MSK Neoplasia 2024 VMS3010 Bacon PDF

Musculoskeletal Neoplasia Nick Bacon MA VetMB CertVR CertSAS DiplECVS DACVS FRCVS ACVS Founding Fellow, Surgical Oncology RCVS Specialist (Surgical Oncology) Clinical Director, AURA Veterinary Professor, Surgical Oncology, University of Surrey...

Musculoskeletal Neoplasia Nick Bacon MA VetMB CertVR CertSAS DiplECVS DACVS FRCVS ACVS Founding Fellow, Surgical Oncology RCVS Specialist (Surgical Oncology) Clinical Director, AURA Veterinary Professor, Surgical Oncology, University of Surrey www.auravet.com @ifitwasyourdog  Conflict of interest I do not have a relevant financial interest, arrangement, or affiliation with any organization or business entity (including self-employment and sole proprietorship) that could be perceived as a conflict of interest or a source of bias in the context of this presentation.  Learning Objectives Understand…. - the origin of the main types of soft tissue sarcomas (STS) - the factors determining prognosis - the differences between canine and feline STS - how bone sarcomas differ from STS - the major treatment options for osteosarcoma  Classi cation Connective Tissue bone, muscle, collagen, cartilage, BV, nerves SARCOMA, -OMA Epithelial Tissue glandular, secretory, lining CARCINOMA, -OMA Round Cells immunity, melanocytes -OMA fi  Incidence / Tumour type 100,000 Histiocytoma 337 Lipoma 318 Adenoma 175 STS 142 MCT 129 Lymphoma 114  Soft Tissue Sarcomas Soft Tissue Sarcoma (STS) Spindle Cell Sarcoma Mesenchymoma Malignancy of mesenchymal origin Can arise anywhere Subcutaneous Alimentary Urinary  Clinical Appearance Soft, uctuant, mobile, subcutaneous 15% canine skin / SQ masses fl  Palpate LNs HAEMATOGENOUS SPREAD 3 view chest radiographs Grade 1 - 10% metastasize Grade 2 - 20% metastasize Grade 3 - 50% metastasize Radiographs if on / near bone CT (contrast) or MRI if proximal limb, ank, neck - usually deep and large fl  Tumour biology Locally aggressive, expansile Macroscopic Microscopic malignant halo surrounding heterogenous mass Often extra- compartmental, margins poorly de ned Distant metastasis GRADE DEPENDENT fi Enneking resection classi cation Pseudocapsule Reactive zone Muscle Tumour Tumour Satellite tumour Skip metastasis fi  LNs - reactive Onyx Myxosarcoma Grade II Tumour Vascular response Mesenchymal response In ammatory response fl  Wide Removal with a margin of normal tissue around the mass, …or it incorporates an anatomical mesodermal barrier such as fascia, cartilage or bone Wide - 3cm and one fascial plane  Incisional Biopsy Wide surgical excision Clean margins Dirty Margins Histological Grade Histological grade Low / intermediate grade High grade Low / intermediate grade High Grade Chemo RTH RTH + Chemo Revision Revision surgery surgery  Prognosis In general - excellent prognosis early detection appropriate management Grade 1 and 2 tumours ( spleen > retroperitoneal space > genitourinary tract > subcutaneous tissue Locally aggressive Metastasize depending on grade Paraneoplastic syndrome hypoglycaemia  Synovial cell sarcoma Origin: tenosynovial tissue Metastasis to local lymph node Middle aged dogs Site: sti e > elbow joint Histopathology grade may predict metastatic potential 22% mets at diagnosis 41% mets following treatment fl  Feline sarcomas 1. [ Viral induced (FeSV) ] 2. Non-viral, non-vaccine 3. Feline injection-site sarcoma (ISS) Non-viral non-injection sarcoma Older cats; Head and neck  Injection-site sarcomas October 1991 Recognition of sarcoma development at anatomic sites used for vaccination 61% increase in feline brosarcomas from 1987-1991 Co-incident with shift from modi ed live to killed rabies vaccine products (use of adjuvant!) fi fi  ISS Following this initial report a causal relationship also became apparent for FeLV vaccination Vaccination for other feline infectious diseases Non-vaccine products Lufenuron Baytril  Aluminum adjuvant In ammation in association with Unidenti ed carcinogens or oncogenes PDGF and PGF inappropriate expression Dysregulated p53 In ammatory granuloma precedes sarcoma Skin adjacent to tumour Tumour fl fl fi 11.8% of cats vaccinated will develop post-vaccinal reactions. Vaccine reactions can reach 6.0 cm in diameter (1-3 