Hemangiosarcoma Flashcards by jared Jensen

malignant tumor arising from endothelial cell precursors

hemangiosarcoma

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a malignant tumor of mesenchymal tissue

sarcoma

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What is the most common site of hemangiosarcoma in dogs

Spleen

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What kinds of dogs typically get hemangiosarcoma

middle- aged to older dogs

german shepherds, golden, and labrador retrievers, other large breed dogs

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hemangiosarcoma is uncommon in cats but what sites are more common

Skin and SQ sites more common than visceral

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The spleen is one of the most common sites for hemangiosarcoma in the dog, what are some other common places

-Heart (R atrium and auricle)
-Subcutaneous and IM sites
-Liver
-Skin
others (anywhere with blood vessels): retroperitoneal space, kidney, lung, bone, eye, oral (tongue), nasal cavity

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What structure of the heart is most common for hemangiosarcoma

R auricle and atrium

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What are the clinical signs of visceral hemangiosarcoma

often vague and non-specific clinical signs
-waxing. and waning lethargy/ inappetence
-neurologic/mentation changes
-GI signs
-acute collapse
-respiratory distress
-sudden death

can range from asymptomatic to sudden death

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What are the PE findings of hemangiosarcoma when it occurs and ruptures on the spleen, liver, or heart

-Pale mucous membranes, prolonged CRT
-Weakness, dull mentation
-Tachycardia, poor pulse quality, arrhythmias
-Tachypnea, dyspnea
-Fluid wave, cranial abdominal mass
-Muffled heart sounds, pulsus paradoxus

masses that have not ruptured may only be found incidentally

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hemangiosarcoma masss that have not ruptured may

only be found incidentally

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dermal hemangiosarcoma is often induced by

the sun

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with visceral hemangiosarcoma, what might you see on bloodwork *

CBC: leukocytosis, thrombocytopenic, regenerative or non-regenerative anemia

Chemistry: hypoproteinemia, elevated liver enzymes, azotemia

PT/PTT/FDG/d-dimers: 50% of dogs meet criteria for DIC

May need to blood type or cross match

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What should you do if you suspect hemangiosarcoma

diagnostic abdominocentesis
-appearance of effusion? PCV of effusion? how does it compare to peripheral PCV? clot in red top tube?

do a pericardiocentessi if cardiac tamponade

get blood pressure, EKG, and provide IV fluids, supplemental O2

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What abnormality on the EKG might be common in dogs with hemangiosarcoma

Ventricular arrhythmias common

electrical alternans

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In dogs with hemangiosarcoma, why might you need to be more judicious with your use of fluids

you dont want to disrupt the clot

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One a dog with hemangiosarcoma is stable, what should you do

1) Thoracic radiographs (3 views before surgery)

2) Abdominal ultrasound

3) Echocardiogram

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if you have a non-traumatic hemo-abdomen, what do you need to do before going to surgery

3 view thoracic radiographs - if see pulmonary mets, then this could impact the prognosis

can also assess for pericardial effusion which can tell you prognosis

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once a patient with hemangiosarcoma is stable, why is doing an abdominal ultrasound important

*to identify the source of hemorrhage (often spleen)

-Interpret staging with caution (dont overinterpret)
50% of liver lesions are detected with US
Only 50% of dogs with grossly abnormal livers at time of surgery have HSA mets (could be something else)
Omental mets hard to observe with US

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What are the limitations of abdominal ultrasound in diagnosing hemangiosarcoma

-Interpret staging with caution (dont overinterpret)
50% of liver lesions are detected with US

Only 50% of dogs with grossly abnormal livers at time of surgery have HSA mets (could be something else)

Omental mets hard to observe with US

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Once the patient is stable, what is the significance of using echocardiogram to diagnose hemangiosarcoma

Allows you to look for a R atrial / auricular mass
-more difficult to visualize if no pericardial effusion
-Pre-op staging; low likelihood of concurrent caridac mass with spenic mass (<10%)

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What are your differentials for a splenic mass

Malignant: hemangiosarcoma, marginal zone lymphoma, splenic stromal sarcoma, histiocytic sarcoma, leiomyoma/leiomyosarcoma

Benign: Hematoma, extramedullary hematopoiesis (EMH), lymphoid hyperplasia

many of these can bleed

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T/F: hemangiosarcoma is rare in humans

True

How are you going to start the bleeding of hemangiosarcoma

Exploratory lapartotomy and splenectomy
-or liver lobectomy or nephrectomy, depending on the source of bleeding

provide supportive care?

