Pet Radiation and Chemo Treatment For Nasal Tumors
Hey everyone, welcome back to the article.we are gonna dive in and start talking about test, treatment, and prognosis, let’s do it. Of course, you know, for all of our patients, we are gonna wanna do some basic blood work and urinalysis. If your pet is having a nose bleed, what we call epistaxis, your veterinarian is probably gonna do some extra tests just to make sure that they’re not having something called coagulopathy, a bleeding disorder, so they may run some tests, coagulation tests, to check for that as well, including checking the platelets ’cause the platelets help the blood clot. They may also check blood pressure ’cause high blood pressure can cause nosebleeds as well, so they’re gonna do a full workup to rule out, as we say, some of the other things that can cause nosebleeds. There are other nasal cancers, fungal disease, and non-cancerous processes that can cause nose disease as well, so a lot of these cases will, in my practice, would get worked up by an internist, often my husband. But what’s gonna be really important is getting a piece of tissue and some imaging of what’s going on inside the nasal cavity, and skull x-rays or radiographs are just really not a very good test, they’re not very sensitive or specific, so really, and they need to be done under anesthesia anyway. So if they’re recommended, I would highly encourage you not to have them done, and a CT scan is really, or an MRI, is gonnA be the best way to look in that nasal cavity. One of the reasons that we medical and radiation oncologists prefer a CT scan over an MRI is that can be used for radiation planning. So typically our internist would do a CT scan, and then if, based on the CT scan, determined he needed a biopsy would do rhinoscopy, which is a scoping procedure where he uses a fiber optic camera, or he or she, to get a piece of tissue, and that allows us to get a diagnosis. So, and then we’re gonna use, you know, get a biopsy report that’s gonna tell us if it’s cancer and then the type of cancer, and go back to . A few other staging tests, staging means test to look for spread, that we’re going to want to do for once we’ve confirmed it’s cancer is I usually will aspirate these lymph nodes, the mandibular lymph nodes, to see if it’s spread to the mandibular lymph nodes. On the CT scan, we’ll be able to evaluate some of the deeper lymph nodes that we can’t see.
They’re called the retropharyngeal lymph nodes. I recommend looking at the chest, though if you’re doing a CT, we would often scan the chest with the CT as well when we’re doing the head and neck area. Chest radiographs are another option, and I do have another YouTube article comparing and contrasting chest X-rays to a CT. But in my opinion, if you’re doing a CT of the head and neck area, just go ahead and CT the lungs to look for metastasis. As for an abdominal ultrasound, usually, most of these nasal cancers in dogs don’t go to the abdomen, to the abdominal organs, but in my opinion, if you’re about to embark on a journey where you’re considering radiation therapy, which is quite expensive, I do recommend doing an abdominal ultrasound or some other imaging, just to make sure that there’s nothing else there that we should know about from a general health screening standpoint, like a splenic mass. I had one pet where we had, a cat, that we found bladder cancer. It was a cat with an oral tumor, so I just like to know, you know, everything that could possibly be there before we’re doing thousands and thousands of dollars of radiation. So, an abdominal ultrasound is not really needed for most dogs with nasal cancer, but I still think, you know, a couple of hundred dollars for an abdominal ultrasound is a reasonable test to do. For cats with nasal cancer, we talked about that lymphoma’s the most common cancer that we see, so definitely abdominal ultrasound to look at the liver and the spleen and the GI tract is recommended in my opinion. So let’s talk about treatment, because there’s a range of treatment options, and we’ll talk about definitive treatment options, which is sort of the best chance for long-term survival and then some more palliative options where you’re trying to improve the quality of life. We’re always trying to improve the quality of life, but you’re not treating as aggressively just trying to alleviate some of the symptoms and make the pet more comfortable. So these are cases where I think it’s helpful to talk to a radiation oncologist specifically because that is the treatment of choice for most of these nasal cancers, especially dogs, and we’ll put links.
