PowerPoint - Mast Cell Tumor

Practical Oncology
Mast Cell Tumor
Wendy Blount, DVM
Mast Cell Tumor
• Mast cell granules contain histamine and
heparin, among other things
• Degranulation is largely responsible for
• Release of histamine
– Increased gastrin secretion (anorexia, ulcers,
– Anaphylactoid reaction
• Release of heparin – less clinically
Mast Cell Tumor
• Most often found on the skin
– Most common skin tumor in the dog
– Brachycephalics & retrievers predisposed
• 2nd most common cancer in dogs
• Also visceral & elsewhere
– Gastrointestinal, Spleen, bone marrow
• Less common sites
– Oropharyngeal
– Mediastinum
– Nail bed, ocular & periocular
Mast Cell Tumor
Can have many different appearances
Can be infiltrated with fat
Symptoms can be waxing and waning
Tumor gets bigger and smaller over time
5-15% have multiple masses at
• 20-50% will have more MCT in the future,
even if the first are cured
Staging for Metastasis
• Allergic skin disease?
• C-KIT mutation (aka SCFR, CD117)
– In “high risk MCT” (high grade II & all grade III)
– These have decreased survival time
– can be treated with tyrosine kinase inhibitors
(Palladia & Kinavet-CA1 )
– SCFR – stem cell factor receptor
– C-KIT normally regulates proliferation,
migration and differentiation
– When C-KIT is mutated, it is constantly turned
on, dysregulating cell growth an promoting
Clinical Signs
• GI Signs
– Anorexia, vomiting, melena
Pruritus and skin flushing
Facial swelling
Weakness, lethargy
Delayed wound healing
Darier’s Sign
– swollen, itchy, red skin after scratching or
stroking the skin
Clinical Signs
• GI Signs
– Anorexia, vomiting, melena
Pruritus and skin flushing
Facial swelling
Weakness, lethargy
Delayed wound healing
Darier’s Sign
– swollen, itchy, red skin after scratching or
stroking the skin
• FNA Cytology often diagnostic
– Round cells with or without granules
– Granules intracellular or in background
– Granules form a halo around the relatively
pale nucleus
– eosinophils
• Give diphenhydramine before or right
after aspiration
– FNA can cause degranulation
– Dexamethasone as well if mass is visibly
Mast cell granules - fine
LSA azurophilic granules – coarse
Lymphoid cells have less cytoplasm than
mast cells
Poorly granulated MCT
Agranular mast cell tumor
Resembles histiocytoma
Staging for Metastasis
• Histopathology for grading
– Excisional if resectable
– Incisional if not
• May not heal well
• Degranulation may be a problem
• FNA draining lymph node
– Clusters of mast cells likely metastasis
– Single mast cells likely not
• Abdominal US with FNA liver and spleen
• CBC, panel, buffy coat
Staging for Metastasis
• Staging less important for high risk MCT
– High grade II & Grade III
– palliative treatment for best outcome
• Palliative drugs, chemo, radiation
– Cure is unlikely, especially for grade III
• Staging more important for single local low
grade II that is not resectable
– If staging is clean for metastasis, then
radiation can be curative (Sadie)
Staging for Metastasis
• Non-resectable MCT
Staging for Metastasis
• Non-resectable MCT
Staging for Metastasis
• Non-resectable MCT
Staging for Metastasis
• Lymph node cytologies
Staging for Metastasis
• Lymph node cytologies
Staging for Metastasis
• Lymph node cytologies
Tumor Stage (WHO)
• Stage 0 – microscopic disease only
• Stage I – tumor confined to the dermis
• Stage II – tumor does not infiltrate
subcutaneous tissues, lymph node
• Stage III – large, infiltrating tumor (or
multiple tumors)
• Stage IV – distant metastasis
Consideration is being given to reducing
stage of multiple dermal tumors
Mitotic Index (MI)
Surgical margins – clean, narrow or dirty
Invasiveness – dermal or invasive
Histopathology tells a great deal about
prognosis and treatment indicated
for mast cell tumors
Staging tells less, unless single
unresectable low grade II
Histopathologic Grading
• Grade I – well differentiated, behaves
benignly (dermal in cats)
• Grade II – intermediate differentiation,
behavior is widely variable
– Low grade II – often behaves benignly
– High grade II – may have C-kit mutation, often
behaves malignantly
• Grade III – anaplastic, aggressive behavior
This is the Patnaik System
Histopathologic Grading
• We used to think grade II unpredictable
