Vaccine - associated sarcoma

Re: Vaccine - associated sarcoma

Rebecca MacMillan — Fri, 07 Feb 2014 17:44:52 GMT

[quote user="Gerry Polton"]

Can I finish by saying that I am so delighted to hear that you performed an incisional biopsy rather than removing the mass and finding out later that it was a high-grade sarcoma. I know I see a disproportionate number of these cases so my experiences have jaded me a little, but there is nothing so heartbreaking as seeing a cat that could have been cured no longer being curable because the first surgical intervention has opened up tissue planes and distributed the tumour way beyond any kind of rational surgical limit. Please can anyone else who reads this also remember that if you ever see a fast-growing mass in the subcutaneous soft tissues of a cat, mostly, but not exlcusively in the interscapular site.

[/quote]

Ha ha, thanks! In fairness though, sarcoma was so high on my differential list that I did a bit of reading up on how best to handle it, hence the careful incisional biopsy! So a lot of the credit goes to my oncology textbook...

Thanks for your post, I guess it is hard to give a median life expectancy because as you say, a lot of owners opt for euth when presented with a poor long term outcome. I just want to give the owners as much info as I can, but unfortunately I don't think referral is an option. I don't want to waste their money (and cause the cat any more unnecessary discomfort!) by attempting surgery here really, especially given how sizeable the mass is. I've already discussed with them that there is not much point just attempting a 'de-bulk'. I'm seeing them tomorrow, so we'll have a discussion again then but I wanted to be armed with as much info as possible, especially in terms of what to expect if they don't treat.

Re: Vaccine - associated sarcoma

Wren — Fri, 07 Feb 2014 15:08:54 GMT

[quote user="Gerry Polton"]

Hi Rebecca

I seem to be slow off the mark on this one! And I only stopped typing to answer one phone call. Perhaps not so surprising as this is a real hot potato. I don't know where you are based but I have a CPD evening on this scheduled for April 9th down in sunny Surrey if that might be of interest.

Anyway, back to the question. The most important element of therapy for injection site sarcomas is surgery. For the owner with the limited budget, do not consider adjuvant therapies if there is a chance that surgery might be performed. There is no doubt that radiotherapy and chemotherapy and now immunotherapy can all improve the prognosis once surgery has been undertaken (OK they can be used before surgery but what I mean is that they are added to surgery, not used instead).

Hope that helps

Gerry

[/quote]

I won't quote your reply in full but I'd just like to thank you for taking the time to type it out. Even as a horse vet I found it fascinating. I'm afraid I was one of the 'remove to biopsy' lot in a previous life. I wish I'd known better at the time.

Re: Vaccine - associated sarcoma

mariette asselbergs — Fri, 07 Feb 2014 13:25:50 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Tom Ward"]I think more learning happens on here than in many hours of CPD... now how to claim it on my CPD record ;)[/quote]

You can't. It's "unstructured", it's "undocumented", it wasn't an expensive course or a webinar. It could go in as "informal study" but you are only permitted () to record ten hours of that......

[/quote]

I claim more than 10 hours because it is not undocumented, they can follow proof of your participation by your postings.

Mariette

Re: Vaccine - associated sarcoma

Martin Atkinson — Fri, 07 Feb 2014 09:37:55 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Tom Ward"]I think more learning happens on here than in many hours of CPD... now how to claim it on my CPD record ;)[/quote]

You can't. It's "unstructured", it's "undocumented", it wasn't an expensive course or a webinar. It could go in as "informal study" but you are only permitted () to record ten hours of that......

[/quote]AFAIU you can claim it in addition to the ten hours if you can show that it has changed the way you work. How anyone could prove this or how you quantify the length of time spent on here is another matter.

Re: Vaccine - associated sarcoma

Thomas Johnson — Fri, 07 Feb 2014 08:44:16 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Tom Ward"]I think more learning happens on here than in many hours of CPD... now how to claim it on my CPD record ;)[/quote]

You can't. It's "unstructured", it's "undocumented", it wasn't an expensive course or a webinar. It could go in as "informal study" but you are only permitted () to record ten hours of that......

