Labrador cross with mass on antebrachium

Signalment:

7-year-old male neutered Labrador cross

Presenting sign:

7 x 5 cm firm mobile mass on the caudal aspect of the proximal antebrachium, which has grown over the past three months. Otherwise clinically well, with no evidence of lameness and no other history of illness. Physical exam is otherwise within normal limits.

1

What would be your next step? Excisional biopsy of the mass Incisional biopsy of the mass using a Tru-Cut biopsy needle under sedation Incisional biopsy, taking a wedge of tissue from the edge of the lesion under general anaesthesia, including a small section of grossly normal tissue, in a way that does not compromise further resection under general anaesthesia. FNA cytology in-house Please select an option Incorrect. This is definitely not the way to proceed. Revise principles of surgical oncology. Incorrect. Not a bad choice, but as the mass is so large and the sample is so small, the sample may be friable and necrotic, leading to difficulty in interpretation, so this should not be your first option. It would be best to perform a fine-needle aspirate (FNA) before histopathology, in case a diagnosis can be reached using cytology only (e.g. lipoma, mast cell tumour, abscess). Incorrect. Correct technique for a histopathological diagnosis, including an idea of behaviour. However, it would be best to perform FNA before histopathology, in case a diagnosis can be reached using cytology only (e.g. lipoma, mast cell tumour, abscess). Correct. It is best to perform FNA before histopathology, in case a diagnosis can be reached using cytology only (e.g. lipoma, mast cell tumour, abscess.) The FNA reveals blood only, but suspicion of sarcoma is increased, as sarcomas do not exfoliate cells readily and it is common to aspirate blood with soft-tissue sarcomas. Abscess and lipoma are ruled out, and a mast cell tumour is unlikely. You proceed to incisional biopsy (technique as described in option 3).

Histopathology report

Gross pathology One pot is submitted:biopsy of the leg. A pece of pale tan resilient tissue measuring 7 x 5 x 5 mm. A representative section is placed in Cassette A. Histopathology This is a section of a tumour composed of sheets of neoplastic pleomorphic polyhedral to spindle cells with a mitotic index approximating 1-2 mitoses per high power field. They are accompanied by minimal collagen. The neoplastic cells have mild karyomegaly and nucleolar prominence together with abundant eosinophilic, vacuolated cytoplasm. Diagnosis Cutaneous soft-tissue sarcoma, grade 2. Comments This diagnosis is in keeping with the previous cytological findings. The minimal collagen and cytoplasmic vacuolation evident in this case raises the possibility of liposarcoma as a more specific diagnosis. In any case, this tumour is likely to be characterized by infiltrative local growth but negligible tendency for metastatic spread.

2

Review the histopathology report. What do you understand about the behaviour of soft-tissue sarcomas (STS)? Locally minimally invasive but generally a high rate of early metastasis Locally minimally invasive and generally a low rate of metastatic disease Locally very invasive and generally a high rate of early metastatic disease Locally very invasive and generally a low rate of metastatic disease Please select an option Incorrect. Review STS before retrying. Incorrect. Review STS before retrying. Incorrect. Review STS before retrying. Correct.

3

What is the metastatic rate of grade 2 STS? Up to 10% Up to 20% Up to 50% Up to 80% Please select an option Incorrect. This is the metastatic rate for low-grade (grade 1) STS. Choose again. Correct. Metastasis tends to occur late in the course of disease. Incorrect. This is the metastatic rate for high-grade (grade 3) STS. Choose again. Incorrect. STS are characterized by a low-to-moderate metastatic rate.

4	What is the metastatic rate of grade 1 STS? Up to 15% Up to 20% Up to 30% Up to 10% Please select an option Incorrect. Choose again. Incorrect. Choose again. Incorrect. Choose again. Correct.

5	What is the metastatic rate of grade 3 STS? Up to 20% Up to 50% Up to 80% Up to 90% Please select an option Incorrect. Choose again. Correct. Incorrect. STS are characterized by a low-to-moderate metastatic rate. Incorrect. STS are characterized by a low-to-moderate metastatic rate.