Radiation is even harder sometimes to find than a medical oncologist or radiation oncologist, but we’ll put some links, so you can try to find one near you, or you can talk to your veterinarian or talk to a medical oncologist, ’cause at least we can present the different options for you and hopefully help you find someone in your area. So, as I mentioned, radiation is the treatment of choice, and I do have a good amount of experience. So I was at a practice for about eight years where we had stereotactic radiation, which is one of these advanced forms of radiation, and nasal tumors was the second most common cancer that we treated with stereotactic radiation, right after brain cancer, brain tumors, because it was a very precise form of radiation, so it really focused on the tumor with not a lot of radiation to the tissues surrounding the tumor. And if we think about the nasal cavity, there’s a lot of critical structures near the nose, the mouth, and the gums, and the mucus membranes that line the mouth, and the eyes, and things like that. And over the years, as we’ve shifted towards stereotactic radiation, we really have been able to decrease the number of radiation treatments for nasal cancers, by treating with stereotactic radiation and decrease the side effects. So that is really, in my opinion, the treatment of choice for dogs with nasal cancer is gonna be stereotactic radiation. When we first started stereotactic radiation, I think in about 2009, we were one of two facilities in the US who were doing it, it was us in New York and Colorado state.
Now fast forward, you know, 11 years, there are many more radiation facilities, you know, that are offering stereotactic radiation, so you don’t have to come to New York or Colorado to get that, so that’s really great news for pets. But I did have people come from, we had one cat come from Hong Kong, and we had, I had people drive up from Florida and Texas, I had people come in from Canada and New Jersey, which isn’t that far, but Massachusetts and DC and things like that. So, you know, people really trekked quite far for radiation, but again, it’s not that hard to get stereotactic radiation. But the reason that people drove for it, ’cause there are other radiation facilities, is that this allows for nasal cancer to treat, usually with three treatments was what we were treated with, so on a couple of consecutive days with a lot less side effects, so they didn’t get a lot of the burning and the mucositis or the inflammation of the tissues in the area. And so the reason I kinda go into that is a lot of people are scared of radiation. Traditional radiation was often 15 to 20 treatments, and in dogs and cats, it does require anesthesia, so I think it’s just important to realize that things are constantly evolving. I haven’t been doing stereotactic radiation directly, I’m at a different practice now, so I want you to go talk to a radiation oncologist. And what’s really important is, if you’re considering it, is to do it sooner rather than later, because we know that, you know, getting that treatment on early is gonna be better than waiting a month or two and just seeing how things progress. So, and things are constantly changing protocols, technology, things are improving, so if you’re thinking about it, I want you to get more information, and I hope this article is giving you a little bit of hope and encouragement to do that. There’s a second type of radiation called palliative radiation, where you’re still giving small numbers of treatments, so maybe usually three or four treatments, often on a weekly basis, but it’s not giving, it’s not delivering the same high dose of radiation. And it’s more for comfort, so maybe just to shrink the tumor. You’re not gonna get the same longterm benefits that we’ll talk about when we talk about prognosis.
But again, I want everybody to know that there are different ranges of options there, you know, there’s no treatment obviously, which is okay, and maybe just some pain medications and appetite support, there’s palliative radiation, and then there’s gonna be what’s usually called external beam radiation, and I would recommend stereotactic radiation for these dogs with nasal tumors. And so, you know, there is a range of options. So in general, radiation’s gonna be better, much better than surgery. So surgery’s pretty invasive. The problem with surgery, these are malignant cancers, and, if you watched some of my other articles, we know that we need to remove tumors with margins, and you can’t just get margins without removing the nose. So these tumors grow back pretty quickly with surgery, and if you de bulb the nose tumor, you’re still gonna have to do radiation anyway. So we don’t, in general, recommend surgery for dogs with malignant nose tumors.
There was a study where they did surgery after radiation, and in that small study, if I remember correctly, the dogs did live for years, but there was an increased side effect in those dogs and obviously increased cost as well. So it may be something you want to talk about with your radiation oncologist and a surgeon and your medical oncologist as a possibility, but, in general, surgery is not the treatment of choice, radiation is going to be. Chemotherapy, again, this is a solid tumor in the nasal cavity, unless you have a cat with lymphoma or a dog, a rare dog with nasal lymphoma, in general, chemotherapy is not gonna have much of an impact on a dog with nasal cancer, so the adenocarcinomas, chondrosarcomas.
