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Practical Oncology Soft Tissue Sarcomas

Practical Oncology Soft Tissue Sarcomas. Wendy Blount, DVM. Soft Tissue Sarcomas. Locally invasive, but slow to metastasize Fibrosarcoma (FSA) Hemangiopericytoma (HPA) Nerve sheath tumor, Schwannoma Leiomyosarcoma (LMSA) Spindle cell tumor Liposarcoma (LPSA)

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Practical Oncology Soft Tissue Sarcomas

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  1. Practical OncologySoft Tissue Sarcomas Wendy Blount, DVM

  2. Soft Tissue Sarcomas • Locally invasive, but slow to metastasize • Fibrosarcoma (FSA) • Hemangiopericytoma (HPA) • Nerve sheath tumor, Schwannoma • Leiomyosarcoma (LMSA) • Spindle cell tumor • Liposarcoma (LPSA) • Different from infiltrative lipoma • Myxosarcoma (MXSA) • Pleomorphic Undifferentiated Sarcoma (PUS) • Aka malignant fibrous histiocytoma (MFHA)

  3. Soft Tissue Sarcomas • A few behave differently – not included here • Hemangiosarcoma (HSA) • Lymphangiosarcoma • Rhabdomyosarcoma • Soft tissue osteosarcoma • Synovial cell sarcoma

  4. Soft Tissue Sarcomas • Often extend beyond the visible mass • Microscopic tendrils • know what you have before you excise • FNA all masses except SGA prior to excision • Send out for cytologic evaluation if necessary • Not enough experience • Not enough time • Can be difficult to distinguish from fibroplasia, especially if inflammatory • Send stained and unstained – Giemsa stain is superior for some features • Take a quick look to make sure you have adequate cells other then RBC

  5. Diagnosis • Often cytological diagnosis is “sarcoma” • May need histopathology for definitive diagnosis • Excision biopsy (“en bloc” excision) is best for diagnosis • If unresectable, may need to get incisional biopsy • Best excision for large mass is done after CT scan • If dirty margins, re-excise or radiation therapy (if histopath indicates radiation)

  6. Cytology

  7. Cytology • Wispy cytoplasm with streaming tails

  8. Cytology • Wispy cytoplasm with streaming tails • Occasional binucleate cell • Round to oval nuclei, inconspicuous nucleoli

  9. Kristina Lemm– Houston TX Shawn Penn – Lufkin TX

  10. Cytology • Wispy cytoplasm with streaming tails • Occasional binucleate cell • Round to oval nuclei, inconspicuous nucleoli

  11. Cytology • Wispy cytoplasm with streaming tails • Occasional binucleate cell • Round to oval nuclei, inconspicuous nucleoli • Cells in whorls, rare mitotic figures • Hemangiopericytoma

  12. Cytology

  13. Cytology • Blunt ended nuclei, indistinct cell borders • Parallel alignment

  14. Cytology • Blunt ended nuclei, indistinct cell borders • Parallel alignment • Variation in cell and nucleus size

  15. Cytology • Blunt ended nuclei, indistinct cell borders • Parallel alignment • Variation in cell and nucleus size • Intranuclear inclusions • Leiomyosarcoma

  16. Cytology • Spindle shaped cells with minimal cytoplasm • Oval nuclei

  17. Cytology • Spindle shaped cells with minimal cytoplasm • Oval nuclei • Characteristics of malignancy • Fibrosarcoma

  18. Cytology • Anaplastic Sarcoma

  19. Cytology • Fibroma

  20. Cytology

  21. Cytology

  22. Cytology • Individual polyhedral cells with basophilic foamy cytoplasm • Round to oval nuclei with prominent nucleoli

  23. Cytology • Individual polyhedral cells with basophilic foamy cytoplasm • Round to oval nuclei with prominent nucleoli • Characteristics of malignancy • Liposarcoma

  24. Cytology • Non-staining, large ballooning cytoplasm • Collapsed cells with scan, lacy cytoplasm • Peripherally compressed nuclei • Lipoma or Infiltrative Lipoma • Well differentiated liposarcoma

  25. Cytology • Well differentiated fusiform & stellate cells

  26. Cytology • Well differentiated fusiform & stellate cells • Low cellularity with granular background

  27. Cytology • Well differentiated fusiform & stellate cells • Low cellularity with granular background • Occasional multinucleate cells • Mucin stains with Alcian blue stain • Myxosarcoma

  28. Cytology • Large multinucleate cells • Spindle/mesenchymal cells

  29. Cytology • Large multinucleate cells • Spindle/mesenchymal cells • Histiocyte-like round cells

  30. Cytology • Large multinucleate cells • Spindle/mesenchymal cells • Histiocyte-like round cells

  31. Cytology • Large multinucleate cells • Spindle/mesenchymal cells • Histiocyte-like round cells • Malignant Fibrous Histiocytoma • Pleomorphic Undifferentiated Sarcoma

  32. Surgery • The mainstay of treatment for STSA • 3 cm lateral borders to visible mass • 1 fascia layer deep to visible mass • May appear to be encapsulated, but are not • Pseudocapsule made up of tumor cells • Still respect the border rules • “shelling out” results in recurrence

