Hi everyone. My name is Nicola. I'm an oncology nurse at the Royal Veterinary College, and I have been lucky enough to be invited by the webinar vet to talk to you about canine hemangiosarcoma and look at whether or not it is just a bleeding nightmare.
Sections that we're going to go through when we talk about subjects within the 60 minute webinar is what is canine hemangiosarcoma. We all need to know what it is. We need to know what the incidence of it is, what the risk factors are, and potentially what causes Hemaniosarcoma in these patients.
We need to understand the biological behaviour, so what the clinical signs these animals are experiencing, what presentation we might find them in, what kind of workup we need, and what staging we need to do in order to determine how much disease these patients have on board. From that, we'll have a look at therapy and predictive response, so look at surgery, chemotherapy, and is there anything else in which we can offer these animals? From this, I hope that your learning objectives of this session are to be able to identify.
So list the locations where Hemangiosarcoma is commonly manifest itself and which animals are more likely to be affected. I want to hope that you are able to explain the reasons for staging a patient with canine hemangiosarcoma and what tests may be used to determine the burden that these animals have as a disease process. We want to be able to differentiate, so describe the therapeutic options for patients that have hemangiosarcomas, so what are available to us and what type of circumstances, and then therefore validate and apply the understanding that we have with regards to relevance for our clinical practise.
Hemangiosarcoma is a malignant or cancerous transformation of endothelial cells. Endothelial cells line blood vessels and lymphatic vessels. They are found exclusively in the vasculauris tissue and the heart.
Basically they are present throughout the entire body. Endothelial cells form a tissue layer that fulfils various functions. These include blood vessel formation, regulation of vascular tone, and they have a role in inflammation and coagulation.
Endothelial cells of the capillaries have a vital function in the exchange of substances including oxygen, water, and lipids, as well as the transfer of carbon dioxide and urea from tissue to a vessel and vice versa. Hemangiosarcoma is seen mostly in middle age to older animals, although there are rare reports of homangiosarcoma occurring in dogs less than 3 years of age. Any breed sadly is potentially at risk, but German shepherds, golden retrievers, Labrador retrievers, and other large breed dogs are overrepresented in several case theories, which in some also suggest there might be a slight male predisposition.
Some reports suggest a hormonal association with canine hemangiosarcoma development, specifically when it comes to neuterine. Some studies describe findings that hemangiosarcoma appears more commonly in spayed females versus intact females, and that lately neutered females versus intact or early neutered females can have some significance over these findings. But the general population of client owned dogs, this is unclear.
Cutaneous hemangiosarcoma can develop more frequently in the skin along the ventral abdomen and conjunctiva in short-haired and lightly pigmented breeds, which could suggest an association with ultraviolet light exposure and has also been documented in research animals. Saying this, however, despite modern advances developing a better understanding about cancer, the known aetiology for developing hemangiosarcoma for dogs and in humans still remains unknown. Hemangiosarcoma represents approximately 2% of all tumours that are reported in dogs.
The primary site for hemangiosarcoma is in fact the spleen, which accounts for approximately 50% of cases and makes sense considering the spleen is a highly vascular organ responsible for red blood cell homeostasis. However, unsurprisingly, other common sites for Hemangiosarcoma to develop also include the heart, the liver, the skin, or the subcutis. In addition, the Hemangiosarcoma tumours can be reported to originate from other primary vascular sites, including the lung, kidneys, retroperitoneal space, muscle from within the bone.
The oral and nasal cavities, eyelids, conjunctiva, the urinary bladder, the toes, and even the mediastinum. A number of pathological studies have looked into the occurrence of Hemangiosarcoma in dogs, and results do vary slightly but have a similarity in the pattern of findings. Somewhere between 2/3 and a half of dogs presented with a splenic mass which was submitted for histology following splenectomy had malignant disease.
Of those dogs, anywhere between 2/3 and 3/4 had hemangiosarcoma. Some texts will quote the 2/3 rule when discussing the likelihood of a diagnosis with owners when their pet has been presented with Hemangiosarcoma. This is estimated at approximately 2/3 of mass lesions will be neoplastic, and 2/3 of those neoplastic masses will be hemangiosarcoma.
These odds do increase though for dogs that are presented with a non-traumatic hemo abdomen where approximately 70% of these cases will have had a ruptured maniosarchirallegium. All in there, although I'm sure you'll agree that a high chance of hemangiosarcoma is on the differentials list when we have a patient with a hemoabdomen and fits the bill. We saw in the last couple of slides that hemangiosarcoma's second most common site for occurrence is the heart, and it is in fact the most common cardiac tumour in dogs, with some techs reporting as much as 60% of cardiac's tumours owing to being a hemangiosarcoma.
These tumours typically tend to arise on the right atrium or the oracle as it's otherwise sometimes known. Masses may advance into the chamber of the right atrium or appear as a pedunculated mass or even a mass that spans from the inside to the outside walls as you can see from these series images from the left to the right. I'll just get my wand.
Here we go. So essentially you've got here an echocardiogram and you've got a mass therefore entering into the right atrium here and there it is this bulble thing here. You've then also got a pedunculated mass originating from the right atrium or oracle here.
And then this is taken in surgery, so where the pericardium has actually been opened and this right atrial external mass is just popping out from the myocardium. One really interesting fact to note as well is that up to 25% of these patients presented for a hemangiosarcoma, whether that's in the spleen or the heart, about 25% of them will have a mass in both areas. So it's really important when these animals are presented for us, we're looking in both places just to make sure.
And it's uncertain at this time whether or not these masses originate as two primary masses, so completely separate, or whether or not one metastasized from the other. That kind of thing is currently unknown, but it's definitely something worth noting and keeping an eye on as we go through these next slides. Although typically aggressive, the biological behaviour of Hemangiosarcoma can vary depending on primary tumour location.
As certain primary hemangiosarcoma sites, specifically the skin, as you can see here on this top left hand image, these can be associated with a less aggressive disease course and take on a more contained and isolated appearance. The more common visceral forms, however, which we've started to look at are characterised by local infiltration and metastatic dissemination early in the course of disease. Tumours are defined as a high vascularated activity that can lead to irregular diameters, a fragile anatomy, and even a leaky structure which then makes some prime candidates for metastasis or other words spread to the other parts of the body.
Grossly, hemangiosarcoma lesions may be of variable size, pale grey to dark red or purple, soft to gelatinous and friable is often disguised by the surgeons that handle them, and typically contain blood-filled or necrotic areas that can ooze or bleed, which is their main problem for the patient. Because of the commonality and our session theme, we will be looking mainly at patients presenting with this tumour type in the two most common areas, so the viscera and the heart. The patient history and presenting clinical signs will be governed by primary site and may vary from vague, non-specific signs of illness to acute collapse and death secondary to hypovolemic shock.