How are you going to get the definitive diagnosis of hemangiosarcoma

Exploratory laparotomy and splenectomy with histopathology

*Cytology often unrewarding (RBCs only), caution with cystic or cavitated masses

If a dog is presenting for non-traumatic hemoabdomen then what percent of these are from hemangiosarcoma

65-75% are hemangiosarcoma 73% are malignant

If a dog has a splenic mass that is incidental, what amount are hemangiosarcoma

30% are malignant with 1/2 being hemangiosarcoma "also called splenic nodules" if not bleeding then the chances of it being hemangiosarcoma is lower

hemangiosarcoma is more common in dogs that are what body size

>20 kgs

If a patient has a higher ___________ ratio and _________ percentage of body weight then it is more likely to be benign

if a patient has a higher Mass to Splenic Volume (MSV) ratio and splenic weight as a percentage of body weight (SWPBW) then it is more likely to be benign

What is the treatment of hemangiosarcoma

1) Surgery - mainstay of treatment, but may be challenging with some locations (cardiac), may be the only therapy needed for dermal HSA 2) Radiation therapy - for incompletely excised tumors (often SQ or IM) Palliation- cardiac, SQ, or IM tumors (gross disease) 3) Chemotherapy- post operatively to delay onset of metastasis, (Doxorubicin based chemotherapy protocols)

What might be the only therapy needed for dermal hemangiosarcoma

surgical excision

radiation therapy for hemangiosarcoma is indicated when

for incompletely excised tumors (often SQ or IM) Palliation- cardiac, SQ, or IM tumors (gross disease)

Why do you do exploratory laparotomy and splenectomy for hemangiosarcoma

1) Remove source of bleeding 2) Biopsy abnormal lesions - liver, omentum (remember only about 50% of abnormal lesions in liver are consistent with metastasis on histo path) 3) Biopsy of normal liver - low yield to ID occult mets

What is the perioperative mortality rate of splenectomy for hemangiosarcoma

8% (doesnt include patients euthanized intra-op for suspected metastatic disease

What are the major complications of splenectomy for hemangiosarcoma tx

1) Hemorrhage 2) Thromboemoblic events - pulmonary thromboembolism, portal system thrombus 3) DIC 4) Cardiac arrythmias (VPCs)- do continuous ECG 12-36 h post-op 5) Intra-abdominal / incisional tumor seeding

What stage of hemangiosarcoma is when it ruptures

Stage 2

What stage of hemangiosarcoma is when there are mets

Stage 3

What prolongs the survival of HSA

chemotherapy surgery alone (weeks to 3 months) Stage I Sxand Chemo = 9 months Stage II Sxand Chemo = 6 months Stage III Sx and chemo = 3 months

hemangiosarcoma chemotherapy protocols generally consist of

Doxorubicin given once every 2-3 weeks for 5-6 treatments can combine w other agents 2

You should be cautious with Doxorubicin in what patients

1) Breeds predisposed to DCM 2) Breeds at risk of MDR-1 mutations

Why is hemangiosarcoma such a poor prognosis

1) High metastatic cancer 2) Common sites: lungs, liver, peritoneum, omentum, brain (most common tumor to spread there) can go anywhere

What is the most common tumor to spread to the brain

hemangiosarcoma

After the spleen, what is the 2nd most common site of hemangiosarcoma

R atrium or auricle

How do you treat cardiac hemangiosarcoma

surgery excision of mass possible in some cases (not commonly performed and pericardiectomy not beneficial) 1) Radiation therapy- palliative or sterotactic (may decrease bleeding episodes) 2) Doxorubicin- MST = 4 months

What does Dermal / Cutaneous HSA look like

often small, blood blister like masses on poorly haired areas-ventral abdomen may be solar induced

What breeds are predisposed to dermal / cutaneous hemangiosarcoma

Whippets American Staffordshire Terrier / Pitbulls Italian Greyhounds Beagle Dalmation likely solar induced

How do you cure Dermal/ Cutaneous HSA

Surgery - often curative MST = 18months to >4 years

What are the better prognostic factors of dermal / cutaneous HSA

1) Predisposed breeds 2) Ventral abdominal location 3) Actinic changes on histo (ie solar induced) 4) High recurrence rates, but prolonged survivals no effect on progosis is multiple masses

What are worse prognosis factors for dermal / cutaneous HSa

1) Non-predisposed breeds 2) SQ invasion 3) Increased risk for metastasis and shorter survival no effect on progosis is multiple masses

T/F: multiple dermal / cutaneous HSA masses is a worse prognosis

False - no effect on prognosis

What does the coriolus versicolor mushroom do

known as turkey tail mushroom -contains polysaccharopeptide (PSP) possible inhibition of cancer cell growth through cell cycle inhibition, immunomodulation and gene modulation expensive - side effects = nausea, diarrhea

WHat do you need to diagnose hemangiosarcoma *

Histopathology the liklihood of HSA for dogs presenting with non-traumatic hemoabdomen is high but not 100% likelihood of HSA for incidentally found splenic mass is much lower

T/F: Visceral hemangiosarcoma is an aggressive cancer with a low metastatic rate

False - it is aggressive AND it has a high metastatic rate

How do you achieve the best outcomes of visceral hemangiosarcoma *

multimodal therapy 1) Surgery + Chemotherapy +/- radiation therapy (depending on site of tumor) *Splenic HSA has some unique complications secondary to surgery *Long term prognosis is poor even with aggressive therapy exception is dermal HSA- surgical excision is sufficient for most cases

T/F: for dermal HSA, surgical excision is sufficient for most cases

True