Sometimes it can be tried palliative just to try to shrink the tumor a little, improve airflow, improve the quality of life, so maybe if you’re in a part of the country where radiation’s not available or the cost is, you know, too far or too far, the cost is too far, the cost is just not, you know, within your financial budget that might be something to talk about. But again, usually gonna be palliative, just to try to shrink the tumor a little. I have used off label PALLADIA in some cases as well and have seen some effect in some cases, so it’s something to talk to your veterinarian or your oncologist about as well. But again, going back to just radiation is going to be the treatment of choice. One of the things that’s really important about radiation, you know, when you go to surgery, and your dog has its tumor removed, it’s removed out of it, so, you know, if they have mammary cancer, breast cancer, it’s, when they come home, the cancer is gone. With radiation, we are damaging the DNA of these cancer cells, and it’s not until those cancer cells try to divide that the cell then dies, and so the take home message is a lot of these tumors will have a slow regression, especially if they’re slowly dividing tumors. And so we did a lot of repeat CT scans in our, our unit was called CyberKnife, our CyberKnife patients, we usually recommended at least a six month CT scan, if the owners could, and then every six months, and some of our clients would let us do them every three months. And it was really interesting to see these tumors slowly regress, and sometimes there was minimal change, just visually, on the CT scan at three months, but then at six months and then at nine months. So it can be very slow regression of these tumors, and sometimes the tumor wouldn’t go into a complete remission until one year. So, you know, just to remind you that these doesn’t zap and melt the tumor, and on the next CT, you can still have visible mass, but what it doesn’t tell us is whether those cancer cells are alive or dead when we see mass in the nose on the CT scan. I hope that makes sense, but it’s a slow regression, but it still works. But it’s just a little bit different than when your pet’s tumor is removed surgically. Another thing with radiation, side-effects usually are not immediate, so if they’re gonna occur, they usually occur about two to three weeks after radiation, and they can last a couple of weeks after that. And those are called the acute side effects, and then sometimes they can have late side effects that can occur 6 to 12 months after. And so, if you’re considering radiation, your radiation oncologist, depending on what is included in the field, is the tumor extending back into the brain, the side effects really will depend on where the tumor is. Is it on one side of the nasal cavity? Is it eating into the palate,
which is the bone that separates the mouth? If it is, they could have, you know, a fistula, which is a hole between the nose, so that CT scan before for radiation planning is gonna give us a good idea of what the extent of it is, what the potential side effects are, and how big the tumor is. Cause like I said, you can have a dog that looks, and a cat, that looks really normal, we really need that CT scan to figure out what the tumor is doing internally. Is it going into the sinus, et cetera? So again, once your pet has the CT scan, you’ll get more information about what potential acute, early side effects you may see and then the late side effects after radiation. “All right Doc, how’s my dog gonna do?” Always the question that we get. And so just remember, maybe you haven’t watched any of my articles, is that there’s always gonna be ranges with numbers, so there will be pets that do better and pets that do worse. And we do our best to make predictions, but these are just generalizations. Obviously, please talk to a specialist yourself, but again, just, you know, that’s my disclaimer with these numbers. In general, for dogs and cats with nasal cancer, not treated, it’s usually about three months. It’s usually they’re gonna succumb to the local disease when these cancers do metastasize, it’s usually later in the course of the disease. So usually it’s a quality of life issue, from the tumor, you know, affecting the different structures in their face and just causing a deterioration in their quality of life. With dogs treated with radiation, on average, for about, from the most common one, adenocarcinomas, it’s usually about a year. Year, that’s not, that’s not a lot of time,
