osteosarcoma
> 75% are in metaphysis of long bones
Front > back legs
Away from elbow, towards the knee
Flat bones (axial) can occur but more rare
221
Cytology to diagnose osteosarcoma
Use Alk Phos staining
222
How to diagnose an osteosarcoma
Gold standard is histiopath
Can be hard to get good biopsy, will often amputate then submit leg (could be a different tumor type so you really should do the histo)
223
How to stage osteosarcoma
- check lungs: high potential for met to lungs via blood; CT more sensitive than rads
- can LSA met to other bones
224
What to tell owners about lung Mets post amputation
Mets are most likely to grow after the primary tumor is removed
225
Poor prognosis for osteosarcomas that:
- lung/bone met from onset
- LN met: not normal for a sarcoma === bad
- tumor in bad location that can’t be removed
- elevated ALP
226
Tx for K9 osteosarcoma
There is no curative tx
All txs are palliative
227
Palliative treatment for osteosarcoma
- amputation/no chemo: not recommended b/c metastatic lesions will grow after surgery
- radiation for pain control
- pain meds like NSAIDs, opioids
- Amputation w/chemo: CARBOPLATIN (less toxic than Cisplatin) or Doxorubicin as second choice
228
Tx for axial osteosarcomas
Surgery often impossible due to location (vertebrae, pelvis, etc)
Palliative radiation, pain meds, +/- chemo
229
Feline osteosarcoma
- rare but can happen
- metastasis comes much slower than in dogs
- surgery is tx of choice
230
What is a hemangiosarcoma?
Sarcoma that arises from vascular endothelial cells
Basically blood vessels gone bad
231
Signalment for hemangiosarcomas
Large breeds: Goldens, GSD, Labs (any breed can get)
Mean age 8-13 years, as young as 3 years
232
Biologic behavior of hemangiosarcomas?
Extremely aggressive, high rate of early metastasis
25% have right atrial involvement at diagnosis
14% have brain involvement at diagnosis
233
Presentation of hemangiosarcoma
Sudden collapse, weakness, pallor from bleeding
Sudden cardiac tamponade: arrhythmias, bleeding
Sudden enlargement of a mass
234
Hemangiosarcoma common sites
Can be anywhere there is blood
Spleen, liver, right atrium most common
235
You see a splenic lesion - what do you already know?
2/3 of splenic lesions are malignant and 2/3 of those malignant lesions are hemangiosarcomas
236
How to diagnose hemangiosarcoma
Histopath like always, but you can see some things and be highly suspicious:
- splenic lesion, splenic rupture
- R atrial mass
- biopsy / cytology only yielding blood
- schistocytes or acanthocytes in blood smear
- DIC
237
How to stage hemangiosarcoma
Required for all cases:
- basic database: anemia, fragmented RBCs, thrombocytopenia
- thoracic rads: mets to lungs quickly, check for R atrial mass
Nice to have but not required:
Coag panel, EKG, AUS, cardiac U/S
238
Tx for hemangiosarcoma
Surgical removal
- radiation: shrinks skin/heart base masses
- chemo: doxorubicin is best, so combo protocols are rare
- metronomic chemo: cyclophosphamide daily; this is anti angiogenic tx
- NSAIDs
239
Prognosis for hemangiosarcoma
Poor
Surgery alone for splenic: 2-3 months median survival
Surgery + chemo: 4-6 months
R atrial: doxorubicin + chemo longest survival of about 175 days
240
WSU protocol for hemangiosarcoma
- control local disease with surgery or palliative radiation
- doxorubicin 4X
- follow up with metronomic chemo
- repeat doxorubicin when measurable progression of tumor occurs
- at least six month survival in most cases
241
Cutaneous hemangiosarcoma
Likely from sunlight in light coat colored dog/cat
If tumor doesn’t invade into deep tissues, surgically curable disease
Repeated lesions can met internally and cause serious disease
242
External carcinomas
Glandular: mammary and apocrine gland adenocarcinoma
Skin: SCC
243
What increases K9 mammary tumors?