• Now that we divide grade II into low and high,
there is much more predictability
• Most path labs now give you high or low grade II
in the report
– Be sure to request this and for border reads
• More information from MSU prognostic panel
(form) - $210
• Obsolete system has grade I the worst and grade
III the best prognosis
• Mainstay of low grade MCT treatment
• Mast Cell Tumors often extend well beyond
the visible mass
• Diagnose by FNA before you excise
• Lateral margins 2-3 cm beyond visible mass
– Small tumors <1 cm, 1.5-2cm margins may be
• One fascia layer deep to visible mass
• Avoid manipulating the tumor
• Intraoperative cytologies on 4 lateral and
deep margins can be helpful
Prednisone for pre-surgical cytoreduction
• Out of favor by oncologists at this time
• I still like use it
– Stabilizes lysosomal membranes – may
prevent degranulation caused by surgery
– Controls inflammation around the tumor so
tumor borders are easier to see
– Usually makes the dog feel better, so client
perceives better toleration of surgery
• Prednisone 40 mg/m2 PO SID x 7days, then
20 mg/m2 PO SID x 7days, then QOD
Re-excision where borders are dirty on
grade I or II
• Grade III tumors considered systemic
– More surgery only for local palliation
• 3 cm beyond original surgery
• One fascia layer deeper than original
• Complete resection results in long survival
• If clean borders, 95% cured with second
excision, using these rules
NeoAdjuvant Therapy
• Given to a patient with non-resectable
tumor in hopes of making it resectable
• Chemotherapy and/or radiation
• Best managed by medical and/or radiation
• Need to understand effects of neoadjuvant
therapy on healing and when and how to
do surgery
• Not indicated for multiple dermal MCT that
are cured by excision
• To deal with multiple dermal MCT when
removing all becomes impossible
• To deal with MCT at the tumor borders when
radiation not possible
– Radiation more likely to be curative
• To improve post-surgical prognosis for high
risk grade II and all grade III MCT
• To palliate metastatic or systemic disease
• Surprisingly, there are few studies to evaluate
efficacy of various protocols
Two categories:
1. Traditional chemo
VP – vinblastine prednisone
CCNU – popular 20 years ago
Alternating VP and CCNU
CVP – cyclophosphamide vinblastine pred
2. TKI – tyrosine kinase inhibitors
– Palladia
– Kinavet
Vinblastine and prednisone (VP)
• Median survival 134 days (5 months) – gross
disease after surgery
• Median survival 1013 days (3 years) – microscopic
disease after surgery
• 45% survival at 2 years
• Half of these had surgery prior to chemo
• Most grade III have gross disease after surgery
– Most dead in 2-6 months
– All gone within the year
• Vinblastine 2-2.2 mg/m2 IV slow IV push once
weekly for 4 weeks, then every other week for 4
• Prednisone 40 mg/m2 PO SID, then 20 mg/m2 PO
SID x 2 weeks, then 20 mg/m2 PO QOD (intervals)
• 60-70 mg/m2 PO q3-4 weeks
– 4 week interval the first time, then shorten if
symptoms return during the 4th week
– Baseline liver tests (ALT, SAP, albumin, bile acids)
– Pretreat with diphenhydramine
• Check before 3rd dose and then prior to each
• Stop if signs of liver disease to prevent liver
• 6-8 doses common maximum
– I have reached 12 at most
• Grade III median survival 2 months
Alternating VP and CCNU
• Alternate vinblastine and CCNU every 2
weeks for a total of 8 treatments
– Doses on previous slides
• Prednisone 2 mg/kg PO SID tapered gradually
to maintenance dose of 0.5 mg/kg PO SID x 6
• Macroscopic disease grades II and III
– 3 remission, 4 PR
– median duration of response 58 days
• 2 patients did not reach 4th CCNU treatment
due to ALT >1000
Vinblastine, prednisone, cyclophosphamide
• All dogs had either high grade II with
lymph node metastasis or grade III MCT
• Dogs with macroscopic disease:
– 4 grade II, 7 grade III
– 64% had a measurable response to treatment
• 46% CR, 18% PR
– 18% SD, 18% PD
– Median PFST was 74 days
– Median OST was 145 days
– 54% also had radiation treatment
Vinblastine, prednisone, cyclophosphamide
• Dogs with microscopic disease:
– 22 grade II, 3 grade III
– 10 recurrent disease, 2 multiple tumors, 13
first time single tumor
• Two subgroups:
– A – 19 dogs with local microscopic disease.
