Practical Oncology Hemangiosarcoma Bone Sarcomas Wendy Blount, DVM

Hemangiosarcoma Diagnosis Many oncologists condone fine needle aspiration of abdominal massesMany oncologists condone fine needle aspiration of abdominal masses Doing so increases risk of hemorrhageDoing so increases risk of hemorrhage I prefer diagnostic surgery with splenectomy if no evidence of metastasisI prefer diagnostic surgery with splenectomy if no evidence of metastasis histopathology for diagnosishistopathology for diagnosis Biopsying metastatic abdominal lesions increases propensity to bleedBiopsying metastatic abdominal lesions increases propensity to bleed 50% of bleeding splenic masses in young dogs are HSA50% of bleeding splenic masses in young dogs are HSA 75-80% of bleeding splenic masses in older dogs are HSA75-80% of bleeding splenic masses in older dogs are HSA Aspiration of peripheral masses often yields blood onlyAspiration of peripheral masses often yields blood only

Hemangiosarcoma Treatment Evaluate for propensity to bleed and metastasis prior to considering treatmentEvaluate for propensity to bleed and metastasis prior to considering treatment CBC, platelet countCBC, platelet count PT, PTT if possiblePT, PTT if possible Thoracic radiographs (3 views)Thoracic radiographs (3 views) Abdominal ultrasoundAbdominal ultrasound EchocardiogramEchocardiogram Check for mass in right atrium, pericardial effusion, pleural effusionCheck for mass in right atrium, pericardial effusion, pleural effusion Thoracic radiographs and abdominal ultrasound every 6-8 weeksThoracic radiographs and abdominal ultrasound every 6-8 weeks

Hemangiosarcoma Radiation Only local control for a localized massOnly local control for a localized mass Bulky subcutaneous or muscular massesBulky subcutaneous or muscular masses Palliative – to relieve pain and mediate symptomsPalliative – to relieve pain and mediate symptoms When there is no suspected propensity to bleedWhen there is no suspected propensity to bleed Adjuvant chemotherapy is advisableAdjuvant chemotherapy is advisable Median survival 95 daysMedian survival 95 days

Hemangiosarcoma Surgery Splenectomy or right auriculectomy to stop acute hemorrhageSplenectomy or right auriculectomy to stop acute hemorrhage More likely to be helpful if no thoracic metsMore likely to be helpful if no thoracic mets Debulking is not usually recommendedDebulking is not usually recommended Manage DICManage DIC Discuss possibility of euthanasia on the table or shortly thereafter if remaining propensity to bleed is identified on surgeryDiscuss possibility of euthanasia on the table or shortly thereafter if remaining propensity to bleed is identified on surgery Median survival with splenectomy only is daysMedian survival with splenectomy only is days Median survival right auriculectomy daysMedian survival right auriculectomy days

Hemangiosarcoma Transfusion To prevent death due to exsanguinationTo prevent death due to exsanguination To manage DICTo manage DIC To minimize anesthesia riskTo minimize anesthesia risk Whole fresh blood is bestWhole fresh blood is best Surgery and chemo gives the longest survival times – doxorubicin x5 More myelosuppressive protocols may be more efficacious, but side effects are considerable Median survival 3-7 months

Osteosarcoma Clinical Signs Lameness in a giant breed dogLameness in a giant breed dog “Toward the knee” and “away from the elbow”“Toward the knee” and “away from the elbow” Some evidence that metal implants may increase riskSome evidence that metal implants may increase risk Possible increased risk for sterilized animals as compared to sexually intactPossible increased risk for sterilized animals as compared to sexually intact

Osteosarcoma Diagnosis Cytology taken with 18g needle can be diagnosticCytology taken with 18g needle can be diagnostic If not, sedate and take radiograph guided biopsy of the lytic bony massIf not, sedate and take radiograph guided biopsy of the lytic bony mass Do not amputate without biopsyDo not amputate without biopsy DDx fungal osteomyeltiisDDx fungal osteomyeltiis DDx metastatic carcinomaDDx metastatic carcinoma Abdominal ultrasound is a low yield test for OSA, but a reasonable test for fungal infection and carcinomaAbdominal ultrasound is a low yield test for OSA, but a reasonable test for fungal infection and carcinoma FNA of liver and spleen can reveal systemic mycosisFNA of liver and spleen can reveal systemic mycosis

Osteosarcoma Diagnosis Osteoblasts (“flag cells”)Osteoblasts (“flag cells”) Osteoclasts (multinucleate giant cells)Osteoclasts (multinucleate giant cells) Mesenchymal cellsMesenchymal cells

Osteosarcoma

Osteosarcoma Amputation Amputation provides pain relief, but virtually all have already metastasizedAmputation provides pain relief, but virtually all have already metastasized Surgery alone improves quality of life, but does not prolong survivalSurgery alone improves quality of life, but does not prolong survival May not be indicated for dogs with pulmonary metastasisMay not be indicated for dogs with pulmonary metastasis Median survival 4 monthsMedian survival 4 months 10% of dogs are alive at one year10% of dogs are alive at one year Mobility issues should be consideredMobility issues should be considered Large dogs can have difficulty ambulating without a front limbLarge dogs can have difficulty ambulating without a front limb Orthopedic problems in remaining limbs can be exacerbatedOrthopedic problems in remaining limbs can be exacerbated Radiograph all 4 limbs prior to amputationRadiograph all 4 limbs prior to amputation

