Osteosarcoma?

Re: Osteosarcoma?

Rob Davis — Tue, 09 Oct 2012 15:19:54 GMT

[quote user="Gillian Mostyn"]Just a note- this thread is from January- I doubt the dog is with us any more... [/quote]

Sadly you are correct.

I discussed the case with our local orthopaedic referral centre. The surgeon offered TPLO with amputation of the other leg at the same time, though we both agreed that we would not go down that route if the dog was ours. The owner agreed and decided on palliative care only. He was comfortable on carprofen and tramadol for a while, but was euthanased in May due to increasing pain.

Re: Osteosarcoma?

Gillian Mostyn — Mon, 08 Oct 2012 13:25:56 GMT

Just a note- this thread is from January- I doubt the dog is with us any more...

Re: Osteosarcoma?

james herriot lied — Sun, 07 Oct 2012 19:53:55 GMT

ps I'm sorry to say also, Guilherme, that we have a person on the site who seems to like giving very poor ratings for posts which don't deserve it. Please don't be put off by him or her - they have a problem, that's all.

JHL

Re: Osteosarcoma?

james herriot lied — Sun, 07 Oct 2012 19:51:04 GMT

[quote user="GUILHERME PIOCZCOVSKI"]

Do you have references about papers that confirms what you said about chemo and radiotherapy aren't useful in this case?

[/quote]

Interesting stuff there, Guilherme: I too have the same impulse to challenge any old idiot who doesn't back their argument up. You'll do fine on here

But.

The single reference you give is for a referral centre which exists to get more patients - which will happen if people think that their treatments are effective. And it's not exactly peer-reviewed stuff, although they reference to other papers. So I'd challenge you to back up your statement, too.

The key here is that most papers discuss the effects of chemo after amputation; in this case, amputation wasn't considered an option, and you'd have to ask the original poster about the reasoning behind that (I happen to think they were right). In the example reference you've given, the most vague option - I'm not sure what 'No amputation; pain relief with oral medications and radiation therapy and/or aminobisphosphonates and/or chemotherapy' means exactly - is it all of them, or just the radiotherapy in some? The survival times given, interestingly, are the least specific. And the 2-month survival time is for oral painkillers only, which isn't necessarily the option that many of us would take in any case: the use of injectable bisphosphonates to control bone pain, and possibly delay pathological fractures, is something which we're well aware of, and our analgesia may well extend beyond some pills for the owners to take away.

So, in other words the authors of the website compare a very, very basic approach to treatment of osteosarcoma with a very involved treatment and come up with two (or possibly more?) months of additional life. It's not a persuasive argument, exactly. No detailed discussion of whether that would be really good quality of life, either. And the cost of bisphosphonates is extremely high, which certainly leads to restricted use.

So, if we amputate then we get better survival - my expectation is six months maximum, although I once had a patient which survived for ten years after a documented osteosarcoma, following amputation without chemo. That's an anecdote, by the way, rather than evidence - but it was true. Survival time depends heavily on whether there are detectable metastases, and survival even with chemotherapy for these patients is short - again, perhaps a few weeks more with chemo than without.

It's when there are no detectable metastases that things get interesting. Leaving aside the arguments about whether researchers in referral settings can give a truly accurate picture about real-world outcomes, with chemo then median survival is quoted at anything between 10 and about 17 months, which is certainly a longer period of time and which may be seen as worthwhile.

But (again). I refer you to my previous comment about waiting for the clever people to come along - all of them know more than I do and I'm sure they'll be willing to impart wisdom. What I do currently have is scepticism, in part from this:

http://www.biomedcentral.com/content/pdf/1746-6148-8-56.pdf

It's a recent meta-analysis of prognostic factors (as opposed to specific treatment outcomes) for median survival times in patients with osteosarcoma. Basically, forty years' worth of papers were scrutinised, and out of over 800, only about 50 were found to be sufficiently controlled to draw conclusions from. That's not to say that chemo doesn't work - remember that I'm not clever and that my natural state is not to believe that benefit outweighs risk, cost, adverse effects and impact on welfare of both patient and owner - but it's evident that not all studies are equal. The researchers had problems with inadequate, biased and missing data in over 90% of papers.

