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Stacy Santoro Binstock DVM, DACVIM (Oncology)
Cat cancer: from kitty nose(s) to kitty toe(s)

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What is cancer?
- Abnormal cell growth
Bening vs. malignant
Bening tumors more closely resemble normal tissue
Sometimes orderly progression
Bening -> premalignant -> malignant
- Invades into surrounding tissue
- Potential to spread

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Language of cancer
- Benign/malignant
- Grade
Degree of malignancy
How abnormal are the cells
Predictive biologic behavior
-Stage
Spread throughout the body -> metastasis
Regional
Distant
-TNM
GRADE: DESCRIPTION
1: Small, uniform cells, tightly packed
2: Varied cell sizes and shapes, loosely packed
3: Increased cell size and shape irregularity, less distinction between cells
4: Large, irregular, fused cells
5: Irregular, fused cells that have invaded surrounding connective tissue cells

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How does cancer spread?
- Lymphatics
Regional LNs
Carcinomas
- Blood
Distant organs
Sarcomas
- Does not correlate with size
Anal gland adenocarcinoma

How cancer spreads
Primary cancer
Local invasion
Angiogenesis-tumors grow their own blood vessels
Lymph vessel
Metastasis - cells invade other parts of the body via blood vessels and lymph vessels
https://www.cancervic.org.au/cancer-information/cancer-types/advanced-cancer

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Some are good, some are bad
- Age of animal
- Size of tumor
- Presence of metastasis
- Low grade vs. high grade
- Lymphoma in cats
- Small cell - good
- Large cell - bad
- Some are more treatable
- Lymphoma

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Why are cats special?
- Different than dogs
- Less predictable response to treatment
- How they handle treatment
- Immune response
VAS
- Administration of drug

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Symptoms
- Weight loss
- Hyporexia/anorexia
- Vomiting/diarrhea
- Finding a lump

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Treatment
- Surgery
Mainstay of treatment for solid tumors
- Chemotherapy
High risk tumors
EX: high-grade mammary tumor
Lymphoma
Preserve QOL
- Radiation therapy
Local tumor control
- Definitive vs. palliative

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Things to consider
- Type of cancer
- Location
- Grade
- Stage
- Metastasis

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Supporting the cat with cancer
- Pain management
- Appetite
Diet
Medications
Mirtazapine, Entyce, steroids
Feeding tube
-Symptom management
EX: antibiotics for oral SCC
- Instruct owners what to look for at home
"ANOTHER PILL? GIVE IT TO THE DOG."

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Squamous cell carcinoma

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SCC
- Most common oral tumor in cats
- Risk factors
Flea collars
Canned food (fish)
Cigarette smoke
p53 mutation

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SCC
-Biologic behavior
- Grow quickly
- Locally extensive
Including invasion of bone
Often ulcerated with secondary inflammation/infection
- Metastasis uncommon
10-30%
Incidence truly unknown d/t poor long term outcome
- Paraneoplastic syndromes rarely occur
Hypercalcemia (rare)
www.veterinarypracticenews.com/why-clean-margins-are-crucial-in-feline-oral-scc/

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SCC
- Clinical signs
Excessive salivation
Weight loss
Halitosis
Dysphagia
Bloody discharge
Facial swelling
Loose teeth
Thickened/prominent jaw

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SCC
- Diagnostics
FNA or biopsy
Lymph node cytology
Thoracic radiographs
CT scan

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SCC
- Treatment
- Surgery
- Chemotherapy
Palladia
Metronomic chemotherapy
- Radiation therapy
Palliative protocol
May be combined with chemotherapy as radiation (carboplatin, gemcitabine)
Benefit short-lived
< 3-4 months

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SCC
- Palliative therapy is the mainstay of treatment
Pain management
NSAIDS
Opioids
Magic mouthwash
Acupuncture
Antibiotics
-Prognosis grave
< 10% at 1 year

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Nasal tumors
https://www.animage.com/case-studies.php

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Nasal tumors
- > 90% malignant
- Symptoms
Facial swelling
Epistaxis/discharge
Sneezing
Loud breathing
Often present for months prior to DX
Temporary improvement with antibiotics, steroids
-DDX: rhinitis, foreign body, polyp, infection

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Nasal tumors
- Lymphoma is most common
Majority are B cell origin
- Other tumor types
Carcinoma
Sarcoma
Round cell tumor