Dr. Sue. Again, let’s put that into perspective with the dog’s life, and so a year for a dog is like maybe five. I know when it’s your pet, it’s never long enough. I get that, ’cause I’ve had pets with cancer and other diseases, so I absolutely get that. But a year of quality of life is pretty good, it’s not horrible, especially considering some of the other cancers that I treat. So, and that’s just the median, there are dogs that live longer, and I’ve had dogs that I’ve treated with nasal cancer that are, with adenocarcinomas, that are out three and four years. Some of the cancers will do better, so chondrosarcoma is one that has a better reported prognosis. And then some of them are shorter, so some of the squamous cell carcinomas can do worse, especially there may be other more specific information on your pet’s biopsy that may help your oncologist give you a better prognosis, so the grade, poorly differentiated, did it spread to the lymph nodes, other concurrent things going on with your pet. So again, these are just really broad generalizations. Please, I encourage you to see a specialist, have them examine your pet or have your veterinarian consult with a specialist. So I’m now doing that through, if I do that, I’ll put a link below as well. So, but again, it’s really important that those recommendations are based on your pet and their biopsies and more specific information, but this is just to give you a ballpark, and I hope that that is helping. With palliative radiation, often about half a year, about six to seven months. Again, depends on some of the other things that we talked about. Palliative chemo can be about the same, about five to seven months, so again, it’s just to really make them more comfortable, hopefully shrink the tumor. And then palliative medical management, so pain management, appetite stimulants, usually gonna be a little bit shorter than that, usually about three to four months, but again, there’ll be variations on, on all of that. What about kitty cats? So for the non-lymphoma kitties, similar to dogs, are usually those kitty cats with the adenocarcinomas that are treated with radiation about a year, so three months versus a year.
you’ll get a little bit of variation with that. So for the kitty cats that are treated with radiation, you’ll see variations depending on what source, but about, you know, 18 months, a year, which is a year and a half to two years, and if they have a complete response, you know, some of the papers will report that three years. The question that we often have is, did the kitties need chemotherapy because often they will progress systemically to those other common sites that we see lymphoma, so liver, spleen, lymph nodes, and things like that. So I typically do recommend chemotherapy for in conjunction with the radiation as well. A common theme with cats, even like very similar, if you watched my GI lymphoma, is getting them into a complete remission. Cats that have a partial response or don’t respond, you know, their survival times are usually very short, less than six months, often about four months. So really important that we’re getting them into a complete remission. What if you can’t do radiation because of the cost or, you know, things like that? I will treat them with chemotherapy, and survival times range anywhere from six months to a year, and I’ve had some do better than that. I always, you know, like to give some examples, and I’m sure because Micu’s mom is reading, so Robin is reading. So Micu was one of the first cats that I treated with the CyberKnife stereotactic radiation at the other facility that I was talking about. It was a nasal lymphoma kitty,
we did six months of CHOP chemotherapy, and MICU is now out, I think, over seven and a half years and has yet to relapse, I just knocked on wood, with her lymphoma. So, you know, great example. One of the nice things about the lymphoma, you know, is it a lot, it spares the eyes, they don’t get cataracts and things like that, so, you know, a great, great, you know, example. And I, I told Micu’s mom that I was hopeful, you know, if she had a complete response, you know, two or three years, and so here we are way double that. So, you know, great, I love when I’m wrong. I always hope that I’m wrong when it’s to the patient’s advantage. And then finally, cats, like dogs, that are treated palliatively, usually just a couple of months, I’d say about three or four months. And again, I find that cats are more sensitive to anything in their nose, whether it’s just an upper respiratory infection or a nasal tumor, so appetite support, you know, there’s Mirataz, which is a topical ear transdermal medication, just so important to make sure that they’re eating and monitoring their weight. So again, I’m gonna put that link below about monitoring for weight loss and different medications that we can do, but I hope this highlights that there is a range of options for these dogs and cats. You know, radiation is expensive. I didn’t give the cost of radiation on purpose because it varies in different parts of the country, I’m in the Metro New York area, which is as many people know, not an inexpensive part of the country, and, you know, stereotactic radiation is over $10,000. So it’s not inexpensive, and different parts of the country will range. Palliative radiation can be a couple of thousand dollars, but it’s gonna vary on the facility that you see. So again, I encourage you to, you know, make an appointment. Consultation is just a consultation, it’s a nonbinding appointment, Thank you so much for reading. I appreciate the positive feedback.,and I look forward to seeing you at the next article.