Clinical advanced imaging data and outcome of inflammatory and neoplastic orbital disease in 81 dogs and 16 cats in Australia (20102019).pdf

Received: 3 July 2021 | Revised: 3 September 2021 | Accepted: 5 September 2021 DOI: 10.1111/vop.12936 ORIGINAL ARTICLE Clinical, advanced imaging data and outcome of inflammatory and neoplastic orbital disease in...

Received: 3 July 2021 | Revised: 3 September 2021 | Accepted: 5 September 2021 DOI: 10.1111/vop.12936 ORIGINAL ARTICLE Clinical, advanced imaging data and outcome of inflammatory and neoplastic orbital disease in 81 dogs and 16 cats in Australia (2010–­2019) Sarah M. Coall1 |Johana E. Premont1 | Katharina Flatz2 | Kate Hindley1 | Allyson Groth1 | Francis M. Billson1 1 Department of Ophthalmology, Small Animal Specialist Hospital, Sydney, Abstract New South Wales, Australia Objective: To characterize the clinical presentation, advanced imaging features, 2 Department of Radiology, Small and outcome of orbital disease in a referral population of dogs and cats that un- Animal Specialist Hospital, Sydney, New South Wales, Australia derwent computed tomography (CT) or magnetic resonance imaging (MRI). Animals studied: Client-­owned animals. Correspondence Procedures: Animals referred for orbital disease undergoing ophthalmic exami- Sarah M. Coall, Department of Ophthalmology, Small Animal nation and either head MRI or CT were included. Demographic and imaging fea- Specialist Hospital, 1/1 Richardson tures were compared between animals diagnosed with inflammatory disease and Place, North Ryde, NSW, Australia, neoplastic disease using Mann-­Whitney U and Fischer's exact tests. 2113. Email: [email protected] Results: Ninety-­seven animals (81 dogs and 16 cats) were included. Eighty-­four and 13 patients underwent CT and MRI scanning, respectively. Inflammatory or- bital disease was more frequently detected than neoplasia in dogs (59% vs. 41%) and cats (62% vs. 39%). Orbital cellulitis was the most common diagnosis in dogs (36/81, 44.4%) and cats (8/16, 80%). A foreign body was suspected in 36.1% of dogs with orbital cellulitis but only 3 were retrieved during orbitotomy. Multi-­drug re- sistant bacteria were identified in 3 samples and influenced treatment plans. The most common neoplasms were sarcoma (10/30) and carcinoma (7/30) in dogs and lymphoma in cats (3/6). Imaging findings of osteolysis (p = 0.0002) and in- tracranial extension (p = 0.0001) were significantly associated with neoplasia in dogs. In contrast, osteolysis extension was present in cats with both inflammatory (7/10) and neoplastic (6/6) orbital disease. Conclusions: Inflammatory disease, particularly orbital cellulitis, was more common than neoplasia in dogs and cats with orbital disease in our population. We recommend including bacterial culture and susceptibility as part of the diag- nostic work up when orbital cellulitis is suspected. KEYWORDS cat, computed tomography, dog, magnetic resonance imaging, orbit © 2021 American College of Veterinary Ophthalmologists. Veterinary Ophthalmology. 2022;25(Suppl. 1):37–50.  wileyonlinelibrary.com/journal/vop | 37  | 14635224, 2022, S1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vop.12936 by Robin Stanley - National Health And Medical Research Council , Wiley Online Library on [25/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 38    COALL et al. 1 | I N T RO DU CT ION 3. to describe the clinical and therapeutic outcome of in- flammatory and neoplastic orbital disease. Orbital disease in dogs and cats is frequently due to neo- plasia or inflammation and infection. The characteristic Our hypothesis was that inflammatory etiologies were clinical signs of orbital disease are exophthalmos, reduced more common than neoplastic processes in dogs and cats retropulsion, and prolapse of the nictitating membrane.1 with orbital disease undergoing imaging. This is in con- Blindness has also been reported in dogs where the optic trast to previously published reports. nerve is involved in the disease process.1,2 Age and dura- tion of clinical signs are