[/quote]

I thought that if you documented it as you did it you could count it on top of the 10 hours undocumented private study. From the RCVS website:

Private, documented, self-directed learning such as keeping up to date with relevant veterinary journals can be incorporated into your CPD plans and it is good practice to keep your own personal record of such activities, perhaps in the form of a learning diary. You can use the online PDR to keep such notes. Otherwise, undocumented private studies can only account for up to ten hours per year on your CPD Record.

Re: Vaccine - associated sarcoma

Gillian Mostyn — Fri, 07 Feb 2014 08:33:28 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Tom Ward"]I think more learning happens on here than in many hours of CPD... now how to claim it on my CPD record ;)[/quote]

You can't. It's "unstructured", it's "undocumented", it wasn't an expensive course or a webinar. It could go in as "informal study" but you are only permitted () to record ten hours of that......

[/quote]

I'm sure this isn't the case... didn't Arlo get something sorted where it became 'documented' because your activity record shows what you've been up to? (I'm not sure because I haven't actually needed to log it...)

Re: Vaccine - associated sarcoma

Evelyn Barbour-Hill — Thu, 06 Feb 2014 23:23:14 GMT

[quote user="Tom Ward"]I think more learning happens on here than in many hours of CPD... now how to claim it on my CPD record ;)[/quote]

You can't. It's "unstructured", it's "undocumented", it wasn't an expensive course or a webinar. It could go in as "informal study" but you are only permitted () to record ten hours of that......

Re: Vaccine - associated sarcoma

Tom Ward — Thu, 06 Feb 2014 19:53:29 GMT

Incisional biopsies it is! I think more learning happens on here than in many hours of CPD... now how to claim it on my CPD record ;)

Re: Vaccine - associated sarcoma

Gerry Polton — Thu, 06 Feb 2014 18:12:53 GMT

[quote user="Rebecca Benge"]Soooo... if left untreated what would you expect to see in terms of the disease? [/quote]If left untreated these lesions ulcerate and become infected. Euthanasia actually typically follows because it is a discharging mess. It is true that these cats do become somewhat listless and depressed, no doubt due to the systemic consequences of the presence of the tumour and extensive inflammation and necrosis that is present within it, with or without the presence of bacterial infection/contamination. Here is a photo of a cat called Charley's tumour on the day of initial presentation to me. The second photo is Charley happily receiving chemo. This tumour was not amenable to excision.

Re: Vaccine - associated sarcoma

Martin Atkinson — Thu, 06 Feb 2014 16:59:56 GMT

[quote user="Gerry Polton"]I have a CPD evening on this scheduled for April 9th down in sunny Surrey if that might be of interest.[/quote] I used to get mail shots from NDSR for their CPD sessions but they seem to have dried up lately - maybe they don't want me because I ask too many awkward questions. Is it one of their's, is it at the usual location and am I invited?!

Re: Vaccine - associated sarcoma

Gerry Polton — Thu, 06 Feb 2014 16:50:14 GMT

Hi Rebecca

However, there are small tumours, tumours that don't grow that fast and surprisingly-less-invasive-than-expected tumours, all qualify as injection site sarcomas. These all bring up the published average when you start asking about survival times, particularly for those which are left untreated, because the really big nasty ones typically lead to a decision to underake euthanasia soon after initial presentation.

For a tumour of the size you describe, I would expect an approximately 60 day survival with no therapy. Unfortunately surgery would have to be radical. The probability of complications and tumour recurrence will be high if the surgery is not performed with prior advanced imaging and if the surgery is not performed by somebody who is regularly performing this surgery. For your client, this may therefore mean that the best thing is to do no surgery at all.

Palliative therapy on a budget is tricky. The only treatment I have come across which might be considered to loosely fit this description is chemotherapy. For the fast-growing injection site sarcoma chemotherapy sometimes works remarkably well. However, it does not work forever. The (two) longest survivors I have had with tumours that were considered poor candidates for surgery both lived for thirteen months on chemotherapy alone. I have had cases that have gone into complete remission with only two doses of doxorubicin. Whether doxorubicin is sufficiently low budget or not is another matter of course.