  33. Radiation • If histopath indicates likely radiation responsiveness • STSA not terribly radiation responsive unless high MI • 20-30% response rate for gross disease • Results in long disease free interval when post-surgical disease is microscopic • 4-5 years • For tumors that can not be adequately re-excised • Taking more tissue not possible • Dirty borders after re-excision

  34. Radiation • For tumors that are too large for “en bloc” excision • Neoadjuvant therapy • Palliative therapy • Shrink tumor • Pain control • When margins are “clean but close” • When concurrent condition precludes anesthesia or surgery • Coagulopathy (VWDz, hemophilia) • Renal failure • Radiation may not be better, as it requires multiple sedations

  35. Radiation • For limb sparing tumor treatment when post-amputation mobility difficulties expected • Response rate for radiation alone is poor when compared to radiation + surgery • When you have hemangiopericytoma Chemotherapy • STSA tend to be chemotherapy unresponsive

  36. Prognosis • Local control is usually curative • Staging is a low yield procedure, but indicated prior to starting extensive or expensive treatment • 3 views thoracic radiographs • Aspirate draining lymph nodes • (maybe abdominal US)

  37. Prognosis • Local control is usually curative • Staging is a low yield procedure, but indicated prior to starting extensive or expensive treatment • 3 views thoracic radiographs • Aspirate draining lymph nodes • (maybe abdominal US)

  38. FISS Update • Feline Sarcoma • Vaccine Associated Sarcoma (VAS) • Vaccine Associated Fibrosarcoma • Vaxosarcoma • Feline Injection Site Sarcoma Emerged in the mid 1980’s

  39. FISS Update Usually a fibrosarcoma but can also be • PUS • Rhabdomyosarcoma • Mast cell tumor • Soft tissue osteosarcoma • Liposarcoma • Chondrosarcoma • Undifferentiated sarcoma

  40. FISS Update Relationship between FISS and chronic inflammatory responses following • trauma or injections, including vaccination • some long-acting medications • even foreign materials such as suture and microchips Incidence varies widely between 1 per 1000 and 1 per 16,000 vaccinated cats.

  41. FISS Update • In cats younger than typical fibrosarcoma • Adjuvant and foreign bodies found within the tumors • Site specific, correlating with common injection sites • More aggressive behavior than the typical fibrosarcoma • Some but not all are associated with feline sarcoma virus (FeSV) infection

  42. FISS Update • Especially FeLV and rabies vaccines • When local laws began requiring rabies vaccination in cats, incidence of FISS increased • FeLV is deadly and infects cats at 1-2% of well cats • Rabies is rare but is deadly to people • THEORY • More appropriate extended feline vaccination protocols should help • Vaccination annually with Purevax should be better than triennially with an adjuvanted vaccine Merial Purevax has been out for more than 10 years

  43. FISS Update • Virbac Pharmacovigilance project (Europe) • Adverse event reports 2000-2009 • McGahie, 2012 (WSAVA) • FISS has a possible relationship with recombinant subunit FeLV vaccine as well • FISS rate 1 per 500,000 vaccinations • No such relationship found for the Purevax rabies vaccine

  44. FISS Update Diagnosis • Post-vaccination granulomas are common • If they fail to resolve within 3-4 weeks, if they grow at all after the first week, or if they are larger than 2 cm, they should be removed for histopath • Treated like other soft tissue sarcomas at this point • 3 cm borders • One fascia layer deep

  45. FISS Update Treatment • If FISS is confirmed, treatment should be prompt and aggressive • Consider referral for more surgery • CT scan prior to surgery • Wide, wide margins • Possible radiation and/or chemo depending on tumor site and histopath report • Neoadjuvant therapy for large masses

  46. FISS Update Prognosis • Median survival variable, but can be more than 2 years with surgery alone (average age 6 years) • Almost 4 years survival with surgery and radiation • Prognosis is worse if bone is invaded and the tumor can not be removed by bilateral trapezius muscle excision • Distant metastasis is rare, but it makes prognosis worse • 84% of those treated with neoadjuvant epirubicin were alive at 6 years • Less aggressive tumors were selected for therapy • 10% died of chemo induced renal failure

  47. FISS Update FISS Client Handout

  48. Acknowledgements • Philip J. Bergman, DVM, MS, PhD, DACVIM (Oncology)VIN Consultant, CMOfficer BrightHeart Vet Centers • Louis-Philippe de Lorimier, DVM, ACVIM (Oncology)VIN Consultant, Univ Ill Urbana-Champaign • Karri A. Meleo, DVM, ACVIM (Oncology), ACVRVIN Consultant, Vet Oncol Serv, Edmonds, WA • Mark Rishniw, BVSc, MS, ACVIM (SAIM), ACVIM (Cardiology)VIN Consultant, Clin Res Coord, Ithaca, NY • Kurt R. Verkest, BVSc, BVBiol, MACVSc (Small Animal)VIN Associate Editor, Univ Queensland, Australia

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