Many animals with hemangiosarcoma do actually remain clinically normal for a relatively long period of time, even months, during this awful malignant progression. But when questioned, clinical findings include weight loss, hyperexia, abdominal distention, vomiting, exercise intolerance, and maybe even dyspnea. In affected dogs that do not experience life threatening haemorrhage, clinical signs of non-specific lethargy may fluctuate and an episodic pattern related to intermittent hypovolemia associated with acute third space loss may actually be exhibited.
Clinical signs are usually non-specific and therefore depend on the anatomic lesion of the primary tumour, as well as the magnitude and especially the severity of any resultant haemorrhage. Now the majority of patients with visceral hemangiosarcoma will present in an emergent scenario, secondary to tumour rupture. Subsequent internal haemorrhage and resultant hemoabdomen, which is usually not associated with the specific traumatic incident.
Clinical signs include for these animals an acute lethargy, weakness, and collapse which are all secondary to the blood loss. The magnitude and severity of this resultant haemorrhage will then govern the associated clinical signs, which will also include pale mucous membranes, delayed capillary refill time, low blood pressure, tachycardia, cardiac arrhythmias, and poor pulse quality, potentially hypothermia, pain, and addition, tumour rupture can result in abdominal distention, unlike this balance of fluid waves secondary to hemorrhagic effusion. In cases where this haemorrhage is particularly severe, hemodynamic collapse and then sudden death are very probable.
With careful handling, a large space occupier mass may be palpable, and the location of this mass may be identifiable based on the size and position of the where it is within the abdomen. A hemangiosarcoma diagnosis involving visceral organs is often precipitated by sudden life threatening signs related to this hemodynamic collapse and then this following acute non-traumatic organ rupture and consequence hemoabdomen. The secondary emergency presentation is pericardial effusion, which is secondary to cardiac lesion bleed, which is significant, can lead to cardiac tamponade.
The term cardiac tamponade means compression of the heart, and this can occur when there's a buildup of fluid within the pericardial sac that the heart then sits within and is restricted by its normal movement and the ability to fully dilate to allow it to fill correctly and then pump blood around the body. With cardiac changiosarcoma, the mass can bleed into the pericardial sac or even obstruct the closure of the leaflet valves or the internal chamber or cause an obstructured pattern per per se. Patients with cardiac hemangiosarcoma can display malignant arrhythmias, for example, ventricular premature contractions.
They often have muffled heart sounds, venous congestion, obviously descended visible jugular pulses, facial edoema, because of the lack of venous return, hepatic venous congestion with abdominal effusion, which is usually associated with what we think of as heart failure. And other signs of a patient with obvious cardiac disease. So what is considered to be the minimum database needed for assessing these patients when they present to our clinics?
Well, the first thing is rapid assessment of the pack cell volume or PCB as we know it, and with that together the total solids. This is determined just how much oxygen carrying ability the patient has and then consideration for any form of fluid therapy or transfusion. It's also a useful tool for comparing the PCV of the abdominal fluid and see if there's a similar in number or even higher prior to fluid resuscitation.
One important fact to know is that patients which have had a very acute recent bleed and presented collapse may actually have a normal PCV and this is due to the time it takes for the physiological effects of the body to re-perfuse its circulating volume when blood is initially lost from it. By this I mean water or fluids moving back into the circulation to make up for this volume loss. Therefore, it can, if it takes up to an hour for the body to do this, the PC will be normal in the early phase.
We want to do a focused abdominal ultrasonography, otherwise known as an AAT. It's used to determine the presence of fluid, estimate any fluid volume, identify a safe place to sample, and could also with a trained clinician, identify if present there is a mass and where it's actually arising from. We mentioned abdominal centesis.
We need to determine if the fluid within the abdomen is in fact blood, which contributes to potentially a greater need for these interventions. Now then when it comes to blood work, haematology, so a blood smear evaluation, may reveal an anaemia due to the blood loss, and there's certain red cell markers which you may be able to see. So schistocytes, anthocytes, nucleate for red blood cells, and these are associated with micro pathogenic related changes.
There may be vasculitis and acute haemorrhage, which we'll have a look at later on the next slide, and thrombocytopenia due to haemorrhage. Intra-tumoral destruction and coagulopathic consumption are also quite common when seen on your haematology and abnormalities, and it's actually reported up to 90% in nearly all cases. We may do serum biochemistry, which is actually often non-specific, but it may reveal a hypoprotemia due to the blood loss and fluid space movement, hypoalbionmia secondary to this blood loss, azotemia in cases with renal hemangiosarcoma or elevation in liver enzymes because of the pressure being put on the liver from venous return.
Electrolyte disturbances are usually minimal, however, patients with a a lack of oxygen carrying capacity may have increases in lactate which will be addressed with fluid and oxygen. And then it's also important to check for coagulation panels, so elevation of prothrombin time or partial prothromboplastin time, which is secondary to disseminated intravascular coagulation may be seen. And if these patients require blood products or are likely to go to surgery and there's gonna be a high risk of surgical bleed, blood typing should be considered.
I want to show you some of these red blood cell abnormalities which you might see on a smear because it is kind of cool and it's an interesting skill to have to be able to identify these. So, poikilocytosis is basically a fancy word which is otherwise known as red cell abnormalities. And so I wanted to show you these examples as these are classically haematological changes associated with hemangiosarcoma, which you could have the opportunity to see if you examine a blood smear of a case that you might have come into your practise.
So starting with systocytes, these are fragmented red blood cells that can take on various different shapes. They're typically irregular, jagged, and usually have two or more pointed ends on them. The formation of a schistocyte occurs as a result of mechanical damage to the normal red blood cell, which occurs when there's abnormalities within the vessels as it travels through and clots begin to form there.
The formation of fibrin strands and the clot within the vessels causes these red blood cells to get trapped in the fibrin strands, and the sheer force of the blood flow causes the red blood cell to break. Now if you can imagine, a neoplasia of the endothelium is going to be a disorganised array of tissue formation. And so the blood cells that pass through this abnormal vessel matrix can encounter problems trying to negotiate it.
It's especially a problem for red blood cells which are fragile, and so they have the potential to become damaged as they are forced through these neoplastic vessels powered by the patient's circulatory pressure and at the same time get trapped in micro clot formations due to the sluggish flow within these disorganised vessels. So the fragmented bits that you can see here are the systocytes, so these pointy things here. I think of them as being sheared by the neoplastic vessels or result in micro clot formations, and in severe cases can result in a hemolytic anaemia due to the number of cells being damaged.