- historically, synthetic progestin use
- obesity
- eating home cooked meals, likely b/c obese
244
Presentation of K9 mammary tumors
- 70% of the time occurs as a mammary mass at glands 4/5
- inflammatory tumor is rare, but looks similar to MCT so be careful
- Inflamed plaque like lesion/nodules on skin, edema in mammary area
- any respiratory, neuro signs, or bone pain is from metastasis
245
Biologic behavior of mammary tumors
50% if intact
50% are malignant
50% of malignant tumors are low grade
Older dogs with large tumors more likely to be malignant
246
Staging of K9 mammary tumor
- LN evaluation
- chest rads are a must
- check for widespread metastasis; aggressive tumors do this
247
TX for K9 mammary tumors
Surgery!
Be aggressive, don’t just shell out the mass
Complete mastectomy not usually done; take one gland ahead and one behind the tumor
248
Other tx for K9 mammary tumors
Chemo: difficult to assess efficacy; can do Doxorubicin
Radiation therapy: only when local control is a problem
249
What does prognosis of K9 mammary tumors depend on?
Size, completeness of removal during surgery, and presence of ulceration
250
Feline mammary tumor basics
> 75% are malignant
The third most frequent tumor in cats
Any cat with a mammary mass
MUST be taken VERY seriously
251
Signalment for feline mammary tumors
Short haired most common
Siamese 2X risk of other breeds
Female, spayed
Previous hx of synthetic progestins or estrogens increases risk 3x
252
Biologic behavior of feline mammary tumors
80% are adenocarcinomas
Highly aggressive, metastasis is common
253
How to stage feline mammary mass
Stage before surgical removal
Assess tumor and all mammary glands
Assess draining LNs (including axillary for cranial glands)
Thoracic rads
U/S especially if cat is sick
254
Surgery for feline mammary tumors
Complete radical mastectomy
Include at least the closest LN (axillary for 1 & 2, inguinal for 3/4)
Occasionally require bilateral mastectomy
255
Treatment for feline mammary tumor
Surgery: radical mastectomy
Chemo: more useful compared to dogs
Doxorubicin, Doxorubicin + cyclophosphamide, or carboplatin
256
Prognosis of feline mammary tumors
10-12 months
Size of tumor at time of diagnosis is most important indicator of survival (< 8cm is best prognosis)
257
What are anal sac tumors in most cases?
Carcinomas or adenocarcinomas
Remember, can be any tumor type
258
Perianal adenoma: what is it and who does it happen in?
Benign tumor near the anus
Happens in intact males
Tx = neuter
259
Perianal gland carcinomas: are they good/bad, who does it happen in?
Bad, they are malignant
Possible male predominance
260
Apocrine gland anal sac adenocarcinomas: signalment
Malignant anal sac tumors
Median 10.5 years
Breeds: some spaniels, GSD, but any breed can get
+/- hypercalcemia
261
How to stage anal sac adenocarcinoma
Basic database (look for signs of hypercalcemia, present in up to 50% of cases)
Chest rads
Image abdomen b/c 50% will have already met to LNs by time of diagnosis (sublumbar LN)
262
Tx for anal sac carcinomas
Surgery: remove mass and anal sac, plus LNs PRN
Radiation: mass/nodes
Chemo: Carboplatin/Cisplatin, tyrosine kinase inhibitors
263
Prognosis for anal sac carcinomas with treatment
Survival can be long
264
What are the two most common nail bed tumors in dogs?
Melanoma
SCC
265
How do you stage nail bed tumors?
