It’s comforting to know there is "Hope".
Ilona and Bill
Dr. Kevin Shanley received a K-9 Title Sponsor Award from the Chester County Sheriff’s Office for recognition of his services and support to aid Deputy Sheriff John DiBuonabenturo and his K-9 partner Leo. Leo, a German Shepard K-9 Officer in Chester County specialized in detecting accelerants, suffered from non healing wounds on his back legs. The wounds appeared a week after he visited a house bombing where much debris covered the floor he walked on. His handler and partner, John DiBuonabenturo brought Leo to Hope Veterinary Specialists in November of 2014 seeking an answer and to relieve Leo of the discomfort he was in.
Dr. Kevin Shanley, a board certified veterinary dermatologist diagnosed Leo with Metatarsal Fistulas, an immune mediated condition (resulting from the activity of the immune system) that is fairly uncommon in dogs.The fistulas are ulcerated, infected, deep draining tracts found on the rear feet. The feet are affected on the underside so the inflammation makes it painful to walk. Infected tracts run from the skin surface through several layers of tissue down to the deep layer of the skin. Leo has responded favorably to his new medications and ointment and is back to servicing and aiding the citizens of Chester County.
The Chester County Sheriff’s Office began their first K-9 Unit in August of 2006. Their first two K-9s, Cento and Nero were trained in explosive detection, patrol and tracking. With the addition of more K-9 Officers the team is now well equipped to handle explosive detection, narcotics detection, patrol, tracking, and article searches. The Unit provides security to all county government buildings as well as support and assistance to all law enforcement agencies throughout the country.
We are honored the Chester County Sheriff’s office will be registering their K-9 Unit with Hope Veterinary Specialists so we can better serve these officers in their time of need.
16th Annual PVMA Spring Clinic
May 21, 2015
State College, PA
Dr. Kevin Shanley
First Impressions—Make the Most of Your Dermatologic Examination
Approaching the Pruritic Patient—Part 1
Approaching the Pruritic Patient—Part 2
The MRSP Mess—My Dog has MRSA?!!!
Otitis Externa and Otitis Media
Recognizing Difficult Skin Diseases
WHAT IS LYMPHOMA?
Lymphoma (LSA) is one of the most common cancers in dogs. It is a cancer of lymphocytes which are cells of the immune system. LSA comes in several forms, including: gastrointestinal, mediastinal (chest), multicentric (involving many lymph nodes) and extranodal (involving organs such as the eyes, brain, kidney, skin, etc). Most dogs are diagnosed with the multicentric form (80-85%). The “typical” canine lymphoma patient is a middle-aged dog presented to the veterinarian because one or more lumps have been found. Usually the dog has not been showing any signs of illness and the lymph nodes are not painful to the dog.
Diagnosis is based upon either cytology or biopsy of a lymph node or affected organ. A workup for LSA involves the following: CBC and serum chemistry to evaluate all body systems; Chest radiograph (x-ray) to look for evidence of spread to the chest cavity or lungs; Aspirates of the lymph nodes to determine the phenotype (T cell or B cell), and in some cases an abdominal ultrasound to evaluate the spleen, liver and abdominal lymph nodes for evidence of the cancer.
We generally break LSA in three groups, B cell (~2/3 of the dogs), T cell (~1/3) and null cell (<2%). This information may be obtained through either biopsy or more novel techniques that are less invasive such as immunocytochemistry (ICC), flow cytometry, or PCR for antigen receptor gene rearrangement (PARR). Phenotyping of LSA is important as the result plays a role in prognosis (as B cells carry a better prognosis) and in therapy (as we treat B and T cell LSA with different protocols).
For many years, the “standard of care” treatment for most canine lymphomas has been doxorubicin-based combination chemotherapy, often referred to as CHOP chemotherapy. The acronym “CHOP” denotes the four drugs thought to have the greatest activity against lymphomas: Cyclophosphamide, Hydroxydaunorubicin (doxorubicin), Vincristine, Cyclophosphamide. Oncologists are now modifying protocols depending upon whether the patient has a B cell or T cell lymphoma, thus each are treated at Hope VS differently.
WHAT ARE MONOCLONAL ANTIBODIES?
In human oncology, lymphoma is treated with a combination of chemotherapy, such as CHOP, and monoclonal antibodies. A monoclonal antibody (mAb) can be used to specifically bind to target cells or proteins. This may then stimulate the patient’s immune system to attack those targeted cells and remove them from the body. Normal lymphocytes can be replenished, as stem cells within the bone marrow are not targeted and as such normal cells are replenished but the cancer lymphocytes are not. These have now become standard of care therapy in human oncology.
