Presentation on theme: "Surgical treatment of vaginal leiomyosarcoma in a mixed breed dog"— Presentation transcript:
1Surgical treatment of vaginal leiomyosarcoma in a mixed breed dog Lisa BensonCornell UniversityCollege of Veterinary MedicineClass of 20144/16/14
2History 11 year old FS Mixed Breed Dog Presenting Complaint: Mass of the ColonTenesmus x 2 weeks: 3 Days LactuloseRapid GrowthCough x 2 weeksProgressive Right Hind Limb LamenessBilateral Hind Limb Lameness - Chronic
3History 11 year old FS Mixed Breed Dog Presenting Complaint: Mass of the ColonTenesmus x 2 weeks: 3 Days LactuloseRapid GrowthCough x 2 weeksProgressive Right Hind Limb LamenessBilateral Hind Limb Lameness - Chronic
4Physical exam: Abnormalities Very NervousSensitive Hind Limbs/Caudal TrunkRight Hind Limb Lameness: Lateral ExtensionLeft Hind Limb: Firm, Movable Subcutaneous MassDigital Rectal PalpationHard, Bony Mass: Left Ventral Pelvic CanalFirm, Rounded Mass: Right Ventrolateral Pelvic CanalComplete ObstructionPainful hindlimbs and caudal trunk—indications. RHL Extension, cranio laterally extended during sitting and recumbency, and SWINGS leg laterally during ambulation
5Problem list Chronic, Mild Bilateral Hind Limb Lameness: Lifetime Mass – Pelvic CanalProgressive Right Hind Limb LamenessTenesmusCoughLeft Hind Limb Subcutaneous Mass
6Problem list Mass – Pelvic Canal Tenesmus Progressive Right Hind Limb LamenessCough (?)Left Hind Limb Subcutaneous Mass (?)
7Differential diagnoses BroadPelvic Mass Differential DiagnosisTumor or Abscess Arising from the Following:1. Rectum2. Vagina3. Urethra4. Bony Pelvis
8Diagnostics Bloodwork: Complete Blood Count/Blood Chemistry: UnremarkableImaging: Full Body CT ScanThoraxAbdomenPelvic CanalProximal Hind limbs
15CT Scan: Findings Thorax and Abdomen: Negative for Metastasis Pelvis: Large Mass – Sciatic n. CompressionVaginal Origin – Not ColonIncidental:Left Hind limb Mass: LipomaHip and Shoulder Osteoarthritis - MildBIG PICTURE: LARGE VAGINAL MASS, Likely cause of RH lameness but not her cough. Thorax/Abd: Negative for Mets—Cough no longer big concern—dry heat latelyPelvis: LARGE mass, Inability to defecate attributed to massleft dorsal compression of rectum = Hard bony “mass” left ventral rectum = I really palpated ischium.Ventral displacement of Urethra.Mass Continuous w vagina and unlikely to be arising from rectum.RHL pain was possibly due to Sciatic N. compressionLHL SQ mass determined to be a lipoma (Neg for Neoplasia)Osteoarthritis: explains the chronic mild lameness owners noted for most of her lifeHip OA was MILD and UNLIKELY cause of RHL pain
16Differential diagnoses Vaginal Mass: Neoplasia vs. InflammationNeoplasiaBenign: LeiomyomaMalignant: LeiomyosarcomaInflammation: Stump PyometraLess Likely: 10.5 years post SpayNo Signs of Ovarian Remnant
17Leiomyoma vs leiomyosarcoma Smooth Muscle Tumors: GI more common locationLack of Vaginal Cases and Information2.4% - 3% of ALL Canine Tumors are from Reproductive System83% Benign (Leiomyoma Most Common)Intact FemalesSometimes metastatic, and if excision was incomplete = indication for RT. We don’t have data on the impact on survival with adjuvant therapy. “The impact of adjuvant radiation or chemotherapy on outcome is unknown.”
18Leiomyoma vs leiomyosarcoma Leiomyosarcomas – Hormonally IndependentComplete Excision (Vaginal): CurativeModerate Risk Metastasis/RecurrenceImpact of Adjuvant Radiation/Chemotherapy:Outcome on Survival UnknownSometimes metastatic, and if excision was incomplete = indication for RT. We don’t have data on the impact on survival with adjuvant therapy. “The impact of adjuvant radiation or chemotherapy on outcome is unknown.”
