Tier1 sa grand rounds presentation
- 2. Haemangiosarcomas The most aggressive soft-tissue tumour! Splenic Haemangiosarcoma • Account for 80% of malignant splenic masses • Highly malignant • Haematogenous or transabdomial implantation following rupture • Liver, oementum, mesentary, right atrium, lung
- 3. Storm • 5 year-old, male, German Shepard, 51.7kg • Haemoabdomen • Splenic haemangiosarcoma (HSA) • Splenectomy and chemotherapy
- 4. Typical Presentation • Dog • Middle-old age • German Shepherds (GSD), Golden Retriever and Labradors • Haemoabdomen • Abdominal mass
- 5. Physical Exam • Pale MM, CRT >2s, tachycardia and poor pulse quality. • Fluid wave in abdomen • Palpable mass
- 6. Diagnostic Investigation • Haematology - anaemia, schistocytes, acanhocytes, thrombocytopaenia, neutrophilic leukocytosis • Biochemistry - non-specific • Coagulation tests - PT, APTT, ACT, fibrinogen concentration and fibrin degradation products • Abdominal imaging - mass and metastasises • Abdominocentisis - serosangionous or frank blood • Echocardiography - pericardial effusion, mass
- 7. Definitive Diagnosis • Not all splenic masses are HSA • Not all haemoabdomens are from HSA • Gross and U/S DDx - haematoma, haemangioma • Large mass does not equal malignant mass • Histopathology is necessary!
- 8. Tumour Staging Tumour Node Metastasis T0 no tumour N0 no regional LN involvment M0 no evidence of distant metastasis T1 <5cm confined to primary site N1 regional LN involvement M1 distant metastasis T2 >5cm, ruptured, invading subcutaneous tissues N2 distant LN involvement T3 invading muscle and adjacent structures
- 9. Tumour Staging Tumour Node Metastasis T0 no tumour N0 no regional LN involvment M0 no evidence of distant metastasis T1 <5cm confined to primary site N1 regional LN involvement M1 distant metastasis T2 >5cm, ruptured, invading subcutaneous tissues N2 distant LN involvement T3 invading muscle and adjacent structures
- 10. Tumour Staging Tumour Node Metastasis T0 no tumour N0 no regional LN involvment M0 no evidence of distant metastasis T1 <5cm confined to primary site N1 regional LN involvement M1 distant metastasis T2 >5cm, ruptured, invading subcutaneous tissues N2 distant LN involvement T3 invading muscle and adjacent structures
- 11. Tumour Staging Tumour Node Metastasis T0 no tumour N0 no regional LN involvment M0 no evidence of distant metastasis T1 <5cm confined to primary site N1 regional LN involvement M1 distant metastasis T2 >5cm, ruptured, invading subcutaneous tissues N2 distant LN involvement T3 invading muscle and adjacent structures
- 12. Splenectomy • Stabilise • Total splenectomy indicated given high malignancy • Ligate branches of and the main splenic artery and gastrosplenic vein • Explore abdomen for metastasises • Lavage and change instruments to reduce seeding
- 13. What To Look For • Solitary, multifocal or diffuse • Poorly circumscribed, non-encapsulated, adhere to other organs • Variable size • Pale grey dark red purple • Soft or gelatinous • Blood filled or necrotic cut surfaces • Extremely friable
- 14. Monitoring • ECG intra and post-operatively • Prone to ventricular arrhymias • Hypoxia, hypovlemia, anaemia, neurohormonal response from handeling spleen. • Should resolve in 24-48hrs.
- 15. Chemotherapy • Always indicated • Single agent therapy or combination protocols • Brief and incomplete remission • 30mg/m2 doxorubicin q3wk for 12-18weeks
- 16. Doxorubicin
- 17. Precautions • Recommend heart scan prior to starting • History and haematology prior to each treatment • Premed - Cerenia and Piriton • Infuse over 20minutes with 0.9% NaCl into the pre- placed IV catheter, alternating sites • Anaphylactic shock - adrenaline, steroids and fluids • Extravasation - dexrazoxane and ice compress
- 18. Prognosis • Poor • Splenectomy alone - 3 months • Splenectomy and chemotherapy - 6 months
- 19. The Future • Troponin I - cardiac HSA vs idiopathic pericardial effusion • Plasma VEGF and urine bFGF concentrations • Advanced imaging - malignant vs benign • Blood-based bio markers • Immunotherapy - vaccine, liposome delivery system
- 20. Resources • Merck Veterinary Manual • BSAVA Small Animal Formulary 8th edition • Hayes G, Ladlow J (2012) Investigation and management of splenic disease in dogs, In Practice, 34:250-259 • Withrow, Vail, Page (2013) Withrow and MacEwen’s Small Animal Clinical Oncology. 5th ed., Saunders • WATERS D. J., CAYWOOD D. D., HAYDEN D. W., KLAUSNER J. S. (1988) Metastatic pattern in dogs with splenic haemangiosarcoma: Clinical implications, Journal of Small Animal Practice, 29, 805-814
- 21. Questions?
- 22. Cutaenous Haemangiosarcoma • Stage I: cutaneous • Stage II: subcutaneous involved • Stage III: muscle involved
- 23. • Adult-aged dogs. • Spontaneous or predisposed by non-pigmented skin and light coats. • Whippet, Italian Greyhound, white Boxers and pit bulls; Irish Wolfhound, GSD, Golden Retriver, Hungarian Visla. • Trunk, hip, thigh and distal extremities. • Black and red from necrosis and thrombosis, look bruised. • Moderate malignancy risk (by blood to lung and spleen). • <0.5cm cryosurgery or laser. • >0.5cm wide surgical excision.
- 24. Cardiac Haemangiosarcoma • Presentation: pericardial tamponade, right heart failure (exercise intolerance, dyspnea and ascites) • Physical exam: ascites, muffled heart sounds, pulsus paradoxus (pulse Barry with RESP) • Surgery: palliative pericardectomy, or removal of right atria masses.
- 25. Histology Findings • Immature pleomorphic endothelial cells • Vascular spaces containing blood or thrombi • Immunohistochemistry for von Willebrand's factor.
- 26. Grading System Differentiation Mitosis Necrosis Score Normal 0-9 in 10HPF None 1 Specific subtype 10-19 <50% 2 Undifferentiated >20 >50% 3
- 27. Grade is determined by the cumulative score • Grade I: 4 or less • Grade II: 5 or 6 • Grade III: 7 or more