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Outcome and Clinical, Pathological, and Immunohistochemical Factors

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Outcome and Clinical, Pathological, and Immunohistochemical Factors Small Animals Outcome and clinical, pathological, and immunohistochemical factors associated with prognosis for dogs with early-stage anal sac adenocarcinoma treated with surgery alone: 34 cases (2002–2013) Katherine A. Skorupski DVM OBJECTIVE To determine survival time and metastatic rate for dogs with early-stage Christina N. Alarcón DVM anal sac adenocarcinoma (ASACA) treated with surgery alone and assess Louis-Philippe de Lorimier DVM whether specific clinical, pathological, or immunohistochemical factors Elise E. B. LaDouceur DVM were predictive of outcome for those dogs. Carlos O. Rodriguez DVM, PhD DESIGN Retrospective case series. Robert B. Rebhun DVM, PhD From the Departments of Veterinary Surgical and ANIMALS Radiological Sciences (Skorupski, Rodriguez, Rebhun) 34 dogs with early-stage, nonmetastatic ASACA that were treated with and Veterinary Pathology, Microbiology, and Immunol- surgery only. ogy (Alarcón, LaDouceur), School of Veterinary Medi- cine, University of California-Davis, Davis, CA 95616; PROCEDURES and the Centre Vétérinaire Rive-Sud, 7415 Taschereau Medical record databases of 2 referral hospitals were searched to identify Blvd, Brossard, QC J4Y 1A2, Canada (de Lorimier). Dr. Alarcón’s present address is Biomedical Sciences dogs examined between 2002 and 2013 that had a diagnosis of nonmeta- Program, University of California-San Diego, La Jolla, static ASACA that was < 3.2 cm at its largest diameter. Only dogs that CA 92093. Dr. LaDouceur’s present address is Joint received surgical treatment alone were included in the study. For each dog, Pathology Center, 606 Stephen Sitter Ave, Silver information extracted from the medical record included signalment, clini- Spring, MD 20910. Dr. Rodriguez’s present address is Vista Veterinary Specialists, 7425 Greenhaven Dr, Sac- cal and diagnostic test findings, tumor characteristics, and outcome. When ramento, CA 95831. available, archived tumor specimens were histologically reviewed and tumor characteristics were described; Ki-67 and E-cadherin expressions were Address correspondence to Dr. Skorupski (kskorups@ ucdavis.edu). evaluated by use of immunohistochemical methods. Clinical, pathological, and immunohistochemical factors were assessed for associations with sur- vival time and tumor recurrence and metastasis rates. RESULTS Median survival time was 1,237 days. Seven dogs had tumor recurrence and 9 dogs developed metastatic disease at a median of 354 and 589 days, re- spectively, after primary tumor removal. Cellular pleomorphism was posi- tively associated with development of metastatic disease. No other factors evaluated were associated with outcome. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated dogs with early-stage nonmetastatic ASACA generally had a favorable outcome following surgical removal of the primary tumor alone. Routine rectal examination may be a simple and useful method for detec- tion of dogs with early-stage ASACA. (J Am Vet Med Assoc 2018;253:84–91) n dogs, ASACA is an aggressive malignancy with disease is diagnosed during its later stages; however, Ireported metastatic rates that range from 46% to those studies included dogs treated with both local 96%.1–4 Generally, metastasis initially develops in the and systemic therapies. The metastatic rate and sur- lymph nodes that drain the sublumbar region and vival time for dogs with early-stage ASACA following then progresses cranially over time to the spleen, surgical treatment alone are unknown, and the value liver, lungs, and other organs.1–5 Approximately 25% of adjuvant therapy in those dogs is also unclear. of dogs with ASACA develop paraneoplastic hyper- Tumor size is associated with outcome for dogs calcemia, which has a negative effect on prognosis.6 with ASACA.6,7 In 1 study,6 the median survival time Results of some studies6,7 suggest that dogs in which was 584 days for dogs with tumors < 10 cm2, com- ASACA is diagnosed during the early stages of the dis- pared with 292 days for dogs with tumors ≥ 10 cm2; ease have a better prognosis than dogs in which the however, dogs with metastatic disease at the time of surgery were not excluded from that analysis, and ABBREVIATIONS treatment regimens varied among dogs. Investigators ASACA Anal sac adenocarcinoma of another study7 also reported that tumor size was TTP Time to progression negatively associated with survival time and advocat- 84 JAVMA • Vol 253 • No. 1 • July 1, 2018 Small Animals ed use of a staging system in which a cutoff of 2.5 cm Sud in Québec, Canada, were searched to identify in diameter for a primary tumor was a central deter- dogs examined between 2002 and 2013 that had a minant in a patient management algorithm. histologically confirmed diagnosis of ASACA with a The effect of lymph node metastasis on progno- primary tumor < 3.2 cm at its largest diameter (equiv- sis for dogs with ASACA is less clear. In 1 study,6 the alent to a tumor area of < 10 cm2) and that underwent median survival time did not differ between dogs curative-intent surgery to remove