Next, there's acanthocytes which have an irregular cell membrane. Acanthocytes have sort of coarse, irregularly spaced variable size creatinations as you can see with these cells here. They look a bit like a pointy star.
Now seeing anthocytes on your blood smear can actually be due to a staining and slide drying processing error, mainly by drying the smear too quickly, namely with a hair dryer, for example. But pathologically induced acanthocytes resulted from alterations within the main brain ratio, and this happens due to the ratio of cholesterol to the phospholipids and there being an imbalance. This ratio becomes altered and the membrane becomes pinched and distorted, given it this spiky appearance.
And can happen when patients with liver disease, because of the increased abundance of free cholesterol floating around. So think of patients with a hepatic chemangiosarcoma or those with liver congestion from a cardiac camangiosarcoma. This sort of like rash ratio change also occurs in patients that develop splenic congestion or those with hemolytic anaemia, which could be caused by our neoplastic process as we've just mentioned.
So a likely pattern for our patients' profiles and worth looking for on your blood smear. And then finally, you may see nucleated red blood cells in our hemangiosarcoma patients. Now red blood cells are produced in the bone marrow and they lose their nucleus when they mature and then move from the bone marrow into the circulation.
When nucleated red blood cells are therefore seen within the blood film in sort of largest numbers, it's usually due to there being a high demand for the red cells to be released from the bone marrow too early. So for example, in cases of severe blood loss or anaemia, which in our patients this could be because of tumour haemorrhage or hemolytic anaemia caused by red cell damage or destruction. So this one here is our nucleated red blood cell, it's similar in size, often slightly bigger usually, but you've got like this big fat nucleus sitting within it.
So I just wanted to show you those as they're all pointers which can be seen on your blood film which give you an indication to a potential diagnosis of hemangiosarcoma. And it's pretty cool to see as a nurse if you're doing blood smears in-house. Now the main goals for a patient presented in hypovolemic shock due to the sudden blood loss are to reestablish and maintain effective circulating volume in order to maintain blood pressure, but not only to the core organs which the body naturally does in such situations, which are the brain, the heart, and the lungs, but also to the rest of the body.
And so restoring and maintaining peripheral circulation is in fact a priority. We need to diagnose the hemo abdomen as the cause of blood loss and identify database abnormalities which we looked at in the last slide. And so by restoring blood pressure will aid oxygen carrying capability to the whole body.
However, pack cell volume needs to be assessed as a significantly low PCV will govern the ability to carry oxygen around the body based on red cell actual capacity. The main intervention is to get your minimum databases, secure venous access and administer fluid therapy. Usually as isotonic fluids, which will support the patient in acute phase, but however, we want to remember that these fluids are like quickly lost from the patient's circulating volume and so significant losses may only be transiently supported.
Therefore, blood products would be beneficial in such cases. Baseline blood should be taken prior to initiating IV flow therapies, especially when using shock fluids, because these volumes can cause hemodilution and a falsely low PCV. Further actions thereafter are then taken simultaneously based on the severity of the clinical signs.
And we must always remember to think about provisions making for the patient's welfare. So make sure you're providing analgesia, oxygen, and a warm, comfortable bed or mattress for them to be laying on. We want to be able to help them maintain their ambient core temperature because patients that are cold or shivering will have a higher oxygen consumption and then so therefore all of these things should be actioned as required.
Ultimately, the patient needs to be supported through the crisis if the haemorrhage is limited and not active, and therefore decisions can there be made regarding surgical intervention. So patients that present with pericardial effusion that causes cardiac tamponade are usually collapsed and showing signs of obvious heart failure. Now we've seen that cardiac tamponade results in a decrease in venous return, but also stroke volume, cardiac output, ventricular filling.
Therefore, the body tries to compensate by increasing its heart rate and periphery vascular resistance to help maintain normal blood pressure. As pericardial pressure continues to rise, it causes collapse of the right hand side of the heart, preventing cardiac output into the pulmonary artery. Since blood is no longer leaving the right hand side of the heart, there's no venous return for the left atrium and the ventricle, eventually resulting in cardiogenic shock, manifested by lethargy, hypertension, poor past quality, and tachycardia.
Initial auscultation of these presenting patients is likely to reveal a mus muffled mus muffled heart sound which will preclude the need for further investigation. Starting with a 3 lead ECG can aid the visualisation of any electrical abnormalities and or arrhythmias. These cases you might see small QRS complexes which are quite common, as too is sinus tachycardia, and a really interesting pattern called electrical alternance, which is when the size or the configuration of the QRS complex and occasionally the T wave changes beat to beat.
On this ECG, it may suggest a large volume pericardial effusion resulting from the heart moving back and forth or swinging within the pericardium. You can appreciate that you've got these alternating QRS complexes, so some are high, some are low, but they sort of like swing one to the next. And this is this patient demonstrating this electrical alternism, so by these different heights of the QRS waves.
A focused assessment with sonography in trauma, so FAST of the thorax, otherwise known as a T-fast, or commonly to me in you thoracic ultrasound will help visualise the heart, its chambers, and assess for the presence of fluid within the pericardium, as well as assess for the presence of a mass. As we saw earlier, there's a commonality between visceral and cardiac hemangiosarcomas, and it's useful for patients to be assessed for both forms at the same time. And by this I mean the heart is assessed in the hemo abdomen patient and the cardiac patient has its abdomen checked as well to look for a splenic mass, for example.
I've bracketed here pericardiocentesis, and this is because whilst it's important to establish that the type of effusion present within the pericardium is in fact blood, cytology or pericardial effusions are rarely able to differentiate between neoplastic and idiopathic causes. And so the aetiology of pericardial effusions is actually most commonly determined by echocardiology. It's standard practise for these patients to do the usual baseline bloods for haematology, biochemistry, electrical panel, etc.
Etc. Like what we saw in the previous slides. Importantly, checking coagulation profile is important for these patients again, as it may influence ongoing interventions.
So if you've got a patient with coagularag coagulopathies, then it may be challenging, in order to do further interventions, which we'll talk about in a bit. Here's the image on the bottom left, which we've got here. I hope you can appreciate the borders of the pericardium which are here and round here.
And then you've got the myocardium with the right atrium, right ventricle. So, and this patient has a mass originating from the right atrium. You've got a gap between the myocardium and the pericardium, and that is full of an effusion, and that's how we diagnose a pericardial effusion.
