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4Th October 2008 Surgical Oncology

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4Th October 2008 Surgical Oncology Association of Veterinary Soft Tissue Surgeons Autumn Scientific Meeting 3rd – 4th October 2008 Surgical Oncology The AVSTS would like to thank the following sponsors for generously supporting this meeting: PROGRAMME FRIDAY 3rd OCTOBER 9.00­9.30 Registration & Coffee 9.30‐10.15 Surgical Oncology – What Is It and Where Is It Going? Nick Bacon 10.15‐11.00 Surgical Margins and Getting the Pathologist to Nick Bacon & Evaluate Them. Tim Scase 11.00‐11.30 Grading Soft Tissue Sarcomas and Mast Cell Tumours Tim Scase – why Pathologists keep changing the systems. 11.30­12.00 Coffee 12.00‐12.30 Soft Tissue Sarcomas – Anything New Worth Nick Bacon Knowing? 12.30‐1.00 Soft Tissue Sarcomas – Anything Else Worth Jonathan Bray Knowing? 1.00­2.00 Lunch 2.00‐2.45 Radiation Therapy for Soft Tissue Sarcomas: Susan North What Radiotherapists need to know from the Surgeons, Challenging locations and Outcomes of Incomplete Resection with Post‐ Operative Radiotherapy 2.45‐3.15 Soft Tissue Sarcoma Panel Discussion: Nick Bacon, Susan North, Jonathan Bray 3.15­3.45 Tea 3.45‐4.30 Canine Histiocytic Disorders: an Immunological and Steven Baines Oncological Perspective. 4.30‐4.45 Discussion 4.45‐6.00 AVSTS Committee meeting 6.00­7.00 Tour of Castle Caves 7.30­8.00 Drinks (in Bar) 8.00 Dinner SATURDAY 4th OCTOBER 9.30­10.00 Coffee 10.00‐10.30 Mast Cell Tumours – Anything New Worth Knowing? Nick Bacon 10.30‐11.00 Chemotherapy, New Molecular Targets for Diagnosis Richard Elders and Therapy in Mast Cell Tumours 11.00‐11.15 Discussion 11.15­11.45 Coffee 11.45‐12.30 Maxillofacial Tumours in Humans Andy Burns 12.30­1.30 Lunch 1.30 Abstracts Session: 1.30‐1.45 Intra‐ and Post‐ Operative Electrochemotherapy Ron Lowe (ECT) in the Management of Canine and Feline Tumours 1.45‐2.00 Janos Butinar Reconstruction of Major Dorsal Nasal Defect induced by Intranasal Radiation with a Forehead Transposition Flap 2.00‐2.30 Use of Intra‐Pleural Chemotherapy for Management Ana Lara of Malignant Pleural Effusion 2.45­3.15 Tea 3.15‐3.45 Urinary Bladder and Urethral Tumours Nick Bacon 3.45‐4.15 Options for Prostatic Carcinoma Henry L’Eplattenier 4.15‐4.30 Discussion 2 CONTENTS Page Surgical Oncology – What Is It and Where Is It Going? Nick Bacon 4 A Suregon’s Perspective on Margins Nick Bacon 11 Surgical Margins and Getting the Pathologist to Evaluate Tim Scase 15 Them: The Pathologist’s View Grading Soft Tissue Sarcomas and Mast Cell Tumours – Tim Scase 19 why Pathologists keep changing the systems. Soft Tissue Sarcomas – Anything New Worth Knowing? Nick Bacon 24 Soft Tissue Sarcomas – Anything Else Worth Knowing? Jonathan Bray 29 Radiation Therapy for Soft Tissue Sarcomas: Susan North 30 What Radiotherapists need to know from the Surgeons, Challenging locations and Outcomes of Incomplete Resection with Post‐Operative Radiotherapy Histiocytes, Histiocytoses and Dendritic Cells: Stephen Baines 35 A Review of the Histiocytic Diseases of the Dog Intra‐ and Post‐ Operative Electrochemotherapy (ECT) in Ron Lowe 56 the Management of Canine and Feline Tumours Reconstruction of Major Dorsal Nasal Defect induced by Janos Butinar 60 Intranasal Radiation with a Forehead Transposition Flap Mast Cell Tumours – Anything New Worth Knowing? Nick Bacon 61 Chemotherapy, New Molecular Targets for Diagnosis and Richard Elders 66 Therapy in Mast Cell Tumours Use of Intra‐Pleural Chemotherapy for Management of Ana Lara 70 Malignant Pleural Effusion Urinary Bladder and Urethral Tumours Nick Bacon 75 Treatment Options for Prostatic Carcinoma (PCA) Henry L’Eplattenier 81 3 What is Surgical Oncology and Where is it Going?? Nicholas Bacon MA VetMB CertVR CertSAS DipECVS MRCVS European Specialist in Small Animal Surgery Secretary of Veterinary Society of Surgical Oncology University of Florida Assistant Professor of Small Animal Surgery It is a fact that 60% of human patients who are presently cured from cancer are cured by surgical resection alone and it is likely that the figure in veterinary patients is similar. In humans there are 2 broad but distinct groups of oncologic surgeons: the generalist, and the anatomic‐site‐specific. The general surgical oncologists are able to operate on most solid tumours, and have minimal experience or practice in benign disease. Those that are anatomic site specific retain the right to treat patients with complex benign disorders related to their area of interest, e.g. orthopaedic or musculoskeletal oncologists, who will treat an array of benign bony pathologies such as bone cysts, or osteomata. In humans, the perceived trend is towards growth of the latter group; however, generalists will likely persist given the nature and needs of health‐care globally. Veterinary surgeons are familiar with the concept of general surgery and so veterinary surgeons with an interest in surgical oncology are typically involved in general oncologic surgery (benign and malignant) as the case load and client expectations do not require anatomic‐specific