1. Practical Oncology Hemangiosarcoma Bone Sarcomas
Wendy Blount, DVM

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

3. Hemangiosarcoma Treatment
Evaluate for propensity to bleed and metastasis prior to considering treatment
CBC, platelet count, BMBT
PT, PTT if possible
Thoracic radiographs (3 views)
Abdominal ultrasound
Echocardiogram
Check for mass in right atrium, pericardial effusion, pleural effusion
Thoracic radiographs should be repeated prior to surgery if they have not been done in the past 2 weeks

4. Hemangiosarcoma Radiation Only local control for a localized mass
Bulky subcutaneous or muscular masses
Palliative – to relieve pain and mediate symptoms
When there is no suspected propensity to bleed
Adjuvant chemotherapy is advisable
Median survival 95 days
If the tumor is not in a location that is likely to bleed, or bleeding can be controlled, survival can be much longer

5. Chemotherapy Hemangiosarcoma
Chemotherapy without surgery is not likely to be helpful
Met check prior to first treatment, 2 weeks after surgery
3 views thorax rads + Abd US
Doxorubicin x 5
Met check again prior to 3rd treatment
See Chemotherapy section for more details

6. Hemangiosarcoma

7. Hemangiosarcoma Rebel 4 year old male golden retriever
Rebel was on a pheasant hunt in South Dakota with his breeder/owner
fellow hunter Wayne fell in love with him
Adopted him the next year on the hunt
They did everything together
Presented to regular vet for limping RF
Responsive to Rimadyl and Tramadol for 3 weeks, then returned
Muscle atrophy developed, and mass was palpated in the axillary area
Referred to WSU for CT and surgery, suspected nerve sheath tumor

8. Hemangiosarcoma Rebel
Dx - Hemangiosarcoma with no evidence of metastasis
Wayne was diagnosed with gastric carcinoma the same week
Debulking surgery
Followed by doxorubicin and radiation
Rebel was doing well several months later when Wayne was hospitalized, and never returned home
Breeder flew to Oregon to pick up Rebel and complete his radiation and chemo at TAMU
Recheck at 1 year 9 months

9. Hemangiosarcoma Rebel
Dx - Hemangiosarcoma with no evidence of metastasis
Wayne was diagnosed with cancer the same week
Debulking surgery
Followed by doxorubicin and radiation
Rebel was doing well several months later when Wayne was hospitalized, and never returned home
Breeder flew to Oregon to pick up Rebel and complete his radiation and chemo at TAMU
Recheck at 1 year 9 months

10. Hemangiosarcoma Rebel
Dx - Hemangiosarcoma with no evidence of metastasis
Wayne was diagnosed with cancer the same week
Debulking surgery
Followed by doxorubicin and radiation
Rebel was doing well several months later when Wayne was hospitalized, and never returned home
Breeder flew to Oregon to pick up Rebel and complete his radiation and chemo at TAMU
Recheck at 1 year 9 months

11. Hemangiosarcoma Rebel
Dx - Hemangiosarcoma with no evidence of metastasis
Wayne was diagnosed with cancer the same week
Debulking surgery
Followed by doxorubicin and radiation
Rebel was doing well several months later when Wayne was hospitalized, and never returned home
Breeder flew to Oregon to pick up Rebel and complete his radiation and chemo at TAMU
Recheck at 1 year 9 months

12. Hemangiosarcoma Rebel
Dx - Hemangiosarcoma with no evidence of metastasis
Wayne was diagnosed with cancer the same week
Debulking surgery
Followed by doxorubicin and radiation
Rebel was doing well several months later when Wayne was hospitalized, and never returned home
Breeder flew to Oregon to pick up Rebel and complete his radiation and chemo at TAMU
Recheck at 1 year 9 months

13. Hemangiosarcoma Rebel
Dx - Hemangiosarcoma with no evidence of metastasis
Wayne was diagnosed with cancer the same week
Debulking surgery
Followed by doxorubicin and radiation
Rebel was doing well several months later when Wayne was hospitalized, and never returned home
Breeder flew to Oregon to pick up Rebel and complete his radiation and chemo at TAMU
Recheck at 1 year 9 months

14. Hemangiosarcoma Rebel
Dx - Hemangiosarcoma with no evidence of metastasis
Wayne was diagnosed with cancer the same week
Debulking surgery
Followed by doxorubicin and radiation
Rebel was doing well several months later when Wayne was hospitalized, and never returned home
Breeder flew to Oregon to pick up Rebel and complete his radiation and chemo at TAMU
Recheck at 1 year 9 months

15. Hemangiosarcoma Rebel 2 years after initial diagnosis
Rebel stopped eating and became lethargic
He was humanely euthanized

16. Hemangiosarcoma Rebel 2 years after initial diagnosis
Rebel stopped eating and became lethargic
He was humanely euthanized

17. Hemangiosarcoma Transfusion To prevent death due to exsanguination
To manage DIC
To minimize anesthesia risk
Whole fresh blood is best
Surgery and chemo gives the longest survival times
--only if no mets at the time of surgery
Radiation only if location is amenable
More myelosuppressive protocols may be more efficacious , but side effects are considerable
Median survival 3-7 months
Can be longer in locations where bleeding into a body cavity is not likely

18. Yunnan Pai Yao Other names for this Chinese Herb Yun(n)an Bai Yao
Yun(n)an Paiyou
Yun(n)an Payao
Yun(n)an Piao
Yun(n)an Paiao
Hun(n)an Paiyao