The pericardial effusion volume is actually graded based on an ultrasonal measurement, so between from the border of the pericardium and the the myocardium, and it's graded from small, which is less than 10 millimetres in depth to moderate, which is 10 to 20, and then severe, which is 20 onwards. And the indication therefore for drainage is based on this assessment and the patient's clinical signs. It seems right then that we have a look at pericardiocentesis, which is indicated for these cases which have cardiac tamponade or for those that have moderate to severe pericardial effusion, or those that are experiencing significant clinical signs.
The reduction of pericardial pressure by removing fluid results in greater cardiac output and then a decreasing heart rate, which should improve the overall clinical condition of the affected patient. However, it is important to note that these patients with cardiac haemorrhage due to bleeding hemangiosarcoma, the volume of fusion is often self-limiting because it can only bleed into the pericardial space. So if the patient is not seriously affected, many clinicians will observe the animal's condition and only intervene or do pericardiocentesis if necessary.
However, then, when preparing for pericardiocentesis, our role as nurses include securing venous access and providing sedation and analgesia. Collecting and aseptically preparing the equipment and the surgical site, which will be over the 4th and 5th intercostal space where the cardiac apex beat is palpated. Some texts will suggest positioning the patient in left lateral recumbency for an interventional approach from the right hand side.
However, in my experience, patients can become more distressed being moved into that position rather than gently and more comfortably being left internal. We need to provide Oxman's supplementation by flow by or by mask. And then the clinician will be sterilely prepared and based on the right hand side of the patient, you'll select a suitably sized wide borne needle or catheter which will be attached to an extension set and syringe ready to aspirate.
The needle is usually placed with the age of an ultrasound, and the effusion is drained in one go. And the reason why we choose a wide bore needle, and that's preferably because sometimes the effusion can contain fragments of clotted material which would include a narrow needle, therefore requiring the process to be repeated. It's important that throughout the process, the patient is connected to an ECG which someone keeps an eye on in order to for monitoring of any arrhythmias while the procedure is being performed, which is actually a really critical component to the process as the action of placing a needle close to the myocardium sort of dings it and comes with a risk of inducing ventricular arrhythmias or tachycardia.
Hold on a minute. Let's pause a minute cos we're running away with ourselves a bit. This is Norman, a high five therapy dog, a high fiving, sorry, therapy dog who is apparently an internet sensation.
I found him when I Googled dog's paws when looking for this slide. We've actually painted quite a scary picture so far, and that is nothing untrue regarding our subject title. So far we've seen two types of presentation for canine and hemangiosarcoma, which are pretty scary.
But do remember that some of these patients, as we said a few slides ago, they could have a waxing, waning, . Presentation and just by gentle palpation and abdominal mass is found or through blood work, some of these like biomarkers on the red blood cells are picked up and therefore further imaging is undertaken. However, saying that, hopefully it's OK.
We've got our our presenting patients that have got either a hemoabdomen or a pericardial effusion. They've been stabilised and we've got them through their acute collapse. And now, either way, whether or not we're talking in an acute scenario or a chronic scenario, we need to think of a plan of what we're going to do going forward, regardless of their presentation.
We need to have a look at some of the behaviours of this type of tumour in order to be able to think about what's to be done next. Therefore, right, using the famous words of Matt Hancock, which we heard so much in COVID. Next slide please.
We said earlier that these tumours are nasty, that they are largely aggressive by nature, because they can infiltrate or wrap around sur surrounding local tissues or metastasize through the hematogenous route or via it into cavity implantation after tumour rupture. Now hematogenous metastasis means via the bloodstream. Tumours break off from their primary site and are carried around by the bloodstream to another location where they implant themselves and recoloate, creating metastatic lesions which are equally at risk to bleeding.
Metastatic lesions that have spread via the bloodstream commonly pop up in the liver, the lungs, the heart or spleen, as we said, if not originally from the primary site, and it is interesting fact that in dogs hemangiosarcoma is the most common tumour to metastasize to the brain. There's only one way to find out if it's gone there, and that's with an MRI. What's also not great is that if the primary or meta metastatic lesions bleed out into the cavity of the body, they can too also recolonize as satellite lesions.
In areas such as the omentum, which is the image shown here on the left, so that's the omentum of all of those pin pricks sort of like bubbles, they're metastatic lesions. This can also occur in the peritoneum or pleural cavity, so not a great tumour at all to have, and this is important to bear in mind when it comes to these animals' ongoing management. Although holmangiosarcoma can be presumptively diagnosed based on multiple clinical and physiological findings, presentation, and obviously the patient sigma that we've all talked about and these baseline diagnostic tests, other things can be considered in patients that have a possible hemangiosarcoma, as there are differentials that could be benign or not so aggressive.
Patients which have been presented with a hemo abdomen, they could have been due to a trauma if it hasn't been witnessed just because they're presented for a traumatic reason. They may have had a trauma that wasn't seen by the owner. This may cause a hematoma which has then bled.
Patients which have got significant sepsis and their guts can bleed and things like that and therefore develop a hemoabdomen. They can do that if they've got a clotting disorder and their viscera becomes very highly vascularized and fragile and gets damaged, whether it's through trauma, etc. Things like that.
Some toxins can cause these clotting disorders and other types of neoplasia can cause a hemoabdomen as well. Also with pericardial effusions, so without actually tapping the pericardium, we wouldn't know whether or not the the actual fusion is bloody in origin or a transitate. So it could be due to congestive heart failure.
The mass in there might be a pericardial cyst or a chemodtoma, which is actually a tumour, but it's a benign tumour normally located elsewhere within the myocardium. There's a disease called mesothelioma, which is actually also a cancerous neoplasm, and that occurs within the the pleural pleural cavity, but can also cover the pericardium as well, and that's a tumour of the sort of like lubricating cells in order to keep all these bodily parts moving. The pericardial effusion could be idiopathic, so related to something else, so immune mediated or inflammatory, or with the animals, as we know, can get a bacterial endocarditis which can cause a pericardial effusion or by fungal disease as well.
So essentially what we're saying that if the patient has a mass-like lesion, this does need exploring, but there are other differentials in which we can consider. Definitive diagnosis of hemangiosarcoma requires microscopic identification of tumour cells through cytology or histopathology. The simplest and cheapest and often lowest risk is to try and take a fine needle aspirra of a mass lesion to send off to the lab.
This might seem quite an easy thing to do with a splenic or abdominal mass via ultrasound, but maybe more tricky in a cardiac lesion, especially it's very unlikely to be attempted if the cardiac lesion is within the actual aorta or within the the cardiac space. However, unfortunately, due to the poorly exfoliative nature of these mesenchymal tumours coupled with the hemorrhagic nature of them, fine needle aspiration cytology often produces samples of a low cellularity, which then causes rare identification of these malignant cells because they're contained within too much blood that obscures the sample for interpretation by the pathologist. Cytological examination of hemorrhagic effusions is not typically helpful or diagnostic for hemangiosarcoma because of the low numbers of the neoplastic cells that you actually managed to get mixed up with all these large volumes of blood.
