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(207) 846-6515

ONCOLOGY: BONE CANCER

YVCipedia ONCOLOGY
BONE CANCER

ABOUT THE PROBLEM
Bone cancer is a relatively common type of cancer in dogs, and a less common type in cats and other pet species.

Bone cancer can be primary or secondary. Primary bone cancer arises within the bone, from any of the body tissues within or attached to bone. Secondary bone cancer is cancer that has started somewhere other than bone, and spread to bone.

More than 90% of cases of primary bone cancer in dogs are a particular type called osteosarcoma. Osteosarcoma is somewhat less common in other pet species, but is still the most common type of primary bone cancer in non-canine pets.

Bone cancer is almost always malignant. The most common site of metastasis in dogs is the lungs; bones other than the one that contains the primary tumor are the other common site for metastasis. By the time bone cancer is diagnosed it is extremely likely that it has already metastasized, even if diagnostic tests do not reveal this. 

DIAGNOSIS
PHYSICAL EXAM  Swelling and pain at the tumor site are the most common findings. When the cancer occurs in a leg there is usually a persistent lameness. When the cancer occurs in the skull or spine there might be a bulging eye, nasal discharge, difficulty eating and drinking, drooling, or neurologic problems. When metastasis has occurred, the pet may be lethargic and have a decreased appetite. Any of these symptoms, including swelling of the tumor,  can appear suddenly and progress quickly or slowly. 

Regarding most primary bone tumors in dogs: more than 75% of them occur on a leg; the average age of appearance is 7 to 8 years, with a range of 6 months to very old; the breeds most commonly affected include Golden Retrievers, Labrador Retrievers, Great Danes, Rottweilers, Doberman Pinschers, German Shepherds, Saint Bernards, and Bernese Mountain Dogs; relatively tall individuals within a breed are more commonly affected.

We are often very certain of our diagnosis based on physical exam findings, but the exam is never a 100% certain diagnosis.

X-RAYS  X-rays of the swollen region(s) of bone add significantly to the certainty of a diagnosis of bone cancer. While they might not technically bring this certainty to 100%, we believe for practical purposes x-rays are often definitive. 

When we use x-rays to search for evidence of metastasis, we x-ray the chest, and the bones of the whole body. While metastasis to the chest is more common than metastasis to other bones, research indicates we can find evidence of metastasis in other bones earlier than we can find it in the lungs.  

SURGICAL BIOPSY  This is the only way to definitively diagnose a bone lesion as cancerous, and to determine what type of cancer it is. Biopsy is probably most important when treatment options other than palliative care are being considered.

Of special note, it can be surprisingly difficult to obtain a diagnostic biopsy from a bone tumor. The procedure for obtaining the sample is not usually particularly difficult, but sometimes a sample that appears to be more than adequate at the time of collection does not yield a diagnosis on the pathologist's exam. We have encountered cases that had to be biopsied two or three times before a diagnosis was obtained. 

GENERAL LABORATORY TESTING  A blood profile is a useful test for determining a patient’s over-all health status, and has particular value for helping us to determine the pet’s ability to tolerate the various treatment options that are being considered. Also, abnormally elevated levels of a couple of tests on a general profile are consistent with a worse prognosis for dogs with bone cancer.

ULTRASOUND EXAM  Abdominal organs and other soft tissues are not common sites for metastasis of bone tumors in dogs. They are somewhat more common sites in cats and other pets. We believe it is worthwhile to also do an abdominal ultrasound exam as part of our screening testing for metastasis. 

ADVANCED IMAGING  CT scan and other advanced imaging tests are readily available at local referral practices. They are most useful when surgery is being considered for a bone tumor of the skull or spine, or when limb-sparing surgery is being considered for a tumor of the leg. 

TREATMENT: GENERAL CONSIDERATIONS
Faced with a diagnosis of bone cancer and the poor prognosis that comes along with it, most of our clients express their desire to pursue a course of treatment that will keep their pet comfortable for as long as possible, without “putting them through too much”, and/or without incurring significant expenses. This is palliative care: treatment with the goal of alleviating symptoms but not obtaining a cure by eliminating the cause of the problem. 