cm). Reactions resolve within 30-90 days (30-45). Not necessary to remove unless show malignant behavior or persist > 6 mo. Gobar and Kass; JAVMA 2002;220:12477-1482. Prevention and Monitoring Do not over vaccinate - manufacturer Use single dose vials Keep detailed vaccine records Standardise and separate vaccine injections Excise or biopsy vaccine-site reactions that persist >3 mo., are >2cm diameter, or increase in size 1 mo. after vaccination USP Veterinary Practitioner’s Reporting Program 1-800-487-7776  Natural history OSA Most common primary bone tumour in dogs and cats 85% of bone tumours in dogs 80% of osteosarcoma affects the long bones or appendicular skeleton Lameness Mild→Severe Acute→Chronic Response to analgesics? Pathological fracture? Implant / fracture induced Appendicular Axial Extraskeletal Dimopoulou et al, 2008  Biologic behaviour Highly metastatic 90% micrometastatic Pulmonary 90% After chemotherapy Majority fail in lung, few bone metastases Nodes less common  Diagnosis / work-up Clinical presentation, CBC, Chem, UA Regional radiographs CT, MRI (especially axial) Aggressive staging Need to identify metastasis cases (Stage III) Chest X-ray (CXR) essential soft tissue metastasis 1. Brodey RS, Abt DA. Results of surgical treatment in 65 dogs with osteosarcoma. J Am Vet Med Assoc 1976;168:1032–5. 2.Hammer AS, Weeren FR, Weisbrode SE, et al. Prognostic factors in dogs with osteosarcomas of the flat or irregular bones. J Am Anim Hosp Assoc 1995;31:321–6. 3. Ogilvie GK, Straw RC, Jameson VJ, et al. Evaluation of single-agent chemotherapy for treatment of clinically evident osteosarcoma metastases in dogs: 45 cases (1987–1991). J Am Vet Med Assoc 1993;202:304–6. 4. Boston SE, Ehrhart NP, Dernell WS et al. Evaluation of survival time in dogs with stage III osteosarcoma that undergo treatment: 90 cases (1985-2004). J Am Vet Med Assoc 2006; 228:1905-1908  Biopsy.....? Atypical location / appearance  2 good reasons to try an FNA Thin egg-shell cortex Soft tissue extension Needle Biopsy options Cytology Fine needle aspirate Roll prep Histology Needle core (Jamshidi) Michel trephine Incisional / excisional Jamshidi core biopsy Jamshidi core biopsy  Tumour grade I, II, III 166 dogs cellular pleomorphism, mitotic gures, cellularity, percent necrosis 25% Grade 1,2 > 75% Grade 3 Kirpensteijn J, Kik M, Rutteman G, et al. Prognostic significance of a new histologic grading system for canine osteosarcoma. Vet Path 2002;39:240–6. Kirpensteijn J, Teske E, Kik M, et al. Lobaplatin as an adjuvant chemotherapy to surgery in canine appendicular osteosarcoma: a phase II evaluation. Anticancer Res 2002; 22:2765–70. fi  Risks of bone biopsy Increased lameness Pathologic fracture Non-diagnostic Tumour seeding  One needle, One greyhound, & One hour later.... You’ve got a diagnosis Now what.... Palliative home care Amputation alone Palliative radiation +/- chemotherapy Amputation and chemotherapy Limb spare (sx/xrt) and chemotherapy Pathologic fracture - PTS or amputation  Palliative or Metastasis < 50% length Surgical medical Tx Limb Spare Radius affected Cost Owner reluctance, poor Extensive soft tissue involvement Bone amputation candidate Owner’s perspective cancer Small tumour, mostly intramedullary Any bone treatable Pathologic fracture* Minimal bone lysis Amputation SRS Home-care NSAIDs (prn p.o.) Tramadol (>5mg/kg TID po) Gabapentin (3 - 10mg/kg TID po) Pamidronate (1mg/kg slow iv q4w) Zoledronate (0.25mg/kg slow iv q4w) Dead from limb disease approx 3m Amputation alone Reduction in bone pain Dead from metastasis (lungs) approx 3m 11% alive 1 year post-op 24 hours post-op Limbspare Excellent Ulna Good Radius Scapula Poor Other long bones Buster, 24 hours post-op  Chemotherapy Local disease Systemic disease Keeps patients alive Median survival 10-12 months Radiation External beam Palliative Curative intent Samarium (radioactive injectable) Systemic Regional In summary.... Common, problematic and clinically important disease Over 99% animals die from the disease We have (too) many options for treatment Good quality of life is possible Oscar, fractured radius from OSA Thank you for your attention Advancing patient care through innovation and collaboration auravet.com