reported to vary in inflammatory and neoplastic etiologies. Neoplasia tends to be diagnosed 2 | MATERIALS AND METHO D S in older dogs with a slow disease progression.1 In contrast, inflammatory orbital disease is associated with a younger 2.1 | Patients age and a more acute presentation.1,3–­5 Neoplasia, particularly carcinomas and sarcomas in Clinical records from a single private referral center—­the dogs and lymphoma in cats, have been reported as the Small Animal Specialist Hospital, Sydney—­were reviewed most common cause of orbital disease.3,6,7 Orbital cellu- (2010–­2019) to identify dogs and cats with orbital disease. litis is a well-­documented cause of inflammatory orbital Inclusion criteria included the presence of: disease and etiologies in the dog include foreign bodies, bite trauma, and dental disease leading to bacterial infec- (i) clinical signs consistent with disease involving the ret- tion.1,3,6,8 Bacterial cellulitis is considered uncommon in robulbar space and cats with infectious causes only reported sporadically.1 (ii) advanced imaging (CT or MRI) reports However, a large case series comparing feline inflamma- tory orbital disease and neoplasia is lacking. Signalment, type, and duration of clinical signs, oph- Advanced imaging, including computed tomography thalmic and physical examination findings, imaging ab- (CT) and magnetic resonance imaging (MRI), is consid- normalities, etiological diagnosis, treatment, and outcome ered the gold standard for imaging of the canine and fe- were recorded. line orbit compared to radiology or ultrasound.3,5–­7,9 In dogs, the diagnosis of neoplasia can be associated with the presence of a mass, osteolysis, sinonasal extension, and 2.2 | Etiology periosteal reaction based on CT and MRI.3,6,7 In cats, the predominant neoplasia reported is lymphoma, which ap- The cause of orbital disease was reviewed and divided into pears less invasive and better delineated in nature on CT/ either inflammatory (IOD) or neoplastic disease (OBN). MRI in comparison with sarcomas and carcinomas.3 In A final diagnosis of IOD was based on clinical and imag- contrast to neoplasia, inflammatory orbital disease in dogs ing findings, supportive cytology and/or positive culture is associated with zygomatic salivary gland enlargement, results, and/or a positive response to antimicrobial and a retrobulbar mass effect, mandibular lymphadenopathy, anti-­inflammatory medications, as well as absence of and a fluid-­filled structure with peripheral rim contrast neoplastic disease. OBN was confirmed based on imag- enhancement on CT and MRI.3,9,10 ing findings and supportive cytology and/or histopathol- Specific infectious causes identified in cats, such as ogy. For patients with intracranial disease, where a biopsy mycotic cellulitis, have a less delineated appearance on could not be safely obtained, a high suspicion of neoplasia advanced imaging and can be associated with osteolysis was established based on previously reported characteris- and adjacent compartment extension.11 Advanced imag- tic imaging features. ing techniques are also proposed for detection of orbital foreign bodies in cats and dogs; however, this remains challenging.9,10 2.3 | Clinical signs The aims of this study were as follows: All patients received a complete ophthalmic examination 1. to characterize the clinical and imaging features of performed by a specialist in veterinary ophthalmology and/ orbital disease in a referral population of dogs and or resident in training. This included visual assessment cats. (menace response, pupillary light reflexes, dazzle reflex), 2. to determine the distribution of inflammatory or infec- rebound Tonometry (Tonovet, Acrivet), Schirmer tear test tious versus neoplastic disease in dogs and cats under- (Merck, Provet), slit lamp examination (Keeler PSL clas- going CT or MRI. sic, Keeler Ltd or Kowa SL-­17), indirect ophthalmoscopy  | 14635224, 2022, S1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vop.12936 by Robin Stanley - National Health And Medical Research Council , Wiley Online Library on [25/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License COALL et al.    39 (Keeler Vantage plus) with condensing lenses (30D, 15D, or culture and susceptibility testing (mixture of aerobic, and 2.2D panretinal lenses; Volk, Designs for Vision) and anaerobic, and/or fungal cultures). Where neoplasia was fluorescein sodium stain (Optitech, Provet). suspected on imaging, samples for histopathology were The presence or absence of vision (unilateral or bilat- obtained via incisional trucut or rhinoscopic pinch biopsy, eral), pain, exophthalmos, enophthalmos, and abnormal or excisional surgical biopsy or orbital exenteration. globe retropulsion were recorded. Pain was defined by re- luctance to eat, vocalizing, dysphagia, and/or consistent clinical signs (resistance to retropulsion, reluctance to 2.6 | Therapeutics opening of the mouth, and/or blepharospasm). Treatment was broadly divided into medical or surgi- cal management depending on the etiological diagnosis. 2.4 | Diagnostic imaging Medical treatment included antimicrobial therapy with or without anti-­inflammatory medication and/or chemo- Patients were routinely anesthetized for MRI scanning therapy either with a palliative or curative intent. Surgical and anesthetized or sedated for CT examination. MRI im- management included enucleation or exenteration, mass ages were acquired using a 1.5 Tesla MRI unit (Siemens excision and/orbital exploration (with or without abscess Essenza, Erlangen, Germany). Different MRI protocols drainage) via orbitotomy or dental extractions. were used depending on the radiologist's preference but always included sagittal T2-­weighted (T2W), transverse T2W and T1-­weighted (T1W) pre-­ and post-­contrast, 2.7 | Outcome as well as dorsal or sagittal short-­tau inversion recovery (STIR) sequences. CT images were obtained using a 6-­ Outcome was determined by full resolution of clinical slice helical scanner (Brilliance, Phillips, Amsterdam, signs and preservation of vision for IOD or in the case of Netherland). Pre-­contrast images were obtained with OBN if the patient was still alive at 6 months following brain, soft tissue, and bone algorithms. Post-­contrast initial diagnosis. If a patient was euthanized, this was clas- images of the same algorithms were obtained after in- sified as either immediately after, within the first week or travenous administration of Iohexol (Omnipaque, GE within 6 months following diagnosis. healthcare) for all patients. Images were reported by ECVDI diplomates on site (82/97) or from an external im- aging reporting service (VetCT, Cambridge, UK) for pa- 2.8 | Statistical analysis tients referred prior to 2016 (15/97). Computed tomography and magnetic resonance im- Age, sex, duration of clinical signs, presence of pain, and aging reports were provided by specialist radiologist and imaging abnormalities were compared between animals reviewed by the primary author (SC), and the following with inflammatory or infectious and neoplastic causes of abnormalities recorded as present or absent: orbital disease. Dogs and cats were analyzed separately. Continuous data were assessed by Mann-­Whitney U sta- (i) Ocular abnormalities (enophthalmos, exophthalmos), tistical test while categorical data were assessed by Fisher's (ii) Retrobulbar or pharyngeal space abnormalities (ret- exact test. Statistical significance was defined at p < 0.05. robulbar mass, retrobulbar mass effect, hyperattenu- ation of retrobulbar muscle, zygomatic salivary gland enlargement, retropharyngeal lymph node enlarge- 3 | RESULTS ment, presence of foreign body, and/or presence of a fluid-­filled structure), 3.1 | Patient demographics (iii) Bony changes (osteolysis) (iv) Adjacent compartment extension (sinus, nasal, and/ A total of 97 patients met the inclusion criteria. This com- or intracranial). prised of 81 dogs with a median age of 8 years (0.5–­15 years) and 16 cats with a median age of 7 years (2–­14 years). A total of 24 breeds of dog were represented; 11 Toy poo- 2.5 | Tissue sampling dles, 