Postoperative Adjuvant Treatment of Invasive Malignant Mammary Gland Tumors in Dogs with Doxorubicin and Docetaxel
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J Vet Intern Med 2006;20:1184–1190 Postoperative Adjuvant Treatment of Invasive Malignant Mammary Gland Tumors in Dogs with Doxorubicin and Docetaxel Daniela Simon, Dorina Schoenrock, Wolfgang Baumga¨rtner, and Ingo Nolte Background: Treatment outcome after surgery alone is unsatisfactory in dogs with invasive malignant mammary gland tumors. Hypothesis: Adjuvant doxorubicin or docetaxel will improve the treatment outcome in dogs with high-risk malignant mammary gland tumors, and the use of docetaxel will be feasible in affected dogs. Animals: Thirty-one dogs with malignant mammary gland tumors of histologic stages II and III (vascular or lymphatic invasion, regional lymph node metastasis, or distant metastasis) were used. Methods: A prospective clinical trial in which dogs were treated with surgery alone (n 5 19) or also received adjuvant chemotherapy (n 5 12) with doxorubicin or docetaxel was conducted. Docetaxel was given as an IV infusion at a dose of 30 mg/m2 preceded by dexamethasone and diphenhydramine administration. Results: The recurrence-free interval ranged from 13 to 2,585 days (median not reached); the median metastasis-free interval and overall survival were 294 days and 370 days, respectively. Dogs treated with chemotherapy had a tendency toward higher long-term local control and survival rates, but there was no significant difference in the recurrence-free interval (P 5 .17), time to metastasis (P 5 .71), and overall survival (P 5 .12). Factors found to influence the time to metastasis and overall survival included lymph node metastasis (P 5 .009) and tumor fixation to underlying structures (P 5 .043, time to metastasis), as well as age (P 5 .018) and histologic stage (P , .001, survival). Mild allergic skin reactions were the most frequently observed complications of docetaxel treatment. Conclusions and Clinical Importance: Chemotherapy did not lead to an improved outcome in this population. Docetaxel treatment was well tolerated. Additional investigations of adjuvant chemotherapy in dogs with high-risk mammary cancer are warranted. Key words: Cancer; Canine; Chemotherapy; Mammary carcinoma; Prognosis. ammary tumors are among most frequent tumor efficacy, therefore, are of importance in dogs with high- M types in female dogs.1,2 Because of the protective risk mammary cancer. effect of early neutering, the incidence of canine Preclinical studies have documented the antitumor mammary tumors has decreased markedly in the United activity of doxorubicin and carboplatin in canine States,2,3 however, mammary tumors still are frequently malignant mammary tumor cultures and of cyclophos- encountered in unspayed female dogs, especially in phamide, cisplatin, and 5-fluoruracil in canine mamma- Europe.4–7 ry tumor xenografts in severe combined immunodefi- Surgical excision alone yields unsatisfactory results in ciency mice.10,11 Adjuvant chemotherapy is routinely dogs with malignant mammary tumors exhibiting used in women with breast cancer, however, only limited lymphatic or vascular invasion because these tumors information is available on the efficacy of postoperative have high rates of recurrence and metastasis.8,9 It has chemotherapy in dogs. been revealed that within a 2-year period after surgical Recently, a veterinary study was reported in which excision, dogs with invasive mammary tumors have a 13- adjuvant chemotherapy with 5-fluoruracil and cyclo- fold increased risk of recurrence as compared to those phosphamide improved patient survival in comparison with noninvasive disease.8 The development of adjuvant to dogs treated with surgery alone.12 Also, the efficacy of treatments and the investigation of their antineoplastic doxorubicin chemotherapy for inducing partial remis- sions of pulmonary metastases in dogs with mammary tumors has been documented in case reports.13,14 From the Department of Small Animal Medicine and Surgery In human medicine, the anthracycline doxorubicin is (Simon, Schoenrock, Nolte), and Department for Pathology one of the most effective and frequently used chemo- (Baumga¨rtner), University of Veterinary Medicine, Hannover, therapeutic agents in first-line adjuvant treatment of Germany. Presented in part at the 19th Annual Veterinary Cancer mammary carcinoma.15,16 The taxanes are inhibitors of Society Conference, Woods Hole, MA, November 13–16, 1999, and 17 the 14th European College of Veterinary Internal Medicine- microtubule disassembly that result in mitotic arrest. Companion Animals Congress, Barcelona, Spain, September 9–11, Paclitaxel and docetaxel have established efficacy in the 18 2004, and published as an abstract in J Vet Intern Med 2004;18:790– treatment of mammary tumors in