I hope you can appreciate from these series of images here, just get my wand again. So this is a fine needle aspirate sample that's been taken and dropped onto the slide. The clinician's then gonna do an impression smear, and you can appreciate there's a large volume of blood here.
So when it comes to actually then spreading the slide, there's a lot, a lot of blood, and that's really, really difficult to interpret because when it comes to looking at it under the slide, there's just blood. That's all you can see is blood. This isn't necessarily a great example.
Normally there's just sheets of blood with very, very little gaps in between containing any kind of sort of cellular material. Therefore, biopsy can be suggested instead for definitive diagnosis because benign lesions, for example, in a splenic Hemangio hematoma, can have the same clinical presentation similar to a malignant hemangiosarcoma, and in particular be indicated for cases where masses are not located in an organ that can simply be removed, for example, the kidney or the liver. And to be fair, whilst a dog can live without its spleen, if it was a benign, mass lesion, it would very much be a life limiting thing if it was removed and not found to have neoplastic disease.
So we also do need to be mindful, on the other hand, that common things are common, and we saw that earlier in the, in the session that a positive diagnosis results in another anaesthetic if the mass is found to be malignant. So if we've got a patient which has got a a hemoabdomen, 2/3 is likely to be a malignant mass within the spleen, and 2/3 of that is likely to be hemangiosarcoma. So overall, mostly excisional biopsy is elected because of its diagnostic and therapeutic properties.
All resected tissue samples should then be evaluated and sent off for histology, and features of malignancy and immunohemochemistry stained for endothelial biomarkers to definitely confirm the diagnosis in such cases. Makes sense then we have a look at imaging the patient with a suspected hemangiosarcoma, as it's definitely a must. Rarely is it not indicated or impossible to do.
And so providing the patient is stable, albeit significantly unwell in the emergency case, there is a lot to yield from the information that can be gained. In patients without actively bleeding tumours, investigating the extent of disease will help with the decision making when it comes to treatment options. Actively bleeding or fragile tumours are essentially ticking time bombs, and it's in the animal's best interest that bleeding is stopped with the patient needing to go under sur undergo surgery if necessary.
Given that patient signalment does lead toward the older large breed dog, consideration into life expectancy and comorbidities often do come into the discussion when decision making. And so staging these patients to assess for metastatic disease is actually an extremely valuable thing to do, as it gives a whole and clearer picture for everyone to make a decision. Assessment of disease burden, otherwise known as clinical staging can be done in a number of ways based on cost, access and availability.
Radiographs to include a 3 view chest and abdomen will help identify any abnormal structures and potentially metastatic disease as we can see an infiltrative disease in this top image. Echocardiogram will assess for a primary or concurrent or metastatic cardiac lesion. And also, sorry, I'm running ahead of myself.
So wand again, so you can see here, this is this patient's right atrium and then there is all its mass lesion contained within the right atrium and the myocardium going into the actual chamber there. Then we've got ultrasound, and then, so ultrasound will help you with measuring and sampling. You can hopefully see in this image here, got my one again, yep.
You can hopefully see in this image here, this, spleen has sort of a heterogeneous look. So it's all sort of mottled, different colours, and this is due to the weird vasculature that's been formed by the mass, and it's got these cavitated lesions, probably due to internal haemorrhage within the mass signalling a potentially higher risk for further haemorrhage for that patient. So it makes it more of an urgent scenario.
But it is actually advanced imaging modalities, including computed tomography or CT for soft tissue and magnetic resonance imaging, so MRI for cardiac tumours which are staging methods for Hemangiosar, preferably by referral surgeons and oncologists for their integration into routine metastasis screening, surgical planning, and serial re-staging. This can help improve prognostication and patient selection for therapy. See if you can spot them here, and I'll go through them in a second and where they may be in the body.
Specifically, CT and MRI may aid in defining the atomic origin, as to, to be fair, does, echocardiography as well. It helps with the extent of disease for this surgical planning and due to its appearance can help in discriminating between benign and malignant splenic and hepatic lesions and an early detection of pulmonary metastasis because CT is far more sensitive than X-rays. However, saying that now with digital radiography, being able to zoom in and be very specific and enhance the contrast, pulmonary metastasis detection is becoming much more easier for our clinicians.
This also has the advantage when we are using contrast intravenously for CT patients. You can ascertain whether the mass is actively bleeding as you see a flare of contrast material leak into the adjacent pleural, peritoneal pericardial cavities. Sadly, I was looking everywhere for an image to show you that, but I couldn't.
So let's have a look at what these images are. So the first one, let me get my wand. Hopefully you can see that this is a patient's spleen.
It's got this nice taily effect. And this here is actually a cavitated splenic lesion within the tail of the spleen there. Next one up, this is the CT of the thorax, and this is actually its heart.
This big thing here is its cardiac mass. This patient's got it's actually a pleural effusion which is designated by the EFF here, and the compressed central vena cava. So it's supposed to look round like this one here, this one, this vessel here, that's what these circles are.
But the central venous has been completely and utterly well almost being crushed by this mass here. And then finally, this is kind of a bit of a herring for you. Over here, this is a deep soft tissue swelling, another heterogeneous in appearance, and this is actually was diagnosed as a hemangiosarcoma deep within the muscle wall.
OK, to summarise this section, I think the simple X-ray demonstrates really well if you don't go looking, you're not going to know. The image on the left where arrowed is a large mass associated with this patient's spleen. It's quite obvious and it was very likely to have been palpable.
But whether the patient was stable or not, the decision to treat may be based on the metastatic disease infiltrating throughout its lungs. Now by no means am I suggesting that these patients shouldn't be treated absolutely not, nor should they not go to surgery if they're bleeding or have an elective splenectomy if the mass hasn't yet started to haemorrhage, because it will, and this patient can die as a consequence. If this patient was otherwise non-symptomatic, other than the owner noticed it was a bit slower or they thought he'd put on some weight, which was in fact the mass poking out his left hand side of his abdomen, why wouldn't it be a reasonable thing to take this patient to surgery?
I ask you that. He is surely a better surgical candidate than the dog in your clinic with a hemoabdomen with a PCV of 27. I'll leave you to decide.
Not surprisingly, surgery remains the primary method of treatment for hemangiosarcoma, especially in patients which is actively bleeding from the mass. Otherwise, there's this other option other than euthanasia, but we have a couple of slides in a few minutes to discuss palliative options. For splenic hemangiosarcoma, splenectomy is indicated and can be performed with sutures, staples or electrothermal vessel sealant devices.