10 Staffordshire bull terriers, 8 Golden retrievers, 7 Maltese terriers, 6 Labradors, 4 Boxers, 3 Miniature Ultrasound-­guided aspirates were obtained from masses schnauzers, 2 Rhodesian ridgebacks, 2 Kelpies, 2 Jack or fluid-­filled structures depending on the supervising Russel terriers, and one each of German shepherd dog, clinician's preference and submitted for cytology and/ German short-­haired pointer, Fox terrier, Pomeranian,  | 14635224, 2022, S1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vop.12936 by Robin Stanley - National Health And Medical Research Council , Wiley Online Library on [25/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 40    COALL et al. TABLE 1 Imaging findings in dogs Inflammatory Neoplasia (n = 51) (n = 30) Imaging modality CT 45* 25 MRI 7 5 Imaging Mass 2 30 findings Mass effect 21 9 Muscle hyperattenuation 31 2 Zygomatic salivary gland enlargement 22 1 Fluid-­filled structure 26 2 Osteolysis 7 17 Intracranial extension 0 14 Sinonasal extension 2 7 Peripheral rim contrast enhancement 16 1 Foreign body 13 0 *1 dog underwent both CT and MRI scanning. Husky, Australian cattle dog, French bulldog, Border peripheral nerve sheath tumor, and astrocytoma. The collie, Dachshund, English springer spaniel, Australian tumor cell type could not be identified in 4 dogs. One cat bulldog, Australian terrier, Bernese mountain dog, and was diagnosed with feline restrictive orbital myofibroblas- Curly coated retriever. Seven breeds of cat were identified tic sarcoma. 8 Domestic short hairs, 2 Burmilla, 1 British short hair, 1 Dogs with IOD were significantly younger (median Chinchilla, 1 Exotic, 1 Bengal, and 1 Russian Blue. There 7, interquartile range (Q1–­Q3) 4–­10 years) and had a was no significant difference in gender between IOD and shorter duration of clinical signs (median 7, Q1–­Q3 OBN in either cats (p = 1) or dogs (p = 0.2). 3–­14 days) than dogs with OBN (median 10, Q1–­Q3 8–­13 years; p = 0.005) (median 30, Q1–­Q3 14–­90 days; p = 0.004). Similarly, cats with IOD were younger (me- 3.2 | Etiology dian 7, Q1–­Q3 6–­8 years) and had a shorter duration of clinical signs (median 14, Q1–­Q3 5–­26 days) than cats IOD was more commonly diagnosed than OBN in both with OBN (median 7, Q1–­Q3 5–­12 years) (median 18, dogs (51/81, 63% IOD; 30/81, 37% OBN) and cats (10/16, Q1–­Q3 9–­118 days), although the difference was not sta- 62.5% IOD; 6/16, 37.5% OBN). More specifically, orbital tistically significant. cellulitis was diagnosed in 36 dogs (70.6%) and 8 cats (80.0%), followed by sialoadenitis (8 dogs, 1 cat), extraoc- ular myositis (6 dogs), and orbital inflammation second- 3.3 | Clinical signs ary to chronic rhinitis (1 dog and 1 cat). An exact cause for orbital cellulitis could not be identified in 16 dogs and 2 In dogs, there was no significant difference between IOD cats and was presumed idiopathic in origin. A specific di- and OBN with regard to the presence of exophthalmos agnosis was achieved in 20 dogs and 6 cats and was as fol- (78.4% IOD, 66.6% OBN, p = 1) and reduced globe retro- lows: orbital foreign bodies (7 dogs), penetrating orbital pulsion (64.7% IOD, 70% OBN p = 0.8076). Similarly, in trauma including penetrating wooden material (7 dogs) cats, no significant correlation was found between IOD and bite wounds (4 dogs), sino-­orbital mycosis (3 cats), and OBN for exophthalmos (90% IOD, 83.3% OBN p = 1) inadvertent orbital penetration following dental prophy- and reduced globe retropulsion (40% IOD, 50% OBN, laxis (2 dogs, 2 cats) and extension from tooth root abscess p = 0.5879). in 1 cat. Pain was detected significantly more often in dogs with The most common orbital neoplasms (Table 3) were IOD (66.6%) than in dogs with OBN (23.3%, p = 0.003). sarcoma in dogs (10/30, 33.3% of OBN) and lymphoma in In contrast, only 3/10 cats with IOD were clinically pain- cats (3/6, 50% of OBN). Carcinoma was the second most ful. Twelve dogs and 1 cat were blind in the affected eye. frequent neoplasm (7 dogs and 2 cats). Other tumor types In dogs, blindness in the affected