humans. Docetaxel 791. has been approved for the treatment of metastatic breast Reprint requests: Daniela Simon, Dr.med.vet. Dipl., ECVIM-CA cancer since 1996, and there is increasing evidence for its (Internal Medicine & Oncology), Department of Small Animal beneficial effect in the treatment of early mammary Medicine and Surgery, University of Veterinary Medicine Hannover, carcinoma.18–21 Taxanes, however, are not routinely used Bischofsholer Damm 15, D-30173 Hannover, Germany; e-mail: in veterinary oncology. One report describes the in- [email protected]. duction of partial remissions in 2 dogs with macroscopic Submitted January 4, 2006; Revised February 24, 2006; Accepted March 28, 2006. mammary tumors after treatment with paclitaxel, but the overall toxicity was high.22 To the authors’ Copyright E 2006 by the American College of Veterinary Internal Medicine knowledge, docetaxel has not been used for the 0891-6640/06/2005-0019/$3.00/0 treatment of tumors in dogs. The dose of 30 mg/m2 Chemotherapy in Canine Malignant Mammary Tumors 1185 used in this study was derived from preclinical studies in Follow-Up Examinations Beagle dogs.17 In these studies, the highest nonlethal Follow-up examinations were scheduled at 6 weeks and 3, 6, 9, 2 toxic dose was found to be 30 mg/m IV. Dose-limiting 12, 18, 24, and 48 months after completion of chemotherapy in toxicity in these preclinical studies was gastrointestinal groups II and III. Dogs in the control group were scheduled for re- and hemotologic in nature. examination at the same time points after surgery. Follow-up The aim of this study was to investigate the efficacy of examination included physical examination, CBC, serum bio- adjuvant, postoperative doxorubicin and docetaxel chemistry profile, and thoracic radiographs. If indicated by treatment in dogs with high-risk, invasive malignant abnormalities on physical examination, blood work or radio- mammary tumors in comparison to surgery alone. In graphs, an abdominal ultrasound, an ECG, and an echocardio- addition, it was the aim of this study to document gram were performed. Local recurrence was defined as a recurrent tolerance and toxicity of docetaxel in dogs with cancer. mass at the surgery site with confirmation by cytology or histology in cases in which owners gave their consent. In cases in which cytologic or histologic confirmation was not possible, any mass Materials and Methods developing at the surgery site was considered a recurrence. Patient Inclusion Criteria Cytologic examination, histologic examination, or both of meta- static lesions was performed if possible. Postmortem examination Dogs with mammary tumors were eligible for the study if they was performed in cases in which owners gave their consent. fulfilled the following criteria: (1) surgical excision of the mammary tumors by radical mastectomy or partial mastectomy, depending on Statistical Analysis tumor number and distribution in the mammary chain, (2) a clinical tumor stage I–IV (see the Appendix),23 (3) histologic confirmation of Endpoints that were evaluated included local recurrence, distant malignancy in at least 1 tumor, and (4) histologic confirmation of at metastasis, and overall survival. The recurrence-free interval was least 1 malignant stage II or III tumor (see the Appendix).8 defined as the time from surgery to tumor recurrence in the surgical Additional inclusion criteria were no chemotherapy or radiation field. The metastasis-free interval was defined as the time from therapy before the study, no other serious medical illness that would surgery to the detection of distant metastasis as documented on limit full compliance with the study, and signed owner consent. thoracic radiographs, abdominal ultrasound, or both. Overall survival was defined as time from surgery to death from any cause. Pretreatment Evaluation Kaplan-Meier product limit analysis was used for recurrence- free interval, metastasis-free interval, and overall survival analyses. Dogs underwent complete clinical staging consisting of patient Dogs were censored if their tumor had not recurred (recurrence- history, physical examination, documentation of tumor size and free interval analysis) or no distant metastases had been detected characteristics, CBC, serum biochemistry profile, thoracic radio- (metastasis-free interval analysis) at time of death or data accrual graphs (right and left lateral, ventrodorsal), abdominal radiographs closure. (lateral), abdominal ultrasound, ECG, and an echocardiogram, if In the survival analysis, dogs were censored if they were alive at indicated. Mammary tumors and regional lymph nodes were the time of data accrual closure. In those dogs in which measured directly with calipers or by ultrasonographic imaging. postmortem examination was not performed, determination of whether the cause of death was tumor-related