19plan Surgery: Mass Excision Episiotomy +/- Abdominal Exploratory Pubic OsteotomyPartial VaginectomyHistopathology for Definitive Diagnosis
20Surgery: Neuroanatomy Pudendal n.Pelvic n.Perineal n.Hypogastric n.Pelvic PlexusOrientation: Cranial; Caudal; Bladder; Desc Colon; Vagina.Hypogastric N. Cranial= sympathetic innervation of the bladder- On LATERAL SURFACE OF RECTUMPelvic Plexus ON LATERAL SURFACE OF RECTUM comes off of the Pelvic n- (axons SC S1-S3): innervation of bladder, rectum, Urethra (ext sphincters); genitalia.pudendal n. comes off of pelvic plexus moving caudally—Perineal n and a branches off of pudendal n which branches off of the pelvic NERVE (not plexus)Our main concern: Avoid damaging these nerves. Closely associated with the area we’ll be dissecting, to excise the mass completely—potential for permanent urinary incontinence, rectal incontinence (lesser concern?).Also: Risk of perforated bowel: descending colon or rectum may perforate, cause sepsis with anaerobic bacteria. (pre-operative (24 hrs in advance) started oral Clindamycin, continued perioperatively and post operatively IV. Plus TGH oral x 2 weeks.(Evans, de LaHunta)
21Surgery: EpisiotomyOrientation: Dorsal, Ventral. Standard episiotomy - Full thickness incision. attempt to access tumor and remove it. (Less invasive)
22surgery Mass Orange Catheter: Vaginal Canal White Catheter: Urethral PapillaPalpated mass in vaginal canal– too cranial to remove it via episiotomy.
23Surgery: Abdominal Colon Random Loop of Intestine Uterine Remnant Orient - Pulled bladder caudally; Find uterine remnant and mass. See that a pelvic approach necessary –it’s smack in the middle of the pelvic canal---Osteotomy!Urinary Bladder
24Surgery: Mass located Mass Pubic Symphysis Pulled bladder cranially—urethra, palpable mass continues deep to Pubic SymphysisPubic Symphysis
25Surgery: pubic osteotomy Cleared Pubic Bone: Transected Adductor mm and Gracilis mm with cautery at point of origin along pubic symphysis. Point out holes drilled for orthopedic wire to close pelvis later—22 gauge. Three transections— 2 cranial to caudal cuts: 1 in right and 1 in left arm of pubis, then a transection perpendicular and CRANIAL to the first two . Protected obturator n with miller sens when drilling.
26Surgery: Mass Excision Pubic symphysis flipped caudally—See OBTURATOR MUSCLE on inside of the bone, we left intact.Mass easier to visualiize and dissect away from tissues—CAREFUL OF NERVES
27SURgery: Mass Excision Pelvic PlexusMass within vaginal wall. NERVES: Pelvic Plexus —innervating bladder, rectum, urethra. Pudendal n from pelvic n innervating external urethral sphincter. Hypogastric n, sympathetic nerves also along lateral wall of the rectum too—MUST DELICATELY DISSECT AWAY MASS, dissect Vagina off rectum. –incontinence Risk. Compressed (by mass) for a long time!
28Surgery: Vaginal Wall Reflected Vaginal Wall reflected—see mass
29Surgery: Mass Excision Orient Cranial and Caudal: Almost out!
30Surgery: Dissect Carefully Last remnant of attachment to vaginal wall. Vaginal tissue thin, compromised. Partial vaginectomy. Total vaginectomy was not necessary—--avoid possible harm to nerves.
31Surgery: repair osteotomy Closed pubic bones with 22 gauge orthopedic wire placed into the predrilled holes- circlage technique to stabilize bony pelvis. Reattached gracilis and adductor muscles. Closed vagina where we’d opened it to get the mass out—mass was attached to dorsal wall. Closed the dorsal (and ventral ) defects of vaginal wall– continuous 3-0 PDS. Repaired 2 cm area of compromised rectal serosa w/3-0 PDS (mass compression). THEN STANDARD ABDOMINAL closure after warm abdominal lavage. SUMITTED TISSUE TO PATHOLOGY…
32Surgery: Mass RemovedSUBMITTED FOR HISTOPATHOLOGY!
33histopathologyPALE ISCHEMIC CHANGES (clear spaces BLACK ARROW)) and inflammation: segmented neutrophils (more cellular areas: BLUE ARROW). Loss of cellular and nuclear detail. Small areas of necrosis, hemorrhage, inflammation.