the tumor with no with and without iliac lymphadenopathy, but those additional treatment. Dogs included in the study also findings were likely confounded by the fact that dogs had to have no evidence of metastasis detected dur- with lymphadenopathy were more likely to receive ing staging tests. Dogs that received additional treat- chemotherapy than dogs without lymphadenopathy. ment of any kind after a documented recurrence of In another study,7 lymph node metastasis had a sig- ASACA or development of metastatic disease were nificant negative effect on survival time, and the in- included in the study. Dogs that had bilateral ASACA; vestigators of that study proposed a staging system that underwent radiation therapy, chemotherapy, or in which nodal metastasis was categorized as absent, targeted therapy in the immediate postoperative pe- present with lymph nodes < 4.5 cm in diameter, or riod; or that had insufficient follow-up information present with lymph nodes > 4.5 cm in diameter. In available for assessment of postoperative outcome that study,7 the median survival time for dogs with were excluded from the study. primary tumors < 2.5 cm in diameter and no lymph node metastasis was 1,205 days. In yet another study,8 Medical records review there was a significant negative association between For each dog enrolled in the study, data extracted lymph node metastasis and outcome for dogs with from the medical record included signalment, tumor ASACA. However, all 3 studies6–8 were limited by the size and location, staging test results, presence or fact that treatment regimens were not standardized absence of hypercalcemia, and outcome, including and varied among individual dogs. information regarding local recurrence, metastasis, Histologic and immunohistochemical charac- death, and cause of death when available. Referring teristics have also been evaluated as prognostic in- veterinarians and clients were contacted as necessary dicators of tumor behavior and outcome in dogs to collect follow-up information. with ASACA. In 1 study,9 the risk of ASACA-related death was greater for dogs with tumors with a solid Histologic and immunohistochemical or partly solid histologic pattern than for dogs with review of tumor specimens tumors with rosette or tubular-type patterns. Ki-67, Available archived tumor specimens that were a nuclear marker of cellular proliferation, was iden- prepared with H&E stain for histologic examination tified in ASACA tumor cells for a proportion of the were reviewed by 2 veterinary pathologists (CAN and dogs of that study,9 but its association with clinical or EEBL). For each tumor, the predominant (> 50% of the outcome data was not evaluated. In another study,10 tumor) histologic pattern was characterized as solid, abnormally decreased expression of E-cadherin, a rosette, or tubular. The extent of cellular pleomor- transmembrane protein that mediates cell-cell and phism (ie, variability in cell [anisocytosis] or nuclear cell-matrix interactions, was associated with a poor [anisokaryosis] size) was categorized as mild (< 25% prognosis for dogs with various stages of ASACA that of cells with anisocytosis or anisokaryosis), moderate received various treatments. To our knowledge, the (25% to 75% of cells with anisocytosis or anisokaryo- relationship between specific cellular proliferation sis), or marked (> 75% of cells with anisocytosis or an- indices and the clinical behavior or outcome for dogs isokaryosis). The number of mitotic figures for ten 40X with ASACA has not been evaluated. fields (ie, 10 hpf) was evaluated by each pathologist, Although previous studies6–10 have described out- and the mean was calculated and used for analysis un- come and prognostic factors for dogs with ASACA, less the counts for the 2 pathologists differed by > 5, none have controlled for stage of the disease at the in which case a consensus count was performed. The time of diagnosis or treatment. The purpose of the extent of necrosis within the tumor was categorized study reported here was to determine the survival as < 10%, 10% to 25%, > 25% to 50%, or > 50%. The time and tumor recurrence and metastatic rates for extent of mineralization within the tumor was catego- dogs with early-stage ASACA that were treated with rized as 0% (absent), 1% to < 10%, 10% to < 25%, 25% surgery alone and assess whether specific clinical, to < 50%, or ≥ 50%. Desmoplasia was categorized as pathological, or immunohistochemical factors were minimal (sparse within the tumor), mild (occasional predictive of outcome for that population. to frequent within the tumor), moderate (within the tumor and adjacent connective tissue), or severe (with- Materials and Methods in the tumor and all adjacent connective tissues). In- tratumoral inflammation was categorized as minimal Case selection criteria (rare small clusters or scattered leukocytes), mild (oc- The electronic medical record databases of the casional small clusters or scattered leukocytes), mod- Veterinary Medical Teaching Hospital at the Univer- erate (frequent small clusters or scattered leukocytes), sity of California-Davis and Centre Vétérinaire Rive- or severe (frequent large clusters to sheets of leuko- JAVMA • Vol 253 • No.
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