At the time of splenectomy, the abdomen should be thoroughly explored, and any suspicious lesions which are seen, known as macroscopic lesions, so that, as in you can see them visually rather than with a microscope, they should be looked at and excised and submitted also for histopathology. For solitary hepatic or renal or hemangiosarcoma, liver lobectomy and nephrectomy are indicated retrospectively, providing that patients are stable in generally good condition prior to surgery, they do well, providing, of course, there was no surgical complications as well during the time, and most are home within just a few days of supportive care. I'm sure it comes as no surprise to any of you that given the very high metastatic rate of Hemangiosarcoma, that chemotherapy is indicated in essentially all cases.
With the exception of most purely dermal Hemangiosarcomas which are isolated masses. The literature suggests that doxorubicin has been evaluated in both the adjuvant, which means after surgery, and neoadjuvant before surgery setting, and has been found to be the most effective single agent against hemangiosarcoma. Doxorubicin is often abbreviated to just simply DOX in some protocols.
And so that's how you might see it and used by its drug name, which is just simply an A for anthraccycline, which is its drug classification. Doxorubicin for hemangiosarcoma has been utilised for a number of other anti anti tumour medications, but in the UK the most adopted protocols include doxorubicin as a single agent and doxorubicin containing combination protocols such as doxorubicin and hosphamide, known as the AC protocol, or incristine, doxorubicin, and cyclophosamide called the back. More recently, there is a protocol called doxycycline alternative with dearbazine.
Oh, I can't believe that. I couldn't even say that properly. There is very little in it, but overall the most visceral tumours treated with doxorubicin, average about 8 to 10 months.
And let's take a quick look at one of these studies now. So I wanted to introduce this study of canine visceral hemangiosarcoma, which was treated with surgery alone or surgery in Dr. Rubin, talks about 37 cases between 2005 and 2014, and looks at the prognostic factors of these dogs of a total of 37 dogs over two different hospitals where they were confirmed histologically that they had visceral hemangiosarcoma.
The data looks at patient demographics, tumour characteristics and outcomes, and all of this was abstracted, taken out and looked at and evaluated. Not surprisingly, the most common primary tumour affected was the spleen, however, the primary tumour location had apparently no influence on prognosis. Of this group, 23 dogs were treated with surgery alone, while 14 dogs were treated with surgery and doxorubicin.
The study found that there was a significant, therefore difference between survival times of dogs treated with surgery alone and those treated with surgery followed by doxorubicin. Interestingly enough, the dogs treated just with surgery had a mean survival time of 66 days. And for those of us who aren't necessarily familiar when we look at these kinds of papers, when we talk about a mean survival time, it means all of those dogs within that group, so as in every single individual that was treated just with surgery alone, they averaged out their survival time.
This totaled 666 days, and then when we talk about the meal or average survival time, that was of that group. Now compared to the dogs in the group that were treated with surgery and doxorubicin, of all of those dogs, they had an average survival time of 274 days, which is significantly improved. Therefore, confirming that on average dogs do better with chemotherapy.
It also found that the stage of disease also had an influence on survival, so discounting whether or not they had surgery or surgery on doxorubicin, and dogs with stage one tumours and grouped together had a mean survival time of 196 days. When we talk about stage 1, that means dogs which were presented without a hemo abdomen and without any clinical signs and without metastatic disease. And that was 196 days compared to dogs which are stage 3 which had detectable metastatic disease and were presented with a hemoabdomen.
So a massive difference between those two. Overall, regardless of treatment, when we look at the entire group that were presented, those that were presented had a 1 year survival rate of just 29%. Now everyone's got to admit that that sounds pretty dismal, right?
I guess that if I told you out of all the dogs in the study, interestingly enough, the longest surviving dog was 1,741 days, and that was a dog that had a visceral tumour with stage one disease, and they were treated with surgery and doxorubicin and an incredible 4.5 years of life. Certainly this case was an outliner, as we've seen on the average for all patients with surgery and chemotherapy is around 10 months, that repeating itself is very possible and I'm gonna share something really personal to me very a little bit later.
Traditionally, the prognosis of cardiac hemangiosarcoma is considered poor. Without treatment, most adults could succumb to the disease within 2 weeks. And the rare case where surgical removal of cardiac hemangiosarcoma is possible, survival times generally range from 1 to 3 months or not long at all.
As you can imagine, there are not many surgeons brave enough to excise these tumours, and so the literature is very limited. However, in a small group of dogs receiving adjuvant chemotherapy after surgical tumour removal, an increased survival mean mean survival time of 175 days is reported. We have all seen that pericardectomy via thoracotomy or thoracoscopy can be considered as a palliative measure.
It may not appear to improve survival by itself, but reported mean survival times come anywhere between 2 and 0.7 months to 4 months. Overall, it appears that chemotherapy does appear to offer some benefit as a retrospective study evaluating the use of doxorubicin chemotherapy for dogs with presumptive cardiac hemangiosarcoma, and we say presumptive because as you can imagine, these dogs with tumours inside the heart chamber are not always amenable to biopsy in any form, so diagnosis is based on imaging and signalum.
This study documented a 41% objective response rate, so nearly half the patient's tumours positively responded to the treatment, and overall the group had a mean survival time of 4 months. Again, this was used in Doxorubicin as a chemotherapy treatment of choice. I've included the study here if you want to have a look, as it's laid out really comprehensively and so includes a wide range of what we've talked about today.
One outlining option for our patients that that have hemangiosarcoma is to essentially do nothing or do the bare minimum, and that is a form of what we call metronomic chemotherapy. It is a treatment used in low doses of anti-cancer medications, so anti-cancer drugs, whether or not we're using cyclophosamide or chlorambazil, which is shown to have a positive effect on this type of cancer. Plus or minus used in combination with non-steroidals which have an angio an antiangiogenic effect.
So anti blood. Vessel building effect. This given on a continuous or frequent regular schedule, such as daily or weekly, usually over a very, very long time, also spares the host cells.
So when we think about all the different things that can chemotherapy drugs can do and the problems that it causes to our patients, essentially what it does is we give them the drugs that work and has a positive effect on their cancer, but we're not actually having the negative effects of giving them chemotherapy over a regular period of time. The whole aim of this is to stop the growth of new blood vessels, and that's what the tumours need to grow. And we want to in sort of like create a form of stable disease or slow down progressive disease.
So we end up almost like freeze framing what we have at the moment and therefore these patients learn to live with their cancer in a very mindful way that obviously they still do have cancer, but what we're trying not to do is cure them anymore. So what do these studies say about the use of metronomic chemotherapy for cases of hemangiosarcoma? Well, personally I find it really, really difficult to interpret it.