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

20. 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)
I have had dozens of patients with HSA survive for 1-2+ years and never bleed, when taking this herbal product
Protocol
Used orally and topically
Dosage table in the handout
The little red pill is for bleeding emergencies
Ordering information in the handout 

21. Clinical Signs Osteosarcoma Lameness in a giant breed dog
“Toward the knee” and “away from the elbow” (shoulder, carpus, stifle)
Some evidence that metal implants may increase risk
Increased post-radiation risk
Increased risk for large breed dogs sterilized at less than a year of age

22. Lisa Anderson Forney TX
“We who choose to surround ourselves with lives even more temporary than our own, live within a fragile circle; easily and often breached. Unable to accept its awful gaps, we would still live no other way." --Irving Townsend
Watch with glittering eyes the whole world around you, because the greatest secrets are always hidden in the most unlikely places. Those who don't believe in the magic will never find it. --Ronald Dahl
Lisa Anderson Forney TX

23. Osteosarcoma Diagnosis
Cytology taken with 18g needle can be diagnostic
If not, sedate and take radiograph guided biopsy of the lytic bony mass
Do not amputate without biopsy
DDx fungal osteomyeltiis
DDx metastatic carcinoma (Blue)
Abdominal 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 mycosis

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

25. Osteosarcoma

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

27. Osteosarcoma Limb Sparing Surgery
Reasonable option only for relatively small lesions in the distal radius
Function 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 mobility
CT/MRI reveals that tumor is often larger than it appears on radiographs, and is required prior to this kind of surgery

28. Palliative Radiation Osteosarcoma Once weekly for three weeks
75% have significant clinical improvement in lameness and pain score
Median pain relief is 2 months
Increased mobility may increase risk of pathologic fracture (?)
Cost - $5-6K
The most effective pain control method

29. Chemotherapy Osteosarcoma
lengthens survival significantly following amputation (2-3x)
doxorubicin q3 weeks x 5
Or carboplatin q3 weeks x 5-6
Least expensive, least toxic option
Cisplatin or cisplatin + doxorubicin are equally effective, but much more toxic
Chemotherapy should begin 2 weeks after surgery
Not effective without surgery

30. Osteosarcoma Pamidronate
Biphosphonates inhibit osteoclastic activity and palliate pain (osteoclast apopotosis)
Also helps with hypercalcemia
2 papers 2010 Vet Cancer Society
demonstrable improvement in lameness as measured by forceplate analysis, although the owners reported NO clinical improvement
(70 dogs) compared survival time (ST) with
radiation therapy + chemo
radiation + chemo + Pamidronate
no data was provided regarding pain
MST pamidronate 69 days, without Pamidronate 307 days

31. Pamidronate Osteosarcoma
2 previous studies using force plate analysis showed no benefit to pamidronate
Radiation therapy is definitely the way to go for pain palliation, and addition of chemotherapy has been shown to improve pain relief and survival
However…
Cost of radiation - >$5,000
Cost of Pamidronate - hundreds

32. Zoledronate (stronger derivative)
Osteosarcoma
Pamidronate
Add 1 mg/kg dose to 250 ml saline
Give IV over 2-3 hours
Repeat PRN every 3-4 weeks for hypercalcemia, and possibly for pain
Reflexive hypocalcemia possible
More likely when not hypercaclemic
Monitor kidney function
Zoledronate (stronger derivative)
0.25 mg/kg IV over 15 minutes
repeat every 3- 4 weeks 

33. Osteosarcoma Pain Control – Palliative Radiation NSAIDs
Amantadine 3 mg/kg PO SID
Gabapentin 10 mg/kg PO BID-TID
titrate up by 5-10 mg/kg every 3-5 days, to effect
Up to mg/kg PO BID
amitriptyline mg/kg q12h
Biphosphonates
Tylenol 4 with Codeine
Other opioids (transdermal fentanyl)
acupuncture
NO LASER!!!

34. Osteosarcoma Prognosis MST 4 months - amputation only
MST 6-16 months - amputation and chemo
No gross mets at the time of surgery
10% alive in 1 year with amputation alone
30-62% alive in 1 year with both
2 year survival is 7-21% with amputation and chemo
Dogs almost never survive to 2 years with amputation alone
There is occasionally a cure with amputation (10%?)
Vaccines are in the works

35. Osteosarcoma Prognosis
Those with thoracic or LN metastasis at the time of diagnosis do poorly no matter how treated (MST < 2 months)
Always FNA draining lymph node
Elevated SAP
Median survival 5.5 months if SAP elevated
Median survival 12.5 months if SAP normal
High grade tumors have worse prognosis
Dogs between 7-10 years of age do the best
Young and older dogs don’t fare as well
Dogs 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%

36. Client Handouts PowerPoint .pdfs of PowerPoint – 1 & 6 slides per page
Hemangiosarcoma
Osteosarcoma
Yunnan Pai Yao
Hidden Slides:
Details on Limb sparing surgery for OSA

37. Acknowledgements
Zachary Wright, DVM, ACVIM (Oncology) Animal Diagnostic Clinic, Dallas TX
Philip Bergman, DVM, MS, PhD, ACVIM (Oncology)
Director, Clinical Studies (VCA)
Oncologist, Ketonah-Bedford Vet Center
Bedford Hills, NY
VetFolio Oncology Certificate Program