34histopathologyThis slide highlights the disorganization and irregular orientation of neoplastic cells. Smooth Muscle tumors are disorganized , interacting at odd angles. Aniscokaryosis: Nuclei changing from normal cigar shaped nuclei to circular. This tissue is not “calm enough” to be a leiomyoma, though it is acting more ”well-behaved” than some leiomyosarcomas/malignant tumors.
35Histopathology: Leiomyosarcoma Blue Arrow: Mitotic Figure. Originally this report was read out as 1-2 MFs per 10 HPF, but reviewed it again and it was more like 3-4 per 10 HPF. –Mild but more than typical leiomyoma. Acting more like a leioMYOMA, but d/t necrosis, inflammation, LACK OF ORGANIZATION, loss of cellular and nuclear detail, anisokaryosis, anisocytosis: which are all features of a MALIGNANT TUMOR: it is not an entirely “nice” benign leiomyoma. Though there is a grey zone and this will likely be a well-behaved tumor. Normal muscle tissue - around tumor’s full circumference, indicating likely fully excised (can’t obtain wide margins in this type location). So it was read out to be a Leiomysarcoma—to err on the side of caution.
36Post surgical care Antibiotic: Clindamycin IV 11mg/kg BID Pain Management:Fentanyl CRI 2 mcg/kg/hr PatchDexmedetomidine IV 15 mcg PRN Q4hCarprofen 2 mg/kg BIDGabapentin 3 mg/kg BIDTramadol 3 mg/kg PRNSupportive Care:IV Fluids, Ice and Check Tegaderm Q6hBACK TO OUR PATIENT…
37Post surgical care Main Concern: Urinary Incontinence Monitor for Urination, Check for Leakage1 Day Post Surgery: Steady Controlled StreamDischarged That EveningDischarged to her owners after 1 full day in hospital for post operative care. Walked very well, urinated “great stream!” less than 24 hours post surgery.
38update 2 week Recheck – Tenesmus Gave Pumpkin and Lactulose Lactulose Overdose Diarrhea OnceOwners “Very Pleased”No Signs NowBladder Control 7 hours (Reduced)Lactulose PO 5 ml BIDOut at midnight and by 7am—Does well, no accidents (BUT 7 hours is her limit—She can’t hold her bladder longer (and she could before surgery).Managed on Lactulose: 5 ml (1 teaspooon) BID. The Owner says he “doesn’t dare” stop for fear of more tenesmus. He has found the right dose—no Diarrhea (No tenesmus—just normal stool).
39Costs Combined Total Costs Dollar Amount Administrative Management 697.00Anesthesia818.50Clinical Pathology67.88Imaging832.20Professional Services100.00Hospitalization/Inpatient Care595.00All Supplies and Materials616.55Pharmacy199.73Grand Total$ 3,926.86Total costs: Just shy of $4,000
40referencesBuergelt, Claus D. Color Atlas of Reproductive Pathology of Domestic Animals. St. Louis: Mosby Print.Evans, H., de Lahunta, A. Miller's Anatomy of the Dog. 4th Ed. St. Louis: Elsevier Saunders Print.Maxie, M G, K V. F. Jubb, P C. Kennedy, and Nigel Palmer. Jubb, Kennedy, and Palmer's Pathology of Domestic Animals. Edinburgh: Elsevier Saunders Print.McEntee, Kenneth. Reproductive Pathology of Domestic Mammals. San Diego: Academic Press Print.Nelissen, P, and RA White. "Subtotal Vaginectomy for Management of Extensive Vaginal Disease in 11 Dogs." Veterinary Surgery : Vs (2012): PrintNorth, Susan M, and Tania A. Banks. Small Animal Oncology: An Introduction. Edinburgh: Elsevier Saunders Print.Thacher, C, and RL Bradley. "Vulvar and Vaginal Tumors in the Dog: a Retrospective Study." Journal of the American Veterinary Medical Association (1983): Print.Tobias, Karen M, and Spencer A. Johnston. Veterinary Surgery: Small Animal. St. Louis, Mo: Elsevier Print.Weissman A, D Jiménez, B Torres, K Cornell, and SP Holmes "Canine Vaginal Leiomyoma Diagnosed by CT Vaginourethrography". Journal of the American Animal Hospital Association. 49, no. 6.Withrow, Stephen J, and David M. Vail. Withrow & Macewen's Small Animal Clinical Oncology. St. Louis: Saunders Elsevier Print.
41Thank you! Dr. Flanders Dr. Hume Dr. Ruby Dr. Asakawa The Class of 2014My FamilyMy Advisors, My Class, and My Family