6

What would you choose to do next? a) Abdominal ultrasound for staging purposes b) Thoracic radiographs for staging purposes c) Bone marrow biopsy for staging purposes d) Palpation of regional lymph node and FNA of this lymph node if enlarged. e) Options b) and d) Please select an option Incorrect. Although this is reasonable to check for intercurrent disease, it is unlikely that a grade 2 STS would metastasize to intra-abdominal organs so not your next choice. This option is more appropriate for high-grade or anaplastic STS. This is correct but there is a better option. This is the commonest site for metastatic disease for STS. However, you should also assess your regional lymph nodes, as in option e. This is of little or no value in this case. This is also correct as STS can metastasize to regional lymph nodes. You should try and demonstrate evidence of metastasis with FNA before surgery, as this may change the prognosis and thus the client’s willingness to treat. However, cytology of regional lymph nodes may not be adequate for staging and histopathology is better to prove lymph node metastasis. It is important to remove enlarged regional lymph nodes at the time of surgery and send for histopathology just to be sure. You should also take thoracic radiographs for staging purposes, as lung is the most common site for metastasis of STS. Choose again. Correct. This is the best answer.]]

7

You now know that the regional lymph node is not palpable, and the thoracic radiographs are unremarkable. You have adequately staged this tumour to stage I (primary site only). What can be expected with adequate treatment of this tumour? Extension in survival time is possible, but a cure is unlikely A cure is likely with adequate treatment. Please select an option Incorrect. Review STS before retrying. Correct.

8

Haematology, biochemistry and urinalysis before surgery are within normal limits. What is your preferred option for treatment of the local tumour? Amputation alone OR chemotherapy alone Marginal excision with adjuvant radiation therapy OR excision with widest margins possible and reconstruction with a skin flap Amputation OR marginal excision with adjuvant radiation therapy Radiation therapy alone OR amputation Chemotherapy alone OR marginal excision alone Please select an option Incorrect. Amputation is a valid treatment option, as wide margins without amputation will be difficult to guarantee with the size of the tumour and its location. However, STS is minimally, if at all, responsive to chemotherapy. Choose again. Incorrect. Marginal excision with adjuvant radiation therapy is expected to provide long-term control of local disease, with 70% of local STS of all grades controlled for at least 1 year. However, excision with widest margins possible and reconstruction with a skin flap is not a preferred treatment option, as wide margins without amputation will be difficult to guarantee with the size of the tumour and its location. However, if radiation therapy is not available and the clients refuse amputation, this could be tried and may give favourable results if margins prove to be clean. Choose again. Correct. These are the two best options to achieve cure or long-term control. Incorrect. STS as gross, large-volume disease is minimally responsive to radiation, so this should not be a preferred option. This dog could be cured! However, amputation is a valid treatment option, as wide margins without amputation will be difficult to guarantee with the size of the tumour and its location. Choose again. Incorrect. STS is minimally, if at all, responsive to chemotherapy. Marginal excision alone is also not a preferred treatment option as local recurrence is expected within 1 year in 60% of cases. Choose again.

9

Unfortunately radiation therapy is not available, and the clients refuse amputation. The specialist oncology surgeon plans the surgery to achieve the widest margins possible (deep and lateral), and then reconstructs the deficit with an axial pattern flap. What is an axial-pattern flap? A skin flap rotated around an axis in a specified pattern A skin flap containing a direct cutaneous artery and vein A skin flap, which is detached from the donor site and placed on the recipient site in an axial pattern A skin flap, which is tubed and after 2 weeks is then ‘caterpillared’ to cover the skin deficit Please select an option Incorrect. You need a better understanding of possible surgical options. Review a general animal surgery text and choose again. Correct. This means the skin flap has a 50% greater chance of survival than a skin flap, which does not contain a direct cutaneous artery and vein. Incorrect. You need a better understanding of possible surgical options. Review a general animal surgery text and choose again. Incorrect. You need a better understanding of possible surgical options. Review a general animal surgery text and choose again.