So, in this case I think your own reference demonstrated that chemo and radiotherapy weren't useful adjuncts, as without amputation your reference doesn't give a brilliant improvement in survival even with these treatments. Bisphosphonates and combined analgesia may well have been useful, but they're not part of the debate.

In other cases, chemo after surgery may be useful, but my experience and expectations are perhaps different to yours, and I certainly don't consider some of the quoted survival times to be accurate, or above scrutiny.

Good to talk to you.

Re: Osteosarcoma?

Nicola Lawlor — Sun, 07 Oct 2012 19:27:46 GMT

Not my personal choice but just to add in the mix that it might be worth contacting someone like Noel Fitzpatrick re possible limb salvage options and any "new" procedures here if the owners want to explore all avenues. If it was my choice I would be going for best analgesia regime we could find for this patient and euthanasia at the appropriate point.

Re: Osteosarcoma?

Evelyn Barbour-Hill — Sun, 07 Oct 2012 16:57:08 GMT

Is it just me?

I'd guess that most owners who are truly fond of their dogs would choose on the dog's behalf 2 months pampering and pain relief, in preference to 10 months pain relief and all the hassle and distress of radiation and/or chemotherapeutic drugs.

Re: Osteosarcoma?

GUILHERME PIOCZCOVSKI — Sun, 07 Oct 2012 16:21:59 GMT

Hello James

I'm thought that those treatments are options because in all literature that i usually read it confirms a good pain relief and better survival time of dogs that can't go for the limb amputation.

Here comes a part of a text (not cientific, but of a reference institution: http://www.vetcancerspecialists.com/resources/osteosarcoma/):

How can we palliate or control pain in dogs with osteosarcoma?
When amputation or limb sparing surgery is not a good option for the patient due to size of the patient, the location of the tumor, or the presence of pre-existing osteoarthritis, several treatment options are available for pain management. While long-term survival may not be achieved with these protocols, quality of life can be preserved for many months in most cases. Thus, treatment with oral medications such as NSAIDs, tramadol (Ultram) and/ or gabapentin (Neurontin) often results in significant though short-term pain relief. The median survival time for patients with osteosarcoma treated with oral pain medications alone is 2 months, with euthanasia usually occurring due to progressive unacceptable pain levels and poor quality of life.

Course fractionated radiation therapy is the single most effective treatment for rapidly alleviating bone pain in dogs with osteosarcoma. A similar treatment approach is commonly used in humans for control of bone pain due to advanced breast or prostate cancer. Our approach at Veterinary Cancer Specialists is to administer a total of 3 high doses of radiation therapy to the tumor and surrounding tissue. The first and second treatments are spaced by one week and the second and third treatments are given 2 weeks apart. The spacing of these high dose radiation fractions allows normal tissues to undergo repair, thereby avoiding many of the side effects commonly observed with full course radiation therapy. General anesthesia is needed for each radiation therapy treatment but usually only lasts less than 15 minutes.

Administration of aminobisphosphonates (eg, pamidronate or zolendronate), a group of drugs most commonly used for the treatment of bone pain associated with cancer in humans, can be administered alone or optimally in combination with radiation therapy in dogs with osteosarcoma to maximize bone pain relief. Treatment with aminobisphosphonates can be given on the same day as radiation treatment.

Intravenous chemotherapy can reduce bone pain and improve and extend quality of life in some patients that do not undergo amputation for osteosarcoma and is therefore also used in combination with radiation therapy and aminobisphosphonates.

Summary of survival statistics for dogs with osteosarcoma
Oral pain relief only: median survival time of 2 months
No amputation; pain relief with oral medications and radiation therapy and/or aminobisphosphonates and/or chemotherapy: 4-10 months
Amputation only: median survival time of 4.5 months
Amputation with 4 treatments of carboplatin: median survival time 10 months
Amputation with 6 treatments of carboplatin: median survival time of 17.5 months

Do you have references about papers that confirms what you said about chemo and radiotherapy aren't useful in this case?

I'm not specialist in oncology, but here in Brazil is almost a common sense that the chemo always help in the control of the micrometastasis.

Re: Osteosarcoma?

james herriot lied — Sun, 07 Oct 2012 08:28:14 GMT

Welcome, Guilherme

I suspect the clever people will arrive later - maybe tomorrow - but at the moment, just us vets on call.