In veterinary medicine, we now have a B cell and T cell monoclonal antibodies for use in our patients. The monoclonal antibodies are produced by Aratana Therapeutics. The B cell monoclonal antibody has gained full approval by the USDA and the T cell monoclonal conditional approval.
HOW CAN MY DOG RECEIVE THE MONOCLONAL ANTIBODY?
- THROUGH A CLINICAL TRIAL: We are currently enrolling patients in a clinical trial for dogs with T cell lymphoma. Patients deemed eligible will be enrolled to receive chemotherapy +/- a T cell monoclonal antibody. This study is fully funded.
- THROUGH AN EXPERIENCE PROGRAM: We are partnering with Aratana therapeutics on a T cell & B cell experience program in which patients with T & B cell lymphoma can receive the monoclonal antibody. These are NOT clinical trials.
- T cell experience program-Patients with T cell lymphoma can receive any chemotherapy protocol with the monoclonal (no restrictions) once deemed they are not eligible for T Cell trial. The owner is responsible for costs associated with the monoclonal and its administration.
- B cell experience program- Patient with B cell lymphoma can receive B cell monoclonal antibody if they meet very specific criteria. Patients need to have been screened for T-Lab and deemed a “screen failure” due to the diagnosis of B cell lymphoma firs. Once the patient fits this criteria they can then go on to receive B cell monoclonal along as part of the B cell experience program along with any chemotherapy protocol (no restrictions on protocol). The monoclonal antibody itself is provided AT NO COST with owners covering only cost of its administration. Any costs associated with blood work, visits or concurrent chemotherapy are owner responsibility.
This is a very exciting time in veterinary oncology and Hope VS is excited to be on the forefront and provide the B and T cell monoclonal antibodies to patients in our region.
WHO DO I CONTACT FOR ELIGIBILITY?
Primary Contacts at HopeVS: Dr. Craig Clifford and Dr. Kate Vickery
Phone: (610) 296-2099
• Signalment: 7-year-old male spayed American Staffordshire terrier mix (13 kgs)
• Presenting complaint: Slight lethargy, decreased appetite
• Pertinent history: No significant previous medical history until 3 weeks prior when abdominal exploratory surgery performed for liver mass – biopsy consistent with nonresectable, massive, low-grade hepatocellular carcinoma
• Medications: Milk thistle, SaME
• Physical examination findings: Bright, alert, and responsive; body condition score 4/9; Distended abdomen with no fluid wave but palpable firm mass in cranial abdomen
• Complete blood count: 16,600 WBCs, 13200 neutrophils, 410 platelets
• Serum chemistry profile: ALT 1134, AST 596, ALP 980
• Bile Acids: Resting 15, Post-prandial 26
• Coagulation Screen: Within normal limits
• Thoracic radiographs: Thorax within normal limits, hepatomegaly
• Abdominal Ultrasonography: Large, cavitated right-sided hepatic mass abutting diaphragm and caudal vena cava.
• Computed Tomography (CT) Angiography (Figure 1): Heterogeneous right-sided massive liver tumor with portal vein and caudal vena cava compression
This patient had previous abdominal surgery in which the nonresectable liver mass was biopsied. The surgery report described the mass as adhered to the portal vein, pancreas and bile duct, originating from the base of the liver and attaching to the body wall, right lateral, quadrate liver lobes and gall bladder. A biopsy at that time was consistent with a well-differentiated hepatocellular carcinoma (HCC). As these tumors do not demonstrate substantial biological responses to systemic chemotherapy and radiation of the liver is not performed, historical standard therapy involves benign neglect and supportive care until these tumors either metastasize or, more commonly, rupture.