10

Which axial-pattern flap would be most appropriate to close this deficit (see photo)? Cranial superficial epigastric Caudal superficial epigastric Omocervical Thoracodorsal Superficial brachial Please select an option Incorrect. You need a better understanding of possible surgical options. Review a general animal surgery text and choose again. Incorrect. You need a better understanding of possible surgical options. Review a general animal surgery text and choose again. Incorrect. You need a better understanding of possible surgical options. Review a general animal surgery text and choose again. Correct. This is the flap that would be expected to cover this deficit. Incorrect. You need a better understanding of possible surgical options. Review a general animal surgery text and choose again.

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11

You resect the tumour and send tissue for histopathology. How do you prepare the resected tissue so that the pathologist is best equipped to give the information you need? Put the entire tumour in a 10:1 formalin:tumour ratio for 24 hours, then double-wrap the specimen and post it to the pathologist. Ink selected lateral and deep margins with tissue-marking or India ink. Take a large wedge from the centre of the tumour, and discard the rest of the tissue. Fix these samples in 10:1 formalin:tumour for 24 hours, and then post to the pathologist in separately labelled pots. Suture the underlying fascia to the skin on the lateral margins so that the tissue resembles the in situ tumour dimensions. Incise the tumour every few centimetres to allow the formalin to penetrate into the tumour mass: these incisions should be two-thirds through the depth of the tumour. Ink the lateral and deep margins with tissue-marking or India ink. Fix the tumour in 10:1 formalin:tumour for 24 hours, then double-wrap the specimen and post it to the pathologist. Please select an option Incorrect. This is not the best option. Choose again. Incorrect. This is not the best option. Choose again. Correct.

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  Skin surface

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  Muscle surface - note that the underlying deep fascia has been resected en bloc with the tumour)

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  Specimen inkeed

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  specimen sliced

12

The margins are clear and the pathologist confirms your histological diagnosis of grade 2 STS: it is a haemangiopericytoma. What other tumours fit the STS category, characterized by similar biological behaviour? (Choose three of the following.) choice1= Splenic haemangiosarcoma, Histocytic sarcoma, Malignant schwannomas Splenic haemangiosarcoma, Peripheral nerve sheath tumours, Brachial or lumbar plexus nerve root tumours Synovial cell sarcoma, Peripheral nerve sheath tumours, Fibrosarcoma Peripheral nerve sheath tumours, Malignant schwannomas, Fibrosarcoma Please select an option Incorrect. One of more of the options selected are incorrect. Choose again. Incorrect. One of more of the options selected are incorrect. Choose again. Incorrect. One of more of the options selected are incorrect. Choose again. Incorrect. One of more of the options selected are incorrect. Choose again. Correct. Synovial cell sarcoma have a greater affinity for lymph node metastasis than subcutaneous STS. Splenic haemangiosarcoma are more systemically aggressive, with microscopic or macroscopic systemic metastasis expected in 90% of cases at diagnosis. Histocytic sarcoma have a much more aggressive, early metastatic pattern. Brachial or lumbar plexus nerve root tumours have a different pattern of local invasion, extend proximally and distally along nerve roots and can invade the spinal cord.