The evidence is conflicting, some say it's positive, others not so, and so there's a great deal of open to interpretation. The group of papers as a whole are challenging to compare as each of these studies assess different patient groups, some based on their tumour or stage of disease, others bulk together as they include surgical cases or non-surgical cases, patients treated with different chemotherapy drugs, different doses, and so for me, I find them really difficult to compare, but they are certainly interesting when it comes to evaluating the literature. For me, it makes sense that metronomic chemotherapy should have some form of effect on endothelial tumours, as their targeted mechanism of action is to slow down the development of endothelial cell formation, which is generally in all forms of cancer.
So again, jury's out and up to you to decide for what you want to think. If it was me, however, I'd certainly definitely give it a go. So let's have a look at things when we're talking about the palliative sense.
We're gonna have to move into two drugs that are used for cases which have measurable disease. By this I mean cases that are non-surgical or not elected to be surgical by the owner. These cases that might have metastatic disease or being palliatively cared for.
Starting with transamic acid first. So patients with transmic acid is a medication which is used in animals to prevent excessive blood loss from major trauma, significant surgical bleeding, coagulopathies, and tumour haemorrhage. It can be given orally or intravenously for the hospitalised patient, and it is a synthetic analogue of the amino acid lysine and works by stopping or slowing down the body's anti-clot mechanism as part of the normal healing process.
It essentially preserves the fibrinogen fibre matrix of clots, so therefore promoting a homeostatic environment by keeping these clots in place as long as physically possible. Veterinarians have recently been used in tranexamic acid for many hemangiosarcoma patients that have disease in situ and are at risk of a bleed. We use doses in dogs from 15 to 20 milligrammes per metre squared, and that's given every 8 hours or 10 milligrammes per kilogramme IV every 8 hours as a slow intravenous infusion.
There are some adverse reactions, like with mostations, and the most common adverse reaction reported in dogs are nausea, vomiting, and diarrhoea, and these clinical signs appear to be dose dependent but should be addressed with anti-sickness medications. Otherwise patients will become hyperexic and therefore far more sicker. In dogs there has been noted retinal changes reported with prolonged treatment at higher doses and hypersensitivities including dizziness, visual disturbances and thrombosis have been reported in humans.
So we need to look out for those in animals. There are some contraindications, so animals with a history, of course, with an increased risk of thrombosis, so thromboembolism should not be treated with tranexamic acid. Disorders involving renal parenchyma, so hemangiosarcomas, for example, in the renal pelvis are a contraindication to transanic acid.
And this has been found to be highly demonstrated in people, so patients with bleeding, renal hemangiosarcomas should be considered carefully. Now another drugs or drugs group that we use when it comes to hemangiosarcoma, which is often controversial, is complementary therapies. Now we often don't talk about complementary therapies in veterinary medicine, but certainly we do in oncology.
And we need to be more open minded as many people look towards them to support their patient's care, their own care and symptoms associated with the disease. Dogs with angiosarcoma may clinically benefit from alternative complementary therapies, and one in particular is Yin and bio. And it's a commercially available drug, which is a Chinese herbal medicine and has long been used in the eastern countries for its anti-inflammatory, homeostatic wound healing and analgesic properties in people.
It's also been anecdotically used to control breeding in animals in both non-malignant and malignant conditions, including hemangiosarcoma. And there's been preliminary studies to demonstrate that it has an anti coagulant properties for some animals and increase the strength of blood clot formation as measured by thromboestrography. In dogs presented with presumed hemangiosarcoma, Yin and bio can improve postoperative surgical outcomes, but understandably it's still being used with caution with oncologists as it requires future prospective studies to define its role in hemangiosarcoma management.
If you've ever seen the medication, it's actually really interesting. You have these yellow pills that you're supposed to give on alternative days, but if the patient has a suspected bleed, then you give the big red pill, which is kind of like, wow. So if they're sick, you give the red pill, but other than that, you just tick along with every other day of the yellow pills.
Veterinarians are understandably naturally cautious about the whole thing, and there is evidence to suggest that it could work though, so what do you do? At the same time, similar to Yen bio, a PSP extract is a mushroom extract believed to be acting as an immunostimulant and has shown some potential in delay in the onset of abdominal metastasis following following splenectomy in a small pilot study. Although initial results for this kind of mushroom extract are promising, additional and larger prospective studies evaluating its clinical benefit have not yet been published.
The PSP Strat's role in Hermano management therefore remains incompletely defined, but I wanted to drop these two types of drugs or complementary therapies more so in at the end for you to look further into this is the kind of thing that really does interest you. It is, however, worth noting that one of the main reasons why veterinary medicine is slow to embrace so many of these complementary therapies is due to the significant lack of moderating these substances. They're not provided by drug companies or pharmacists, and so the compounds that they contained are not regulated or consistent.
And this makes any sort of like real studies into them very hard to investigate and validate. And so it's something for all of us to bear in mind when we actually consider using them. Well, we have talked so much in the past hour, so I just wanted to give you a couple of references which are really, really important core modern pieces of information.
So using Withrow and McEwan small animal oncology and the commonly treated malignancies in the dog, which are a lot of parts of this lecture which I pulled together in order to create the material for you. In addition to that, we've got some further readings. So some of the studies that we've been talking about as we've gone through, I've quoted, but there's some additional ones here for those of you bookworms that are really, really interested in seeing different things.
Those of you that might have patience or your own animals, which sadly have encountered the diagnosis of Hemangiosarcoma, which gives you a little bit of further reading and all just look through. One final thing though. I need to share with you a patient who is very, very, very important to me.
His name is Dexter. He is our case study because everything isn't always a bleeding nightmare when it comes to hemangiosarcoma. He was an 8 year old neutered male Labrador presented to our ECC department with an acute hemoabdomen in November 2015.
Yes, a long time ago, but I'm giving you that outliner which we talked about before. He had a confirmed splenic mass with his hemoabdomen. But he had no evidence of metastasis, and so he was diseased stage one.
He had a splenectomy and of course looking at the 2/3 rules, most splenetic masses are malignant, and 2/3 of those malignant masses are hemangiosarcoma. So bad luck for poor Dexter. However, We then look at our treatment options when it comes to him.
Concurrently, nothing has changed, like in 2015 to where we are now, 2022, moving into 23. Our treatment options would do nothing. Paul Dexter's not going to live very, very long if he doesn't have a splenectomy, but thankfully his owners went with that.
So he had a splenectomy. Surgery would give him 2 to 3 months, as what we've seen by the paper that we demonstrated earlier, and most of these papers give us the same kind of study results. Surgery plus chemo gives us around 10 months depending on what kind of formula or recipe we use.