Following a CT angiogram (Figure 1), this patient was determined to be a good candidate for drug-eluting bead (DEB) trans-arterial chemoembolization (TACE) which was performed the following day. A combination of 1 ml of DEBs was mixed with Doxorubicin (30mg/m2) in order to allow the beads to absorb the chemotherapy. A 2-3cm surgical incision in the groin permits placement of a vascular sheath within the femoral artery. A catheter is advanced under fluoroscopic guidance into the celiac artery. Super-selective access is gained using a 2.4Fr microcatheter in order to minimize non-target (normal liver parenchyma) embolization and to achieve maximal concentrations of chemotherapy and DEBs within the actual tumor. Figure 2 demonstrates a digital subtraction arteriogram (DSA) of the contributing right hepatic artery illustrating vascularization of the right-sided liver tumor prior to (Figure 2A) and following (Figure 2B) chemoembolization. After delivery of the DEBs, there is less blood supply to the tumor as identified on the subsequent arteriogram. The procedure was repeated six weeks later. Figure 3 demonstrates the same superselection and microcatheter location prior to (Figure 3A) and following (Figure 3B) the second chemoembolization procedure. Notice the smaller, more consolidated, liver mass on this angiogram compared to Figure 2.
This patient recovered uneventfully and was discharged from the hospital the following day with prednisone, Clavamox, tramadol, ondansetron, and omeprazole. Repeat complete blood counts at 1, 2, and 3 weeks post TACE were unremarkable. A second treatment was performed five weeks later at which point the tumor appeared angiographically more consolidated and smaller. Five weeks following the second treatment a repeat CT angiogram demonstrated approximately 25% tumor size reduction with the animal clinically doing well (Figure 4). These procedures can be repeated as needed.
Currently there are no effective treatments for veterinary patients with non-resectable liver cancer. Due to poor responses or complications with systemic chemotherapy and radiation therapy, veterinary oncologists typically treat these patients with supportive care. Similar treatment difficulties for nonresectable human HCCs have led to investigation into regional, or liver-directed, therapies including intra-arterial chemotherapy delivery, trans-arterial embolization (TAE), transarterial chemoembolization (TACE), and ablation therapies (typically chemical or thermal). TACE involves a small catheter placed in the femoral artery. Under fluoroscopic guidance, the catheter is advanced up the aorta, into the hepatic artery feeding the tumor, and a full dose of systemic chemotherapy and embolic particles or microspheres are injected to obstruct bloodflow to the tumor. More recently, the development of drug-eluting beads (DEBs) has enabled 100-400 times the concentration of chemotherapy to be achieved within the tumor compared to the same dose given intravenously (systemically). The DEBs slowly elute the doxorubicin over weeks to months within the tumor resulting in less toxicity to the patient, most of whom show no side effects from the chemotherapy (such as immunocompromise or GI toxicities associated with systemic delivery). TACE has been shown in a number of human randomized clinical trials to be associated with prolonged survival times when compared to systemic therapies. Post-embolization syndrome (PES) is characterized in humans by general malaise, fever, nausea, abdominal discomfort. It occurs in many people following TACE but it is generally self-limiting and well managed with supportive care such as anit-inflammatories, anti-nausea medications, antibiotics, pain medications, and gastroprotectants. In addition, DEB TACE has been shown to result in fewer side effects (like post-embolization syndrome) and better results (for large tumors) than standard chemoembolization. It is unclear if animals experience PES however we currently treat them empirically with the same medications just in case.
A video of the procedure can be viewed below.
For more case studies and to see how interventional radiology and interventional endoscopy can benefit patients, visit http://amcny.org/interventional-radiology-endoscopy/.
Submitted By Dr. Chick Weisse VMD, DACVS
Animal Medical Center
Dyet J, Ettles D, Nicholson A, eds., et al. Textbook of Endovascular Procedures. 1st ed. Philadelphia:
Churchill Livingstone, 2000:357-367.
Weisse C, Clifford CA, Holt D, Solomon JA. Percutaneous arterial embolization and
chemoembolization for treatment of benign and malignant tumors in three dogs and a goat. JAVMA 2002
Soulen MC: Multimodality image-guided therapy for liver tumors. SIR Annual Meeting 2003
Hemingway AP, Allison DJ. Complications of embolization: Analysis of 410 procedures. Radiology 1988;166(3):669-672.
Geschwind JH. Therapy for liver cancer by targeting energy metabolism. SIR Annual Meeting 2003 14(2):P207-P211.
Figure 1: Pre-chemoembolization CT angiogram. A. Sagittal reconstruction of the abdomen with dashed black line outlining the massive hepatocellular carcinoma compressing the caudal vena cava. B. Coronal reconstruction of the abdomen with dashed black line outlining the massive hepatocellular carcinoma compressing the portal vein.