specialists. There is no formally recognised subspecialty in veterinary surgical oncology (as there is in medical and radiation oncology), despite over 50% of companion animals over 10 years old dying of cancer. This figure does not include those that are cured of cancer, or those that have cancer, but die from a co‐existing disease. Potential for surgical oncology training is improving with certificates, diplomas, and residencies in surgery and post‐residency fellowships in surgical oncology growing in number and opportunity but it is important to combine any training with exposure to radiation and medical oncology – major advances in these fields are dramatically changing the face of cancer treatment and the role of surgery. Cancers considered unresectable with curative intent may be brought to potentially curable surgical resection with neo‐adjuvant strategies. Likewise long‐term outcome for patients following local cure of a solid tumour can be significantly improved with appropriate adjuvant strategies. The founding father of human surgical oncology in the UK was Dr Stanford Cade. In 1940 he wrote: “Successful treatment depends on three main factors: a sound knowledge of the disease; a wise selection of the method of treatment; and accurate and skilful technique.” 4 Knowledge of the oncologic condition, rather than simply knowledge of how to perform a surgical procedure is vitally important to successfully manage oncology cases and advise clients. Many people hold the belief that surgical oncology is becoming ever more aggressive and the patient and client considerations are becoming less important – people worry that ‘because we can’ is replacing ‘whether we should’. This may seem true in some select cases, but what is most likely happening is that through better pre‐operative planning, there is an improved understanding of the behaviour and distribution of the tumour, and so ‘big’ surgeries are being performed to effect a cure, where previously surgery would have been less aggressive and more likely to be incomplete. These larger surgeries are supported by improvements in pain management, anaesthesia, availability of blood products, and better understanding of adjunctive therapies. At the same time, there is a growing body of research to challenge previous surgical dogmas about veterinary surgical oncology. An example is the rule concerning 3cm margins, which results in many patients being over‐treated by having large resections for low‐grade masses with small tumour volumes. In the future it is likely many patients will receive significantly LESS surgery than historically, with the same outcome in terms of local control. Second to an improved understanding of tumour behaviour is the role of adjuvant therapies. Whenever and wherever possible multimodality cancer therapy needs to be considered. Not only does this include medical, surgical or radiation therapies, but also immunotherapy and potentially investigational therapies, such as veterinary clinical trials. If possible, cases should be presented regularly between members of the team – all members of the group will learn something from discussion of the treatment options. Some of these discussions may be with the client present in an attempt to identify the right path for them and their family. The surgeon must have sufficient skill to succeed at the goal of surgery – typically to achieve local control of the tumour and to reduce the incidence of local recurrence to as low a level as possible. As much information as possible should be gained on local, regional or distant spread, in particular draining lymph node involvement and pulmonary metastasis. The surgeon must also ensure all of this is achieved with an acceptable quality of life, which leads to the last consideration of surgical oncology ‐ “when not to operate”. Many scenarios exist. Possibilities include: 1. Surgery resulting in significant residual local disease with insufficient benefit to the patient 2. Significant co‐morbidities existing, which are a higher priority than the tumour 3. Surgery itself is associated with severe or grave morbidity, subjectively worse than the symptoms of cancer 4. The patient is not expected to be discharged from the hospital, regardless of surgical outcome 5. Owner wishes hugely exceed realistic expectations 6. Owner wishes supersede patient’s best interests 5 These principles can be applied to something as simple as a lipoma. There are five reasonable scenarios to remove a lipoma – • rapid growth; • change of texture/feel; • owner concern; • causing clinical signs due to physical presence; • dog bothering the mass. If at least one of these is satisfied, the surgeon is justified operating on the patient. It goes without saying that surgeons’ wishes do not feature on any of these lists, but sometimes surgeons’ wishes are thinly disguised as something else, especially if it is a surgery you are ‘desperate’ to try, or feel would be a suitable challenge. An appreciation of tumour biology helps create a clear understanding of biopsy techniques and principles.
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