This document presents the case of an 11-year-old border collie named Glen who was presented for treatment of a nasal carcinoma. On examination, Glen had no airflow through his right nostril and evidence of discharge. CT, biopsy and ultrasound confirmed a diagnosis of nasal carcinoma. Nasal carcinoma accounts for about 1% of cancers in dogs and usually occurs in medium to large breed dogs over 10 years old. While surgery, radiation, and chemotherapy are options, given Glen's specifics, no further treatment was opted for.
3. HISTORY
Presented after having a large epistaxis episode.
Previously treated for intermittent sneezing,
epistaxis and mucoid discharge.
4. CLINICAL EXAMINATION
No airflow through right nostril
Evidence of discharge on hair around nares
Symmetrical face, no swellings
No lymph node enlargement
18. TAKE HOME MESSAGE
Nasal carcinoma is a rare and destructive disease.
Need to treat each case as an individual, wont
always include treatment.
Multifactorial condition, worsen prognosis.
19.
20. REFERENCES
Malinowski, C (2006) Canine and Feline Nasal
Neoplasia, Clinical Techniques in Small Animal
Practice, 21:89-94.
Withrow, S, J. Vail, D, M. Page, R, L. (2013) Small
Animal Clinical Oncology, 5th ed. Elsevier
Saunders. 23: 435 – 446.
Moores, A. Walker, D. (2013) Canine Nasal
Disease: Investigation and Management, In
practice, 35: 197 – 211
LaDue, T, A. et al. (1998) Factors Affecting Survival
After Radiotherapy of Nasal Tumours in 130 Dogs,
Veterinary Radiology and Ultrasound, 40: 312-173.
Hinweis der Redaktion
This is Glen, a case that presented whilst I was on oncology in the small animal hospital
He is an 11 year old, male neutered border collie.
From this presentation, history and clinical signs, neoplasia was the top differential.
Idiopathic and bacterial rhinitis are both less likely as the treatment prescribed by the referring vets didn’t improve the clinical signs clinical signs, instead they worsened. A large epistaxis episode would also be unlikely.
Aspergillosis is possible although isn't likely to cause obstruction of airflow and can be uncommon in this country.
If the animal had only presented with epistaxis on one occasion, the most likely diagnosis would be trauma, but this diagnosis doesn’t fit in with the recurrent epistaxis and discharge from the nares.
Another differential for epistaxis is a coagulopathy although this wouldn’t cause airflow obstruction or nasal discharge it is recommended to carry out a co-agulation profile before biopsies are taken.
A foreign body is a possibility with decreased airflow, but with recurrent discharge, epistaxis and obstructed airflow it doesn’t fit the clinical picture.
Parasites, hypotension, developmental.
So at the small animal hospital further investigations were carried out.
CT – this provides information about the soft tissue and bony structures. It is the optimal imaging tool for diagnosis of nasal pathologies.
On CT there is clear destruction of the nasal turbinate's on the right side with a soft tissue opacity filling the nasal cavity.
There is also indication of the septum being breached although the cribriform plate appeared in tack.
The lung field was also included in CT and it was noticed there was an oval structure identified in the mediastinum, this was not identified to be metastasis but a definitive answer was not reached.
Under anaesthetic we then took a blind grab biopsy. 6 biopsies were taken from the right nostril to send for histopathology and identify tumour type. This is the only diagnostic procedure that will provide a definitive diagnosis. There is a significant risk of causing further damage when performing this procedure and it is vital to mark the distance from the medial canthus to ensure the forceps are not pushed through the cribiform plate into the brain.
After performing histopathology it was suspected the tumour was a carcinoma.
Ultrasonography was then performed to asses for metastasis, although this is not common with nasal neoplasia. Unfortunately when assessing the liver a large vascularised mass was identified on the left hepatic lobe and another small mass with a hyper echoic centre was identified on the quadrate lobe.
A small hypo echoic nodule was also identified on the spleen.
These findings were thought to be separate form the nasal neoplasia so the hepatic mass was sampled but the FNA results were inconclusive.
The definitive diagnosis from the grab biopsy was nasal carcinoma.
Nasal neoplasia only accounts for about 1% of neoplasia in dogs. Of this 2/3 are identified as carcinoma including adenocarcinoma, squamous cell carcinoma or undifferentiated carcinoma.