Viewed from the perspective that a cure can rarely be achieved, all of the possible treatments available for bone cancer might be considered palliative. 

Whenever one of our clients is interested in pursuing a cure, we are ready to provide guidance and treatment.

Euthanasia is the saddest treatment option; it is also likely to become, sooner or later in the course of the pet’s illness, the most reasonable and humane treatment option. (Bone cancer rarely produces complications that cause a pet to pass away without being euthanized.) Sometimes it is obvious that it is the right time for euthanasia: the pet’s pain may become unmanageable, or the pet might stop eating. Sometimes it is not so obvious: the owner, so tuned in to their pet’s behavior, might simply realize that its quality of life has become unacceptable. There is no certain amount of treatment that needs to be attempted before an owner decides the time for euthanasia is at hand; in some situations, little or no treatment is indicated. We will provide as much guidance as possible without taking the decision away from the owner. 

TREATMENT OPTIONS
We create an individual treatment plan for each pet using some combination of some of the following options. Bone cancer of the limb of cats, with no detectable metastasis, is an exception; amputation with no additional treatment yields a prognosis as good as when additional treatment is used. 

AMPUTATION  When the bone cancer involves a limb we can perform amputation to relieve pain. Combined with traditional chemotherapy, amputation is the treatment of choice when we are attempting to cure the patient. Most, but not all pets function well after amputation. We screen pets very carefully for possible contraindications and negative prognostic factors prior to this surgery.

LIMB-SPARING SURGERY  Removal of a section of bone that includes the tumor without removing the entire limb is sometimes an option, depending on the location and extent of the cancer. Compared to amputation: limb-sparing surgery is more complicated; requires referral to a surgical specialist; survival times are similar but surgical complication rates are much higher. It is our opinion that, if limb-sparing surgery is to be attempted, it should be combined with radiation and/or chemotherapy. 

SURGICAL REMOVAL WHEN THE TUMOR INVOLVES THE SKULL OR SPINE  Complete removal of these tumors is often not possible. As with limb sparing surgery, it is our opinion that, if it is to be attempted, this surgery should be combined with radiation and/or chemotherapy.

CONVENTIONAL RADIATION THERAPY.  Radiation can be used as a follow-up to surgery, or it can be used at a lower level on a less-frequent schedule (usually on an outpatient basis) to provide pain relief and decrease lameness. Radiation treatment for pets is not available in Maine; it requires trips to New Hampshire or Massachusetts.

STEREOTACTIC RADIATION TREATMENT  With this specialized radiation treatment, large doses of radiation are delivered very precisely to the tumor. Survival times are similar to amputation. This treatment is even less-readily available than conventional radiation therapy, and it is much more expensive.

CONVENTIONAL CHEMOTHERAPY  Conventional chemotherapy is the use of chemotherapy drugs in the well-known fashion. Typically multiple drugs are used, they are dosed to the maximum amount that the pet is likely to be able to tolerate, and they are given staggered throughout a cycle that is repeated multiple times. Pets generally tolerate chemotherapy better than people do, but side effects are still common. Conventional chemotherapy is used in addition to surgery and/or radiation in an attempt to achieve a cure; it is not used alone. It usually requires referral to a specialist. 

METRONOMIC CHEMOTHERAPY  This is not a particularly new therapy, but it has received increased attention and is increasing in use over the last several years. It involves administering traditional chemotherapy drugs at very low doses on a daily or every-other-day basis. They are administered in oral dose form at home by the pet’s owner. The cost is less, as is the risk of side effects. We can create a metronomic chemotherapy plan, so referral to a specialist is not necessary. (For more information, please see our YVCipedia article “Metronomic Chemotherapy” on our website, yarmouthvetcenter.com, or ask us to print or email you a copy.)

ANALGESIC MEDICATIONS  Early in the course of the problem we can usually provide effective pain relief using one or two analgesics. As the problem progresses, we can often maintain this relief by adjusting doses and adding in one or two additional medications. NSAIDs (nonsteroidal anti-inflammatory drugs) are usually the first choice and are the cornerstone of analgesic therapy; also, they are usually part of our metronomic chemotherapy protocols. 