Osteosarcoma Limb Sparing Surgery Reasonable option only for relatively small lesions in the distal radiusReasonable option only for relatively small lesions in the distal radius Function is poor for the other 3 locationsFunction is poor for the other 3 locations Tumors involving more than 50% of bone or those that invade soft tissue in any location have poor mobilityTumors involving more than 50% of bone or those that invade soft tissue in any location have poor mobility CT/MRI reveals that tumor is often larger than it appears on radiographs, and is required prior to this kind of surgeryCT/MRI reveals that tumor is often larger than it appears on radiographs, and is required prior to this kind of surgery

Osteosarcoma Limb Sparing Surgery – Three Methods 1.Distraction osteogenesis a small piece of healthy radius is gradually pulled down into the defect of removed bone via external fixation.a small piece of healthy radius is gradually pulled down into the defect of removed bone via external fixation. Takes many months to get healthy bone.Takes many months to get healthy bone. 2.Flip and Nuke Tumor excised and then radiated at exceptionally high doses and the re- installed into the defect.Tumor excised and then radiated at exceptionally high doses and the re- installed into the defect. autologous allograft – low rejection rateautologous allograft – low rejection rate most effective with proliferative lesions that have very little cortical destruction.most effective with proliferative lesions that have very little cortical destruction. 3.Titanium Implant

Osteosarcoma Palliative Radiation Once weekly for three weeksOnce weekly for three weeks 75% have significant clinical improvement in lameness and pain score75% have significant clinical improvement in lameness and pain score Median pain relief is 2 monthsMedian pain relief is 2 months Increased mobility may increase risk of pathologic fracture (?)Increased mobility may increase risk of pathologic fracture (?)

Osteosarcoma Chemotherapy lengthens survival significantly following amputationlengthens survival significantly following amputation doxorubicin q3 weeks x 5doxorubicin q3 weeks x 5 Get a baseline echocardiogramGet a baseline echocardiogram Or carboplatin q3 weeks x 5Or carboplatin q3 weeks x 5 Cisplatin or cisplatin + doxorubicin are equally effective, but much more toxicCisplatin or cisplatin + doxorubicin are equally effective, but much more toxic Chemotherapy should begin 2 weeks after surgeryChemotherapy should begin 2 weeks after surgery Not effective without surgeryNot effective without surgery

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Osteosarcoma Prognosis Median survival 4 months with amputation onlyMedian survival 4 months with amputation only Median survival 6-16 months with amputation and chemoMedian survival 6-16 months with amputation and chemo 10% alive in 1 year with amputation alone10% alive in 1 year with amputation alone 30-62% alive in 1 year with both30-62% alive in 1 year with both 2 year survival is 7-21% with amputation and chemo2 year survival is 7-21% with amputation and chemo Dogs almost never survive to 2 years with amputation aloneDogs almost never survive to 2 years with amputation alone

Osteosarcoma Prognosis Those with thoracic metastasis at the time of diagnosis do poorly no matter how treatedThose with thoracic metastasis at the time of diagnosis do poorly no matter how treated Elevated SAPElevated SAP Median survival 5.5 months if SAP elevatedMedian survival 5.5 months if SAP elevated Median survival 12.5 months if SAP within normal rangeMedian survival 12.5 months if SAP within normal range High grade tumors have worse prognosisHigh grade tumors have worse prognosis Dogs between 7-10 years of age do the bestDogs between 7-10 years of age do the best Young and older dogs don’t fare as wellYoung and older dogs don’t fare as well Dogs with elevated lymphocytes and/or monocytes do not do as wellDogs with elevated lymphocytes and/or monocytes do not do as well Advances in the last 20 years have led to increase in survival time by 500%Advances in the last 20 years have led to increase in survival time by 500%

Client Handouts HemangiosarcomaHemangiosarcomaHemangiosarcoma OsteosarcomaOsteosarcomaOsteosarcoma Yunnan Pai YaoYunnan Pai YaoYunnan Pai YaoYunnan Pai Yao

Yunnan Pai Yao Other names for this Chinese Herb Yun(n)an Bai YaoYun(n)an Bai Yao Yun(n)an PaiyaoYun(n)an Paiyao Yun(n)an BaiyaoYun(n)an Baiyao Yun(n)an PaiyouYun(n)an Paiyou Yun(n)an PayaoYun(n)an Payao Yun(n)an PiaoYun(n)an Piao Yun(n)an PaiaoYun(n)an Paiao Hun(n)an PaiyaoHun(n)an Paiyao

Yunnan Pai Yao Uses stop bleedingstop bleeding (promote wound healing)(promote wound healing) (relieve pain)(relieve pain) Scientific support shortened clotting time within 30 minutes after oral administration in rabbitsshortened clotting time within 30 minutes after oral administration in rabbits effects lasted for 4 hours (Ogle, 1977).effects lasted for 4 hours (Ogle, 1977). Decreased clotting times in rabbit and human blood (Ogle 1976), and bovine blood (Monke 2000).Decreased clotting times in rabbit and human blood (Ogle 1976), and bovine blood (Monke 2000).

Yunnan Pai Yao Safety has been given to thousands of dogs over several decades by veterinarians who practice CAVM, with no reported adverse effects (Ogle 1977).has been given to thousands of dogs over several decades by veterinarians who practice CAVM, with no reported adverse effects (Ogle 1977). Protocol Used orally and topicallyUsed orally and topically Dosage table in the handoutDosage table in the handout Ordering information in the handoutOrdering information in the handout