Figure 2: Pre- and Post-chemoembolization hepatic arteriograms during the first TACE procedure. A. Hepatic arteriogram prior to chemoembolization demonstrating considerable vascularization of the tumor outlined by a dashed black line. B. Repeat hepatic arteriogram post-TACE demonstrating reduced vascularity following the TACE procedure.
Figure 3: Pre- and Post-chemoembolization hepatic arteriograms during the second TACE procedure. A. Hepatic arteriogram prior to chemoembolization demonstrating considerable vascularization of the now diminished tumor outlined by a dashed black line. B. Repeat hepatic arteriogram post-TACE demonstrating reduced vascularity following the TACE procedure. Note the smaller mass compared to the prior arteriogram (Figure 2).
Figure 4: Pre-chemoembolization abdominal CT (non-contrast enhanced). A. Sagittal reconstruction of the abdomen with dashed black line outlining the smaller hepatocellular carcinoma when compared to Figure 1A. B. Coronal reconstruction of the abdomen with dashed black line outlining the smaller hepatocellular carcinoma when compared to Figure 1B.
“Scooby” was a 10 year old male castrated labrador retriever who presented to the Oncology service at Hope Veterinary Specialists for a large firm mass arising from the left side of his face. Initial aspirates of the mass obtained at the referring hospital were suggestive of osteosarcoma.
In order to stage the tumor as well as determine whether or not it would be amenable to surgical resection, a CT scan was performed of the entire head, using a bone algorithm and calculating retroactive reconstructions in detail and soft tissue windows. Intravenous contrast (Iohexol) was also given and the scan repeated using the same protocol.
A large well-defined mineralized mass measuring ~4.4 x 6.0 x 7.1cm was found underneath the left zygomatic arch. The mass was arising from a stalk-like projection coming out of a shallow ovoid region of geographic lysis along the junction between the zygomatic process of the maxillary bone. No periosteal reaction was present along the involved or adjacent bones, nor was there any proliferative changes beyond the mass itself. A CT of the thorax demonstrated no evidence of pulmonary metastatic disease.
The owners opted to pursue a more conservative, local surgical resection of the mass involving removal of the caudoventral aspect of the maxillary bone including M1 and M2 and the rostroventral aspect of the zygomatic arch, while preserving the orbit (see figure 3). This was followed up with chemotherapy in the form of low-dose Cytoxan.
After a little over 9 months, the owners noticed recurrence of the soft tissue swelling along the left side of Scooby’s face. A follow-up CT scan of the skull revealed a large multi-lobulated mass with patchy regions of contrast-enhancement and several fluid-filled pockets, but no mineralization. An irregular periosteal reaction was present along the ventral aspect of the zygomatic arch, but no additional lysis (see figure 4). The owners elected not to pursue additional surgery or radiation therapy.
Multilobular osteochondrosarcomas (MLO’s) are locally-invasive neoplasms that typically arise from the flat bones of the skull and tend to occur in older medium and large breed dogs, although they have been reported in younger and small breed dogs, and have also been reported in cats, humans, a horse and a ferret. MLO’s exhibit characteristics of both benign and malignant tumors– they are relatively slow-growing and well-defined, but often cause extensive regional destruction and osteolysis, with metastases possible. They most commonly arise from the top or caudal aspects of the cranial vault, in which cases they often exhibit a finely stippled, granular pattern of mineralization and frequently invade into the cranial vault itself, resulting in various neurologic abnormalities such as seizures. They less commonly arise from the mandible, zygomatic bone and the zygomatic arch and other more rostral areas of the skull– in such cases they tend to exhibit a more coarse, multilobular pattern of mineralization.
The CT and MRI characteristics of a small number of MLO cases have been described, with the tumors on MRI generally being hypointense to brain tissue on T1W, T2W and proton-density sequences, with variable degrees and patterns of contrast enhancement after administration of gadolinium IV. In addition to the different patterns of mineralization, MLO’s arising from the zygomatic arch, the mandible and other more rostral structures of the skull do not typically exhibit much if any significant contrast enhancement on CT (eg Iohexol), whereas those arising from the cranial vault exhibit variable degrees of contrast enhancement. Whether or not the behavior and/or histopathology varies between the two regions of tumor growth remains to be seen.
Submitted by Hadley Bagshaw, VMD, DACVR
Hathcock JT, Newton JC. Computed Tomographic Characteristics of Multilobular Tumor of Bone Involving the Cranium in 7 Dogs and Zygomatic Arch in 2 Dogs. Vet Rad & US 2000, vol. 41 (3): 214-217.