Radiotherapy isn't an option for these: it has no effect on the primary, and the secondaries are likely to be spread around the body. Chemo doesn't really seem to do much, either - on primary or secondaries.

I think the worry with amputation was that the dog was so lame on the other leg, with cruciate disease, that it wouldn't be able to support bodyweight.

My thoughts were also for palliative care and euthanasia as appropriate.

Incidentally, saw a dog last night with two week history of forelimb lameness (not presented) that became 10/10 lame on jumping off the sofa. Bone pain on palpation of humerus. It's that awful sinking feeling when you know it's a pathological fracture of an osteosarc. Old dog, front limb, not a candidate for amputation. Awful, really - just a bolt from the blue for the owners.

Re: Osteosarcoma?

GUILHERME PIOCZCOVSKI — Sun, 07 Oct 2012 02:56:39 GMT

What are the common protocols of chemoterapy in the UK?

I'm from Brazil and here we often use the combination of Doxorubicin and Carboplatin.

About the surgery, a limb salvage procedure can't be done in this case?

Is there access to radiotherapy? Should be an option too.

Sorry for the english!

Re: Osteosarcoma?

Gillian Mostyn — Wed, 01 Feb 2012 15:56:46 GMT

I'm afraid I second that - I would recommend palliative care only.

Re: Osteosarcoma?

Hannah Wynne Richards — Wed, 01 Feb 2012 15:53:51 GMT

Feed it caviar would be my recomendation

Wynne

Re: Osteosarcoma?

Mark Holmes — Wed, 01 Feb 2012 15:03:56 GMT

I would probably tell them not to worry about it being fat anymore spoil it and feed it what they like. Analgesia and euthanasia as appropriate. (Morphine oral tablets work great)

Re: Osteosarcoma?

Rob Davis — Wed, 01 Feb 2012 14:59:48 GMT

I biopsied this the other day. It felt horrible - unable to obtain nice core of bone - soft mush only once through the cortex. Histopath has come back as osteosarcoma. Chest and abdominal radiographs were unremarkable.

Sooooo.... What would you do now? Obviously amputation would seem sensible (I'm hoping that as this was picked up as an incidental finding, there might be a slightly better chance of avoiding metastasis than normal, though I would still give a very guarded prognogis). But, it is still very lame on the other hindlimb with the ruptured cruciate, so amputation would present significant problems.

Any suggestions gratefully received.

Re: Osteosarcoma?

Rob Davis — Wed, 25 Jan 2012 22:34:48 GMT

Sounds like a good scout around for a primary tumour elsewhere would be sensible at the same time as taking biopsies. Assuming the owner does want to investigate further I will post more details as I have them.

Re: Osteosarcoma?

Malcolm Ness — Wed, 25 Jan 2012 20:49:51 GMT

[quote user="Richard Fox"]"star burst" new bone proliferation which is not really present in those radiographs therefore another form of neoplesia maybe more likely?[/quote]

I am with Richard on this one. The location of the lesion in the distal diaphysis would be very unusual for an osteosarc. I would be suspicious of metastatic disease with haemangiosarcoma on the differential list.

Re: Osteosarcoma?

Utlendigur — Wed, 25 Jan 2012 20:26:08 GMT

If it was younger I'd wonder about a bone cyst? but at 9yrs...

PS quick look at BSAVA manual of musculoskeletal imaging - older animals can rarely get aneurysmal bone cysts due to vascular anomalies. Probably not, but just a thought..

Re: Osteosarcoma?

Rob Davis — Wed, 25 Jan 2012 16:54:24 GMT

I agree that it doesn't have the typical star burst appearance of an osteosarcoma, though they don't always look like they're supposed to! What I also find surprising is that the dog has not shown any signs of discomfort on the right leg. Generally osteosarcomas (osteosarcomata?) are extremely painful, and I would expect this to be more prominent than the cruciate pain in the left leg.

Re: Osteosarcoma?

Richard Fox — Wed, 25 Jan 2012 16:49:48 GMT

Not that I am an expert in radiography (although my wife is ;) ) - not many things to me would be a cause of such profound lysis other than neoplasia - OSA obviously often causes the "star burst" new bone proliferation which is not really present in those radiographs therefore another form of neoplesia maybe more likely?