Solid tumour interactive cases

CASE 1

• Soft tissue swelling

• Osteolysis (permeative and moth eaten) of the metaphysis of the ulna

• Interrupted periosteal reaction

• Prolonged zone of transition

CASE 1

• Neoplastic

  • Osteosarcoma

  • Chondrosarcoma

  • Fibrosarcoma

  • Histiocytic sarcoma, Hemangiosarcoma

  • Metastatic lesion less likely

• Infectious

  • Fungal osteomyelitis

  • Bacterial osteomyelitis less likely

CASE 1

Cytology:

• Mesenchymal cell in origin = osteosarcoma likely

  • may not always be diagnostic:

    • ALP staining

    

    • bone biopsy

    • Jamshidi needle

CASE 1 bloods:

Haematology was normal

Biochemistry ALP 550U/L (incr by almost 3x upper limit)

Are you worried by the ALP pre-excision?

Yes —> incr ALP is -ve prognostic factor

CASE 1

Which approach is ass. w/ best survival?

Amputation + adjuvant carboplatin

CASE 1

Follow ups

• Thoracic rads q. 3 months

  • or if any suspicion of clinical deterioration —> cough (lung mets), lameness (bone mets), skin nodule w/ cytological diagnosis of mesenchymal tumour

CASE 1

Rads @ 6 month follow up:

Nodular lesions —> metastasis

started toceranib (tyrosine kinase inhibitor)

CASE 2

Haematological findings:

• Non-regen (or pre-regen) normocytic, normochromic anaemia

• Moderate thrombocytopenia

CASE 2

Schistocytes —> RBCs suffered damage → lost normal circular shape i.e. fragmented

CASE 2

• Mild hypoproteinaemia

• Mild incr creatinine

• Microangiopathic anaemia?

• DIC?

• Haemorrhage?

• Pre-renal azotaemia?

CASE 2

What are the next steps?

• Imaging (thorax & abdo)

• Coag profile —> DEA -ve

  • DIC —> signs = spontaneous bleeding / thromboembolism

    • present in up to half dogs w/ visceral haemangiosarc

  • clinical path —> low / falling platelet count, prolonged PT & APTT, incr FDPs / D-dimers

• Blood type

CASE 2

Mass effect displacing intestine dorsally, abdo effusion

CASE 2

Mass in spleen

Free fluid between viscera

CASE 2

Next step —> abdo fluid investigations:

• Haemorrhagic looking

• PCV 15%

• TP 37g/L

• On cytology —> see RBCs w/ occ. neutros & minimal lymphos

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CASE 2

Tx

Transfusion w/ DEA -ve blood (ideally whole blood) then surgery

Surgery —> surgery alone ass. w/ 2-4 months survival —> chemo may incr this e.g. epirubicin

CASE 3

• Bloods unremarkable

• No abnormalities on thoracic rads & abdo U/S

Recommended tx?

Left total mastectomy or regional mastectomy M3-M5 incl L inguinal LN

(discuss pros & cons w/ owner —> complications higher with total e,g. infection, break down of wound, longer recovery time)

CASE 3

Describe the outcome of spay as tx

• Can decr risk of further development of benign tumour

• Can improve outcome in grade II mammary tumour w/ oestrogen expression

• Make sure to change instrument between spay & mammary tumour removal to avoid seeding

CASE 3

Grade III mammary carcinoma diagnosed

Metastasis to L inguinal node confirmed

Is chem indicated?

Not sure @ this stage —> not enough evidence to say whether improves mammary tumours

What is this?

Inflammatory mammary carcinoma

More extended —> diff from nodular lesions

Poor prog to chemo

CASE 4

DDx?

Most likely:

• Oral melanoma

• Fibrosarcoma

• SCC

• Plasma cell tumour

• Haemangiosarcoma

• Osteosarcoma

• Epulis

• FB

• Transmissible venereal tumour (if hx of travel)

CASE 4

Ddx of melena?

• Oral lesion

• Nasal lesion

• GI lesion

CASE 4

Haemorrhage of mass ddx?

• Friable lesion / trauma to mass / poor quality tumour vasculatur

• Coagulopathy

CASE 4

L submandib lymphadenopathy ddx?

• Reactive inflam

• Neoplasia

CASE 4

What test next?

• Haematology & coags

= regen anaemia

• Thoracic xrays:

no mets

• Biopsy

consistent w/ haemangiosarc

CASE 4

Tx options?

To slow down development of metastasis:

• High dose chemo w/ doxorubicin / epirubicin

and / or

• Metronomic chemo (cyclophosphamide & melox)