eye was significantly in dogs included meningioma (4 dogs) and 1 case each of more common with OBN (40%) than with IOD (12%, multilobular bone tumor, infiltrative lipoma, lymphoma, p = 0.0047). Four cats with IOD had reduced retropulsion  | 14635224, 2022, S1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vop.12936 by Robin Stanley - National Health And Medical Research Council , Wiley Online Library on [25/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License COALL et al.    41 and ipsilateral blindness in comparison with only 1 cat 3 were retrieved during investigative orbitotomy (Figure with being bilaterally blind with intracranial disease due 1). No foreign bodies were identified in cats on imaging. to OBN. Presence of a mass was significantly associated with OBN (30% OBN, 3.9% IOD, p = 0.0001) in dogs with a mass effect identified in 9 dogs. Osteolysis of the orbital 3.4 | Diagnostic imaging bones (56.6% OBN, 13.7% IOD; p < 0.001) and intracranial extension (46.6% OBN, 0% IOD; p < 0.001) strongly cor- Eighty-­four (70 dogs and 15 cats) and 13 patients (12 dogs, related with OBN in dogs (Figure 2). 1 cat) underwent CT and MRI scanning, respectively In contrast, osteolysis (70% IOD, 66.6% OBN, p = 1) (Tables 1 and 2). Hyperattenuation of the retrobulbar was present in similar numbers of cats with IOD and muscle cone (60.8% IOD, 6.6% OBN; p < 0.001), fluid-­filled OBN. Sixty percent of cats with IOD had sino-­nasal exten- hypoattenuating structure within the orbit (51.0% IOD, sion and 66.6% of cats with OBN had intracranial exten- 6.6% OBN; p < 0.001), zygomatic salivary gland enlarge- sion p = 1 (Figure 3). ment (43.1% IOD, 3.3% OBN; p < 0.001), and a periph- In patients with OBN, imaging records reported the pre- eral rim contrast enhancement (31.4% IOD, 3.3% OBN; sumed tissue of origin in 21 dogs and included the nasal p = 0.0039) were all significantly associated with IOD in mucosa (6 dogs with carcinomas), optic nerve or chiasm dogs. A foreign body was suspected or identified on imag- (4 dogs) extraconal soft tissue, bone and pterygoid or tem- ing in 36.1% of dogs with orbital cellulitis; however, only poral muscle (3 dogs each) and 1 case each for the rectus TABLE 2 Imaging findings in cats Inflammatory Neoplasia (n = 10) (n = 6) Imaging modality CT 9 6 MRI 1 0 Imaging Mass 1 6 findings Mass effect 7 3 Muscle hyperattenuation 1 0 Zygomatic salivary gland enlargement 1 0 Fluid-­filled structure 7 0 Osteolysis 7 4 Intracranial extension 0 4 Sinus extension 6 0 Peripheral rim contrast enhancement 7 3 Foreign body 0 0 F I G U R E 1 Transverse CT image (soft tissue algorithm, post-­contrast, W:350, L:50) of a 4-­year-­old female speyed Kelpie diagnosed with orbital cellulitis. There is a hypoattenuating space-­occupying structure within the right retrobulbar space visible (asterisk). This finding was consistent with an abscess causing exophthalmos. A foreign body was identified on imaging and a grass seed was retrieved during exploratory orbitotomy (black arrow)  | 14635224, 2022, S1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vop.12936 by Robin Stanley - National Health And Medical Research Council , Wiley Online Library on [25/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 42    COALL et al. F I G U R E 2 Transverse CT images (soft tissue algorithm post-­contrast W:350 L: 50, bone algorithm W: 1500 L: 500) of a 15-­year-­old male castrated Golden retriever with a nasal adenocarcinoma. There is an aggressive space occupying lesion arising from the left nasal cavity, causing surrounding osteolysis and invading the frontal lobes of the brain (asterisk) and the medial aspect of the left orbit, causing left sided exophthalmos F I G U R E 3 Transverse CT images (soft tissue algorithm, W:350, L:50) of a 1.5-­year-­old male neutered Exotic cat with sino-­orbital myocosis (Aspergillus spp.) (A) Pre-­contrast: a space-­occupying, iso to hypoattenuating lesion (asterisk) within the retrobulbar space with loss of intermuscular fat bands can be seen. (B) Postcontrast: a peripheral