OTHER MEDICATIONS  Pamidronate is a medication that slows bone loss from tumor growth, and relieves pain in 30-40% of bone cancer patients. It is a relatively expensive intravenous medication that is administered once or twice monthly. A blood profile to assess kidney function is necessary prior to each dose. 

Prednisone, the common corticosteriod medication, has various effects that make it useful for some bone cancer patients. 

NUTRITIONAL SUPPLEMENTS  Fish oil (omega 3 and 6 fatty acids) have anti-inflammatory and other effects that makes it a very worthwhile addition to the treatment plan for a pet with bone cancer. It is given as a daily supplement. Fish oil products vary widely in quality; to ensure good quality, we recommend using one of the veterinary products, Derma-3 Twist Caps or Welactin. 

NUTRITION  Hill’s, the manufacturer’s of Prescription Diet and Science Diet, make a complete and balanced canned dog food called N/D, for nutritional support of cancer patients. N/D provides high levels of protein and fat, arginine, and omega-3 fatty acids,  and low levels of carbohydrates. This nutrient profile has the effects of depriving the cancer cells, but not the patient, of nutrition, and stimulating the patient’s immune system. 

TREATMENT: OUR APPROACH TO PALLIATIVE THERAPY
When an owner is interested in pursuing palliative care, we believe one approach worth considering is combining metronomic chemotherapy with analgesic therapy and fish oil. With the exceptions of conventional chemotherapy and stereotactic radiation therapy, which would only be used if a cure was attempted, any or all of the other treatment options could be added to this base of palliative care. We work with the owners to create a treatment plan that is right for their pet. 

PROGNOSIS: GENERAL CONSIDERATIONS
Unfortunately, the long term prognosis for any type of bone cancer, with any type of treatment, is poor. The short term prognosis (weeks to months) is fair for maintaining a good quality of life. 

The vast majority of research on bone cancer in pets has been on osteosarcoma (OSA) in dogs, and the following prognostic details come from these studies. The prognosis for non-OSA bone cancer in dogs has not been studied extensively, but is very likely to be similar to that for OSA.

The prognosis for bone cancer in cats has not been studied extensively, but is generally considered to be better than that for dogs for bone tumors of the limbs, and about the same as that for dogs for tumors of the skull and spine.

The prognosis for bone cancer in pets other than dogs and cats is generally considered to be similar to that for dogs, but proportionally so, with respect to lifespan. For example, 1 year cancer survival for a dog with an average lifespan of 15 years would be 2 month survival in a rodent with an average lifespan of 2 years. 

PROGNOSIS: DOGS 
OSA of the limbs:
- Amputation alone
        4 to 5 month average survival
        1 year survival rate 10%, 2 year 2%
- Amputation, limb-sparing surgery or stereotactic radiation therapy combined with
  platinum based chemotherapy
        10 to 12 months average survival
        2 year survival rate 15% to 25%
- Amputation, limb-sparing or stereotactic radiation therapy combined with
  conventional chemotherapy
        8 months average survival
        1 year survival rate 35%, 2 year survival rate 17%
- Prognosis worse if the tumor is in the upper front leg near the shoulder
- Prognosis worse if alkaline phosphatase (a test in the general blood profile)
  is elevated
- Palliative care without surgery or metronomic chemotherapy
        Survival time up to 4 to 5 months
        Depends on how successful pain control is
- Once metastatic disease is apparent survival times usually less than 2-3 months
  regardless of treatment

OSA of the head or spine (not including the mandible):
- Prognosis similar or worse compared to OA of the limb
- Depends mostly on whether primary tumor can be completely removed

OSA of the mandible:
- Better prognosis than the rest of the head or spine
- 60% metastasis rate (versus almost 100% for OSA in other locations)
- Average survival 17 months with mandibulectomy
- Addition of chemotherapy of uncertain value

Nasal OSA, Digit OSA
-Prognosis similar to OSA of the limb

PROGNOSIS: CATS
Bone cancer of the limbs
-  Amputation alone greater than two years
-  Amputation with chemotherapy or radiation unknown, but considered not to be better than amputation
   alone

Bone cancer of the skull and spine
- Surgery alone average 5.5 months
- Surgery with chemotherapy or radiation unknown, but considered to be worth considering

Yarmouth Veterinary Center
2015, updated 2016

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