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Example of two fairly typical cytologies for a cat that has a nasal tumor

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Diagnostics
- CT scan
Turbinate destruction
Deviated septum
Unilateral
Soft tissue density (mass vs. fluid)
Bony destruction
Cribriform plate

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Se: 3/3
Im: 45/78
Ax S4.0
Acc.
2008 Dec 08
Aca Trn 12:51:34.822989
reconMatrix=512
512 X 512
STD+
120.0 KV
115.0 mA
3.0 mm/0.0:1
Tilt: 0.0
1.0s
Lin:DCM / Lin:DCM / Id: ID
W:350 L:90
DFOV: 11.6 x 11.6cm

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Diagnostics cont'd
- +/- Coagulation panel
- Cytology or biopsy
Trans nasal, retroflex, flush, FNA external swelling
- Thoracic radiographs
- Lymph node cytology
- CT scan

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Nasal LSA
- Multi-modality therapy best
Up to 20% develop distant disease
CHOP + definitive XRT = MST 955 days
- Radiation therapy
High response rate (70-90%)
Prognosis better with higher total dose
Palliative = MST 432 days
Negative prognostic indicators: cribriform destruction, total dose of XRT, response
- Chemo (CHOP) = MST 749 days if CR

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Other nasal tumors
- Carcinoma
- Others - sarcomas, round cell tumors
- Treatment
Radiation therapy
Chemotherapy
Carboplatin/doxorubicin
Palliative care

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Palliative XRT
- 86% clinical improvement
- Median survival 432 d.
- Side effects
Acute
Mucositis
Chronic
Cataract, ocular atrophpy, osteochondroma

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Mast cell tumors

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MCTS
- 3 syndromes
Cutaneous
Visceral
Spleen
Gastrointestinal
- Express KIT
- Granules may contain serotonin

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Cutaneous
-Clinical appearance
Small
Fleshy
Hairless
- Staging
Regional LN cytology
AUS
Spleen
- Remove with narrow margin

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Splenic MCTs
- Clinical signs
Weight loss
Anorexia
- 30% concurrent skin lesions
AUS
- 35% mastocytemia
- ~50% + buffy coat

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Splenic MCTS
- Splenectomy
Improves outcome
MST reported from 390-856 days
Better vs. no surgery
- Chemotherapy
Suggestion that it prolongs life

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GI
- Clinical signs
V/D/anorexia
- AUS
Intestinal mass, enlarged Lns, effusion,etc.
Often located in small intestine
Eccentric, hypoechoic mass
-Treatment
Surgery if no evidence of metastasis
Chemotherapy
Metastasis, after removal
Vet Radiol Ultrasound. 2011 May-Jun;52(3):330-4. doi: 10.1111/j.1740-8261.2010.01792.x. Epub 2011 Jan 4. Ultrasonography of intestinal mast cell tumors in the cat. Laurenson MP1, Skorupski KA, Moore PF, Zwingenberger AL.

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GI
- Prognosis historically poor
<2 months reported
Sclerosing MCT
- New study showed more promising outcome
Variety of treatments
Surgery, sx + chemo, chemo, steroids
Median survival time of 2+ years

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Gastrointestinal lymphoma

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Gastrointestinal lymphoma
- Advanced age
- FeLV -
- Siamese/oriental breeds
- Chronic inflammation/IBD
- SI, stomach, Ll/colon

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Diagnostics
- Lab work
+/- FeLV/FIV
- Abdominal radiographs
- Ultrasound
Loss of layering
Excellent predictive value
Thickening
Lymphadenopathy
Free fluid
U/S guided aspirates

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Cytology vs. biopsy
- Biopsy for small cell lymphoma
- Lymphoblastic lymphoma diagnosis via cytology
Aspirating an abdominal mass

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Types of GI LSA
Low grade
- Indolent
- Lymphocytic/small cell
- "Normal" AUS
Thickened GIT
- Diagnosis:
Histopathology
PARR
- 10% progress to high grade

High grade
- Acute
- Lymphoblastic/large cell
- AUS changes
Mass
Wall thickening/loss of layering
- Cytologic DX