The majority of other tumours recorded are sarcomas including fibro sarcoma chondrosarcoma and osteosarcoma. The possibility of other types of neoplasia arising is small but occurs occasionally. These are often reported to be melanoma.
Glen fits with the signalment of animals affected by nasal neoplasia which is medium to large breed dogs, over 10 years old and males appear to be over represented.
These tumours are locally invasive and are usually unilateral. At the beginning of the disease metastasis is unlikely but as the disease progressed metastasis becomes more common and by the time of death it is reported that it can affect 50% of animals.
If the noeplasia is carcinoma, spread is commonly to the lymph nodes but if sarcoma in origin haematogenous spread to the lungs is usual.
It normally takes three months before clinical signs are apparent. On examination you can look for subjective and objective clinical signs.
From a distance it is important to look for discharge, epistaxis, sneezing, stertor or stridor, epiphora and asymmetry.
When examining the animal it is important to look for decreased airflow as this will narrow your differential list and indicate unilateral or bilateral disease. Pushing the eyes in can tell if there is retro bulbar involvement and facial pain can also help to narrow the differential list.
There are a few treatment options available and this will depend on the stage of disease and the desire of the owners. If untreated the median survival time fore nasal carcinoma is 88 days.
Surgery - In this case surgery (rhinotomy) is not an option as it is to invasive and the tumour is extensive. Nasal tumours usually invade the bone early in the disease process making curative surgery impossible. This option can be used in some cases to debulk the mass present but should not be used as a sole method of treatment. For this case surgery could be considered to remove the hepatic mass.
Cryosurgery – this was not considered ads the tumour is difficult to access and it is not proven to improve the survival time.
Radiotherapy – this is the best option as it provides the best tumour control. Nasal carcinomas are typically sensitive to radiotherapy and it penetrates nasal tumours well. Radiotherapy is usually done with 12 treatments over 4 weeks which will give the best prognosis but there is also an option of treatment every day for 5 days which will aim to reduce the tumour size and slow progression. This usually makes the animals more comfortable but will not give a good long term prognosis.
With a full treatment of radiotherapy the mean survival time is 8-12 months.
Chemotherapy - is indicated if there is presence of metastasis, which in Glens case we are unsure about. Although there are reports of combining radiotherapy and chemotherapy to act on the primary nasal tumour the effects are still unclear and there is no data to prove the effectiveness.
So with radiotherapy prognosis is decreased if there is erosion of the cribiform plate, regional lymph node metastasis, advanced stage of tumour of the animal affected is over 10years. Unfortunately the prognosis for carcinoma is worse when compared to sarcoma.
The prognosis id better if there have been no epistaxis episodes increasing mean survival time from 88days to 224days. It is also increased if the tumour is detected early on in the disease process.
With radiation therapy there are early and late side effects - Early side effects occur within 2-8 weeks of treatment and are usually treatable with antibiotics and analgesia. The main side effects are detailed here.
The later side effects can occur years after treatment and are often irreversible. These are the most common ones reported.
The ideal situation for Glen for the best prognosis would be to remove the hepatic mass and provide radiotherapy treatments for the nasal carcinoma.
The owners were not willing to put Glen through any more treatment and were offered a five day course of radiotherapy for palliative care which was declined. At this moment in time Glen has a good quality of life and the only problem is epistaxis. It was explained to the owner to monitor Glen and if any deterioration is observed then a re-evaluation is recommended.
The take home messages for me nasal carcinoma is a rare disease which can be difficult and expensive to treat. Identifying the neoplasia early is difficult so animals are often presented later in the disease process, making prognosis worse.
You also need to remember that the owner will not always opt for treatment and this is a perfectly acceptable decision. It is their animal and the decision lies with them. Palliative care is always an option.
I also thought it was important that all cases are individual and need to be treated differently. Glen still had multiple pathologies but still had a good quality of life. This is the most important factor to remember and shouldn’t be forgotten about.
When thinking about glens case, the prognosis after treatment of the nasal carcinoma was 8-12 months but this doesn’t factor in his pre-existing conditions and other possible neoplasia in the liver. These factors have the potential to worsen prognosis and unless radical treatment was performed which the owner did not agree with.
I hope you enjoyed Glens case as much as I did.