And he doesn't have metastatic disease, so therefore it has no influence, so it's a really, really good thing for him. Importantly, there's no gold standard chemotherapy, but we do know doxorubicin works really, really well. So, so, doxorubicin, doxycycline, Doxorubicin, I'm getting all confused.
So, single agent doxorubicin, or we can have single agent doxorubicin combined with cyclophosphamide. Which is called the AC protocol. He can go for the VAC, so we can give him lots of different drugs that we all know could work really well.
So doxorubicin, crophosamide and cristine, or we can do this new cool thing which there's not a lot of patients included in those studies, which is the Dacarbazine and Doxorubicin study. Or what we can do, because he's got just stage one disease, we can consider metronomic chemotherapy. So, cyclophosphamide and ferrocoi.
So, an anti-anergenic, pain relief medication, which also has anti-anergenic properties. So what did you think our owner decided to do? Well, our owners were actually very, very committed.
They wanted to do everything for Dexter. He was a lovely dog and believe me, the reason why he sticks with me because he was such a good dog. So he had his splendent hemangiosarcoma via splenectomy and hemoabdomen on the 14th of November 2015.
The owners decided it took them a little bit of a while to think about it, but they went through two cycles of the vac, so vincristine, doxorubicin, and cyclophosphamide. The first one went absolutely OK, but sadly enough, the second one, he had a grade 4 neutropenia, which means he had a significant lack of circulating white blood cells in order to protect him, and that happened over the Christmas period, which was really, really unfortunate. We all know that the way that our lives go and things that, you know, everyone's got all these different commitments, but when it comes to Christmas, nobody wants that kind of thing to be happening.
Sadly, Dexter had to be hospitalised over the Christmas period at his referring veterinary surgeon due to this neutropenia. He was anorexic and he had gastrointestinal signs as well, so he was really quite a sick boy. This had a significant strain on the patient, so he had just gone through just 2 cycles, so even though he had 6 doses of chemotherapy, he was significantly sick and so he needed a plan B.
What the clinicians decided to do with consultation with the owner is that we removed the vincristine from the cycle. So we've we've seen already that one of the possibilities when we talk about chemotherapy with these animals is just to downgrade it slightly and so he changed to just AC, so doxorubicin and cyclophosphamide. He started that again come February once they had had time to recover, he'd had time to recover and do better.
He again received two cycles, but unfortunately by the time it came to February, he was also experiencing neutropenias again. We looked at that and then by the time he had got his doxorubicin number 4, so the second of the second cycles, he actually needed to have a reduced dose. So we're now starting to lean back on the amount of chemotherapy we need to give him in order to make his white cell count acceptable.
By the time it came to his 5th doxorubicin, so he had 2 in the first cycle with the back and then 2 in the second, and then the 3rd, then when it came into his just AC protocol, he was really sick. This dog was really, really nauseous, uncomfortable, anorexic. He had a poor response to anti-nausea medication, he didn't want to do things, and this had a significant effect not just on him but also his owner.
His owner loved his Labrador. We all know that Labradors eat. They all want to go out and they want to play, but unfortunately, Dexter was a really, really unhappy dog.
So what do we do with Dexter? This is definitely not the end of the road for Dexter when it comes to his chemotherapy because his owners still want to do everything. He's responded really well.
He's in the lucky category, isn't he? So he did have a hemo abdomen, but he's got no metastatic disease. So what we're going to do is we're just going to change him to metronomic chemotherapy.
He's had 5 doses of Doxorubicin, which is anything between 4 and 6 doses when we talk about how much to give them originally for their adjuvant chemotherapy. So he just has cyclophosphamide and the furocoi. So in the sense of the word, so he's had all of the chemotherapy in order to try and mop up any potential microscopic disease that's floating around him, and now we're just going to go to the metronomic side of things.
Interestingly enough, the next year, so bearing in mind this dog was diagnosed in November 2015, when we re-scanned him, he had no signs of recurrent disease on his CT scan in July 2016. We re-scanned him again in, so a whole year later, and we checked him just to see whether or not he had metastatic disease again, and he didn't. So we were like, shall we recheck him for his metronomic therapy, his quality of life is good.
And then we re-scanned him again. So we're now talking 18 months later in June 2017, and he's got an improved quality of life. He's got no disease on his CT, so he's stopped his metronomic chemotherapy.
Now that sounds like some kind of weird strange miracle. Is this dog one of these outliners? My recent update, and I'm saddened to say that I don't have anything more recent because actually I love this dog so much.
He came in, he took his neck up when we were taking his blood samples off of him. He put his paw out when we went to give him his chemotherapy despite him obviously feeling quite sick. So I I went up to his update for 2019 because that is what this study for me or what my follow up needed to be.
And the last time I checked on him with his referring vet was the 17th of October 2019, and the update from his referring vet was this dog was still very much alive. He is very well, but he needed some new move and some GABA because and some tramadol because he actually had osteoarthritis. And so he was still ongoing.
Now we need to think back that this dog was originally diagnosed in November 2015, so we are talking nearly 4 years later. He had a meningiosarcoma. It was bleeding.
He was presented it as a hemoabdomen. He had a few rounds of chemotherapy. Yes, he went all whack out there.
Or was it because he was so sensitive to the chemotherapy? His cancer was so sensitive to the chemotherapy, and that's why this dog did so well. Who knows?
Who knows? But there are some of these patients that makes it not just a bleeding nightmare, but an actually really, really highly invested thing to do for these cases. So my final slide, 10 minutes over because there's so much to talk about.
So hemangiosarcoma is, in summary, a neoplasm of mesenchymal stem cells. It's a horrible thing. It's mostly associated with large breed or unknown aetiology, so we don't know how or why it happens.
It can present as an emergency, and treatment requires surgical excision. Or chemotherapy and sadly the prognosis is around 10 months, but there's a lot of value in that 10 months because these patients, if you catch them early enough, you recover them enough, you support them well enough, and you treat them like with dignity and respect and openness with the owners, you can have some of these outliners like Dexter. Thank you everyone for listening.
I hope you understand that, yes, hemangiosarcoma is a bleeding nightmare, but it is very, very much worth it. Thank you. So if you've got any questions, any queries, you're interested in oncology nursing, oncology medicine, then my email address is at the bottom, so feel free to contact me.
Anything that's come up within the session, or if you're interested in seeing what it's like to be an oncology nurse, then please do get in contact. And finally, I just want to say thank you again for the webinar vet who are a fantastic company to collaborate with and I really, really enjoy working with. So thank you very much and I hope to see you all here again.
Bye bye.