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Gl lymphoblastic LSA
- Not surgical
Typically only if obstructed
Consider if discrete lesion
MST 417 days (12-2962 days) Gouldin ED et all, Vco June 2017
- Symptom management
Antiemetics
B12
Appetite stimulants
Anti-diarrheal medications
+/- Pain management, probiotics

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Gl lymphoblastic LSA - treatment
- CHOP based protocol (UW 25)
50-85% response rate
Survival 4-6 months
Depends on response
Can be years if CR
15-20% of cats
- CCNU
50% response rate

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Small cell GI LSA - treatment
- Chemotherapy
Prednisolone
Chlorambucil
Daily/EOD, pulse
Lifelong
Response rate 85-95%
Response to tx can take weeks
Excellent prognosis
Years

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Chemo considerations
- Chemotherapy side effects
Anorexia
Vomiting
Diarrhea
Perforation
17%
Febrile neutropenia
Difficult to differentiate between disease and toxicity

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Mammary gland tumors (MGTS)

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MGTS
- Risk factors
Advanced age
Breed
Siamese
Hormonal association
No benefit if OHE >24 months
- Nearly always malignant (85-98%)
Need for cytology?
- High likelihood of metastasis

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MGT
- Staging
CXR
+/-AUS
- Record size before removal
<2cm, 2-3cm, >3cm

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Male MGT
- Mean age 12.8years
- 36% history of progestin therapy
Adrenal cortical mass reported in one cat
- Median time to local recurrence 310 d(127-1363d)
45% of cat
- Median ST 344 d(14-2135d)
- Tumor size & lymphatic invasion negative prognostic indicators
J Vet Intern Med. 2005 Jan-Feb;19(1):52-5. Clinical characteristics of mammary carcinoma in male cats. Skorupski KA1, Overley B, Shofer FS, Goldschmidt MH, Miller CA, Sørenmo KU.

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MGT prognostic factors
- Extent of surgery
Bilateral radical mastectomy MST 917d
Unilateral mastectomy MST 348 d
Regional mastectomy MST 428 d
Local recurrence up to 50%
- Size
<2cm MST 3years
2-3cm MST ~ 2years
>3cm MST ~ 6months(4-12 mo)
- Lymphatic or vascular invasion
Without MST 863 d vs 195 d with
- Lymph node metastasis
<9 months
- Grade

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Figure 4. Kaplan-Meier curves and their calculated linear slopes of survival period for 18/37 cats subgrouped by diameter of excised mammary adenocarcinomas (P = 0.0706).
Feline mammary adenocarcinoma: tumor size as a prognostic indicator Can Vet J. 2002 Jan;43(1):33-37.

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Chemotherapy
- No good studies to prove efficacy
Suggestion/trend in several
Ex: Unilateral radical mastectomy +/- dox: MST 1998 v 414 d
- Recommended in high risk tumors
Large size, lymphatic invasion, lymph node metastasis, high grade
- Doxorubicin +/- Cytoxan
Up to 50% response rate reported in gross disease setting
Mitoxantrone, carboplatin, Palladia

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Tarsal LSA
- Older age
- FeLV-
- Non-epitheliotrophic
- High grade
- Popliteal LN metastasis in -20%
- Have or develop distant disease
- MST 190d
J Am Vet Med Assoc. 2014 Jun 15;244(12):1429-34. doi: 10.2460/javma.244.12.1429. Cutaneous lymphoma of the tarsus in cats: 23 cases (2000-2012). Burr HD1, Keating JH, Clifford CA, Burgess KE.

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Lung-digit syndrome
- Primary lung tumors
Carcinomas
- Metastasis to digits
Single or multiple digits
Skin, muscle, bones, eyes
- Clinical signs
Lameness
Swelling of digit(s)
- Diagnostics
CXR
Limb radiographs
Extensive bony lysis
Blood work
Elevated CK
-MST < 2 months

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What to do at your practice
- Cancer is treatable in some cases
Cats can live with cancer
- 80% of cats tolerate treatment with no problems
- Establish a diagnosis
Don't wait!
Cytology
Easy, inexpensive, fast, minimally invasive

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What to do at your practice
- Biopsy
Establish a diagnosis if cytology is not diagnostic
Not for LSA
Use info to make a treatment plan
VAS
- Imaging
Thoracic radiographs, ultrasound - know what is indicated for which tumor
CXR for VAS
AUS for lymphoma
- Discuss goals with owners

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Questions?