rim-­like contrast uptake of the lesion within the right retrobulbar space can be detected (black arrow). There is extension of the lesion into the right nasal cavity and nasopharyngeal meatus muscle and olfactory lobe. The tissue of origin was reported (based on imaging and clinical signs), culture and suscepti- in only 2 cats with histologically confirmed carcinomas and bility testing were performed and yielded 6 positive results. included the nasal mucosa and lacrimal glands. Bacteria isolated included Corynebacterium spp. (3 samples), Streptococcus spp. (3 samples), Pasteurella multocida (3 sam- ples), anaerobes (3 samples), and single cases of Klebsiella 3.5 | Tissue sampling pneumoniae and Bacillus spp. Multi-­drug resistance, defined as resistance to more than 1 antimicrobial agent in 3 or more Samples were obtained for cytology in 44 dogs and 13 cats classes,12 was present in 3 bacteria (Table 3). In cats, 5 sam- and histopathology in 18 dogs and 6 cats. OBN was diag- ples were submitted for culture and susceptibility testing. nosed based on cytology in 16 dogs and 4 cats. In samples Two were positive for bacterial organisms: 1 yielded a pure with a presumed diagnosis of OBN based on imaging find- growth of multi-­drug resistant Enterococcus spp. and the ings, cytology was inconclusive for 4 dogs and 2 cats and other anaerobes. The 3 other cultures isolated one of each of histopathology was inconclusive in 1 dog and 2 cats (with the following fungal organisms: Aspergillus spp., Norcardia sino-­orbital mycosis). In these cases, a later diagnosis of spp., and Ramularia spp. (Table 4). IOD was made based on clinical signs, culture results, and response to treatment. Cytology in 25 dogs and 8 cats with IOD revealed mixed 3.6 | Treatment or suppurative inflammation; however, only samples from 2 dogs and 2 cats identified intracellular organisms. In All 51 dogs diagnosed with IOD were prescribed 17 samples of dogs with a presumptive diagnosis of IOD various parenteral antimicrobial and non-­steroidal  TABLE 3 Pathology findings, aetiology, treatment and outcome in dogs. Legend: MDR –­Multi-­drug resistance. Defined as resistance to at least 1 anti-­microbial in 3 or more anti-­microbial COALL et al. classes12 Inflammatory Neoplasia (n = 51) (n = 30) Additional findings Treatment Outcome Length of follow-­up 14–­365 days 6 months -­2.5 years (median 21) (median 4 months) Cytology 25 19 Suppurative 14* *Bacteria identified (n = 6) inflammation Inconclusive 11 3 Histopathology 8 10 Inconclusive (n = 4) Culture and 24 Negative (n = 11) susceptibility Corynebacterium 3 MDR: n = 1 enrofloxacin, spp. marbofloxacin, cefovecin, amoxicillin, cephalexin, augmentin Streptococcus spp. 3 MDR: n = 1 Trimethoprim sulfur, enrofloxacin, marbofloxacin Pasturellla 3 multocida Klebsiella spp. 1 Anaerobes 3 No further specification available Etiology Orbital cellulitis 36 (70.6%) Idiopathic (n = 16), foreign body Foreign body retrieval (n = 3) Full resolution (n = 7), penetrating trauma (bite Investigative orbitotomy (n = 5) wound n = 4, wooden material Oral drainage (n = 3) n = 7), orbital penetration following Enucleation and exenteration dental (n = 2) for intraocular foreign bodies (n = 2) Granuloma removal (n = 1) Sialoadenitis 8 (15.7%) Zygomatic salivary gland excision Full resolution (n = 7) Myositis 6 (11.8%) Medical management (n = 6) Full resolution (Continues) |    43 14635224, 2022, S1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vop.12936 by Robin Stanley - National Health And Medical Research Council , Wiley Online Library on [25/08/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License  | 44    TABLE 3 (Continued) Inflammatory Neoplasia (n = 51) (n = 30) Additional findings Treatment Outcome Rhinitis 1 (1.9%) Medical management (n = 1) Full resolution Sarcoma 10 (33.3%) Surgical debulking and palliative Alive at 6 m (n = 1 soft tissue radiation (n = 1) sarcoma receiving radiation, n = 1 Metronomic chemotherapy osteosarcoma receiving surgical (n = 2) debulking) Surgical debulking (n = 2) Euthanized