The best outcomes reported to date in the veterinary literature are seen with a highly selected cohort of cases that underwent radical surgery and fractionated radiotherapy. I have published my own cases which were simlarly high selected but that fact notwithstanding, we had an 84% 6 year survival. Our treatment protocol comprised a combination of chemotherapy, advanced imaging and surgery. No radiotherapy. No immunotherapy. The paper will be on early view on Veterinary and Comparative Oncology in a few weeks (Bray and Polton).

Regarding the Oncept IL-2, it is licensed for treatment in conjunction with radical surgery and radiotherapy. I have no doubt that it will have application without adhering to the license recommendation though what we cannot do yet is quantify the advantage to the cats who receive it if they do not also receive the radical surgery and radiotherapy combination. I do not believe that it will offer any real advantage to your cat if it is used as a sole therapy.

Hope that helps

Gerry

Re: Vaccine - associated sarcoma

Andrew Kent — Thu, 06 Feb 2014 16:31:58 GMT

We've seen them do a couple of things - I would say most commonly they get bigger and bigger until they cause pain/ulcerate and you end up at euthanasia. We have, however, seen a couple extensively metastasise as well (one a long time after radical excision) so that is also a possibility.

Sounds quite a big horrible mass already so, as you say, extensive surgery would probably be needed. Sometimes the dorsal spinous processes have to be removed with the tumour which means that the cat can't lift its head for a while post-op. So the owners need quite careful counselling if they are going to go down the surgery route as it can be a big undertaking.

There isn't really a cheap way to manage them unfortunately.....

Andy

Re: Vaccine - associated sarcoma

Rebecca MacMillan — Thu, 06 Feb 2014 16:27:38 GMT

Andy -

Thanks! My textbooks only say what the median 'recurrence rates' were.

Soooo... if left untreated what would you expect to see in terms of the disease? Does the mass cause nerve problems or mobility issues? Or is that it becomes ulcerated and painful at some stage?

Just trying to get some info together so that the owners are prepared. I really don't think they can afford thousands on referral fees.

Re: Vaccine - associated sarcoma

Rebecca MacMillan — Thu, 06 Feb 2014 16:21:55 GMT

I guess the location and fast growing nature of this one raised my suspicions! The biopsy just confirmed what I already knew I guess...

The whole mass is a good 6cm or more in length I wound say, with knobbly/rounded bits on top of that. So even with just local incision it wouldn't be a small job! I think when the owners presented it to me initially, they had only really felt the knobbly 1cm diameter mass superficially (not the great big fibrous bit underneath).

Re: Vaccine - associated sarcoma

Andrew Kent — Thu, 06 Feb 2014 16:21:13 GMT

Hi Rebecca,

There is an excellent review of this in JFMS if you have access which summarises most of the literature.

Briefly - untreated the prognosis is pretty poor, in the region of 4-9 months.

With surgery alone there is a wide variety of outcomes from various sources but in the region of 400-900 days (900 with the widest excision).

Again the radiotherapy literature is variable but survival was 1300 days in one study.

Our approach here tends to be advanced imaging to determine extent of tumour and then wide surgical resection +/- radiotherapy (often pre-op), but this does vary depending on finances and preference of the owner.

The other thing that could be worth considering now is Oncept IL-2 which is a new immunotherapy treatment from Merial to be combined with radical surgery.

The first surgery is the most important with these so if the owner is considering this then referral sooner rather than later would be a good idea. It's a pretty horrible disease.

Andy

Re: Vaccine - associated sarcoma

Bob Russell — Thu, 06 Feb 2014 16:14:34 GMT

Probably going to get a red star or two but I have never had one at the classic injection site but had a couple that caught me unawares. I removed them with fairly standard margins and got a shock when path came through. I discussed more radical excision but owners declined. Both recovered uneventfully and without recurrence.

May be someone was looking over me on both days!

Nowadays they would get a FNA first so I might be a little wiser prior to surgery. Not too reliable for grading though!