13

What next step do you propose? Adjuvant doxorubicin chemotherapy to reduce the chance of development of pulmonary metastatic disease, followed by frequent checks for local recurrence (every 3 months for a year) and repeat radiographs at 6 and 12 months postoperatively. Frequent checks for local recurrence (every 3 months for a year) and repeat radiographs at 6 and 12 months postoperatively. Long-term piroxicam chemotherapy as an antiangiogenic treatment to reduce the development of pulmonary metastatic disease, as well as frequent checks for local recurrence (every 3 months for a year) and repeat radiographs at 6 and 12 months postoperatively. Adjuvant carboplatin chemotherapy to reduce the chance of development of pulmonary metastatic disease, followed by frequent checks for local recurrence (every 3 months for a year) and repeat radiographs at 6 and 12 months postoperatively. Please select an option Incorrect. Adjuvant chemotherapy for grade 2 STS is not indicated, as there is no proven benefit, nor is it proven to be of benefit for grade 3 STS in dogs. Chemotherapy may have some value for highly anaplastic sarcomas, where immunohistochemistry is required to determine histiogenesis; however, even this is unproven. Choose again. Correct. Adjuvant chemotherapy is of no benefit for grade 2 STS, so should not be offered. Incorrect. Adjuvant chemotherapy for grade 2 STS is not indicated, and is likely to be of little benefit for grade 3 STS. It may have some value for highly anaplastic sarcomas, where immunohistochemistry is required to determine histiogenesis; however, even this is unproven. The chemotherapeutic agent with the most expected benefit is doxorubicin or similar, so this would be inappropriate therapy. Choose again. Incorrect. Adjuvant chemotherapy for grade 2 STS is not indicated, and is likely to be of little benefit for grade 3 STS. It may have some value for highly anaplastic sarcomas, where immunohistochemistry is required to determine histiogenesis; however, even this is unproven. The chemotherapeutic agent with the most expected benefit is doxorubicin or similar, so this would be inappropriate therapy. Choose again.

14

You recheck your patient frequently and after 12 months there is evidence of a 5 × 3-cm wide, fixed soft-tissue swelling along one area of the surgical suture line at the proximal lateral antebrachium and overlying the ventrolateral chest wall. You biopsy this swelling as a small wedge biopsy and this confirms local recurrence of tumour, this time as a grade 3 STS. You had warned the clients that amputation was your preferred treatment option due to the difficulty in attaining margins because of tumour size and location, and so they are disappointed but not unprepared. It was also explained to them that recurrent disease has a poorer prognosis than optimally treated first-time, curative intent surgery. What would you do next? Thoracic radiographs + abdominal ultrasound (as now grade 3) before amputation if staging is negative. Thoracic radiographs + abdominal ultrasound (as now grade 3) + contrast-enhanced advanced imaging (e.g. CT, magnetic resonance imaging (MRI)) of local disease to ensure recurrent disease is resectable before wide surgical resection (most likely amputation). Thoracic radiographs + abdominal ultrasound (as now grade 3) + contrast-enhanced advanced imaging (e.g. CT, MRI) of local disease followed by marginal resection of local recurrence and adjuvant radiation therapy. Please select an option Incorrect. It is best to have advanced imaging of local tumour before surgery, as this may help you plan your surgery. Choose again. Correct. Incorrect, because you are irradiating over the chest wall and may incur long-term complications of fibrosis of irradiated lung. Therefore this is not your preferred option, as long as the dog has no intercurrent orthopaedic or neurological disease which precludes amputation. Choose again.

15

Luckily, your thoracic radiographs are negative for pulmonary metastatic disease, and there is still no palpably enlarged regional lymph node. You have optimized this patient’s outcome by ensuring frequent rechecks. However, you need to treat the primary tumour. What is the commonest cause of death for dogs with subcutaneous STS? Metastatic disease Uncontrolled or inadequately treated local disease Please select an option Incorrect. Review STS before retrying.]]

16

The clients are prepared for amputation, which your advanced imaging shows is most appropriate, as you will not be able to attain wide margins without it. You perform the amputation and succeed in attaining 3-cm margins around gross tumour, confirmed by the pathologist. You continue your frequent rechecks. Unfortunately, after 6 months there is evidence of two nodules in the caudal lung fields.Now it is optimal for you offer the clients doxorubicin chemotherapy. True or false? True False Please select an option Incorrect. This treatment is of no proven benefit. Correct. There is no proven benefit of giving adjuvant doxorubicin in this setting. You have done all you can do for this dog. It is a shame that the clients would not agree to amputation initially, as a surgical cure was likely at the first adequate surgical attempt at resection with wide clean margins. A marginal excision and adjuvant radiation therapy would have also given a good prognosis.]

This resource was adapted from North and Banks, Small Animal Oncology provided by Elsevier Health Sciences as part of the PublishOER Project.