Aspirate local LN
Chest rads to check for mets
266
Tx for nail bed tumors
Surgery - remove the whole toe
Melanoma vax for melanoma
267
Prognosis for melanoma nail bed tumor
Better than oral melanomas in dogs, can live 1-2 years before mets develop
268
Prognosis for SCC nail bed tumor
Can be cured w/ surgery if single digit
Certain breeds (Black Standard Poodles, Giant Schnauzers, etc) can get tumors in multiple toes; this can lead to poor QOL
269
Signalment for urothelial carcinomas
Small breed older dog
Female
Scotties / Shelties may be overrepresented
270
Presentation of urothelial carcinomas
Pollakiuria
Stranguria
Dysuria
Urinary obstruction
So basically like a UTI
271
Biologic behavior of urothelial carcinomas
The main issue is locally they can block the trigone, if animal can’t urinate they will die
272
Staging urothelial carcinomas
Thoracic rads
Abdominal imaging: U/S if possible
CT: only if planning for radiation
BRAFF mutation in urine: Detects 80% of tumors
273
Tx for urothelial carcinomas
Surgery: only if tumor is at apex, can’t resect all of trigone
Chemo: Mitoxantrone
Palliative radiation is best for rescue or to unobstruct
274
Prognosis of adenocarcinoma of intestines
Depends on surgical margins
Most chemo is ineffective
44% metastasize but can be late
275
Prognosis of leiomyoma/sarcoma in intestines
Depends on surgical margins
Doxorubicin may help
276
Prognosis of GI stromal tumors (GIST)
Low metastatic potential so that’s good
Chemo is meh
Tyrosine kinase inhibitors are helpful
277
Feline hepatic tumors: prognosis
Benign tumors are common
Be careful using U/S to make a diagnosis
278
Canine hepatic tumors: prognosis
Malignant tumors common but often low grade
Surgical removal if possible
Chemo not helpful
279
Treatment for primary lung tumors
Surgery is treatment of choice
Chemo: minimally effective, could try Vinorelbine
NSAIDS +/- metronomic chemo may work
280
Good prognostic indicators of primary lung tumors
Adenocarcinoma
Low grade
< 5 cm diameter
Peripheral location
Negative nodes
No CS
Usually survive 1-2 years
281
Poor prognostic indicators of primary lung tumors
SCC, poorly differentiated tumors
> 5 cm diameter
Pleural effusion
CS present
Positive nodes
Evidence of mets
1-8 month median survival
282
K9 oral melanoma facts
High probability of metastasis
Often friable
Can be amelanotic; harder to diagnose
Take chest rads, LN biopsy, tumor biopsy to stage
283
TX for k9 oral melanoma
Surgery: can live up to one year
Radiation: palliative, must be high fractions otherwise melanomas don’t respond
Merial (?) melanoma vax if owner can afford
284
K9 oral SCC facts
Second most common oral dog tumor
Metastasis uncommon unless its in tongue or tonsil
285
Tx for k9 oral SCC
Surgery: usually doesn’t met until late in disease, so if done early this is a surgical cure!
286
K9 oral SCC in tongue facts
50% metastasize
Prognosis is usually poor
Surgery alone can give them 8 months
287
K9 oral SCC in tonsil facts
Prognosis is bad
Metastasis is common, even into abdomen
288
Tx for k9 oral SCC in tonsil
Surgery and radiation will give them 3.5 months
Chemo is helpful: Carboplatin can give a year or more of survival when added on to protocol
289
K( oral fibrosarcoma facts
Third most common tumor type
Metastasis uncommon but may depend on grade
Sometimes they are flat and look like gingival hyperplasia
These are often low grade, but that actually makes them hard to treat b/c chemo/radiation target dividing cells
290
Name for benign oral epulide in dog
Fibromatous or ossifying epilus
291
Name for malignant oral epulide in dog
Acanthomatous ameloblastoma
This is the best malignant tumor a dog can have b/c it wont metastasize
292
Treatment for acanthomatous ameloblastoma
Surgery: 90% cure rate
Radiation: 85% cure rate
Owner can choose which one they want
293
Feline SCC oral
Most common type in cats
Metastasize late
294
Treatment for feline oral SCC
It is difficult!
Surgery alone: only if small and rostral
Palliative care: pain meds + feeding tube will give them about 2 months
Surgery + radiation: 12 months
Accelerated radiation w/ Carboplatin: 5 months
295
Feline oral fibrosarcoma facts
Second most common oral tumor
Bone involvement is common
Metastasis is rare
296
Treatment for feline oral fibrosarcoma
Surgery: it is rare to get clean margins, so meh
Radiation: cure is rare; used as palliative tx to slow progression for ~6 months
297
Simple trick to check for nasal tumor
Retropulse the eyes
298
Biologic behavior of dog/cat nasal tumors
Locally aggressive
Metastasis as high as 50% at necropsy
299
What type of tumor are nasal tumors most commonly?
2/3 are carcinomas
Adenocarcinomas, SCC, TCC
300
What should you do before biopsy of a nasal tumor?
Image the tumor with CT (or rads if you have to)
301
How to biopsy a nasal tumor
Be aggressive!
Do the “blind trans-nasal core biopsy” which means stick a straw up their nose, then put biopsy needle through straw to sample
Cats: use coffee straws
302
Treatment for nasal tumors
Curative radiation therapy: survival 8-23 months depending on tumor type
303
Treatment for thyroid tumors
Lots
Surgery
External radiation
Radioactive iodine
Long term thyroid supplementation
Tyrosine kinase inhibitors (Toceranib)