• Median PFST was 222 days (7 months)
• Median OST was >2092 days (6 years)
– B - 5 dogs with absolute local control (ALC)
• Median PFST was 865 days (2.5 yrs)
• median OST was >1261 days (3.5 years)
Vinblastine, prednisone, cyclophosphamide
• Protocol:
– Prednisone 1 mg/kg PO SID, tapered and
discontinued over 24 – 32 weeks
– Week 1 - Vinblastine 2-2.2 mg/m2 IV
– Week 2 - Cyclophosphamide 200–250 mg/m2
either PO over 4 days or IV on day 1
– Week 3 – prednisone only
– Continue 3 week cycle for 6 months, or until
death or chemo abandoned
• Vincristine alone not effective for MCT
• Historically, many dirty border grade II did very
well with most chemo protocols
– many months, years or cured
• Historically, some grade II with dirty borders
spontaneously resolved
– Are malignant MCT indistinguishable from
inflammatory reaction?
• Now that we can divide grade II into low and high
grade, prediction of behavior is more accurate
• Even so, even high grade II with dirty borders or
metastasis can do very well with chemo and/or
• Grade III is still way worse than high grade II
Chemotherapy - Summary
• Traditional chemo
– VP or alternating VP & CCNU preferred to CCNU
alone for grade III
– Studies comparing traditional to TKI not available
– many oncologists prefer TKI as first line therapy
for high risk MCT
– Others do traditional chemo, then follow with TKI
– Many oncologists feel that if there is a good
response to TKI, it is more durable than
traditional chemo
– Side effects of TKI are not common in the first 6
weeks, but eventually occur, can be significant
and potentially life threatening
Palladia and Kinavet-CA1/Masivet
• Tyrosine kinase (TKI) inhibitors
• Prednisone and TKI are the chemo drugs
with direct cytotoxicity for MCT
– Probably the most effective chemo for high
grade MCT
• Not appropriate for low grade MCT due to
A game changer for high grade very large
Palladia and Kinavet-CA1/Masivet
• 25% of grade II & III MCT have C-KIT
• Blocking wild type or mutated KIT causes
apoptosis in MCT
• antiproliferative through KIT blockade
• antiangiogenic through other MOA
Palladia and Kinavet-CA1/Masivet
• Indications for use:
– Dogs >11-15 lbs only (not cats)
– Non-resectable MCT
• Dirty borders after re-excision
– Multiple diffuse or coalescing high grade MCT
– Concurrent conditions precluding surgery or
multiple sedations for radiation therapy
– High grade MCT or C-KIT mutation
– Indicated with or without metastasis
– Post Chemo – VP x 4 weeks, then Palladia
Palladia and Kinavet-CA1/Masivet
• Though both are TKIs, there can be resistance
to one but not the other
– If one fails, try the other
– Stable disease is a victory with either
• Palladia has more broad spectrum activity,
and is thought to be more likely to cause
clinical response than Kinavet
• Kinavet response can take up to 2-3 weeks
• Gleevec is a TKI used in people, but it is very
expensive ($100-150 per pill)
– Palladia $6-800, Kinavet $500 /month - 70lb dog
Kinavet Administration
• 12.5 mg/kg PO SID
– Dose chart on package insert (Client Info)
– Cannot be used in dogs weighing less than 15
• Dose reduction in response to adverse
– stop Kinavet for 1-2 weeks
– Reduce dose to 9 mg/kg/day when resumed
• Weekly CBC/panel for the first 6 weeks
– Then every 3 weeks x 2
– Then every 6 weeks thereafter
Palladia Administration
• 2.5 mg/kg PO QOD (or MWF)
– Dose chart on package insert is higher
– With or without food
• Dose reduction in response to adverse events
– Stop Palladia for 1-2 weeks
– 0.5 mg/kg reduction when reduced
– Minimum dose 2.2 mg/kg PO QOD
• Weekly CBC/panel for the first 6 weeks
– Then every 3 weeks x 2
– Then every 6 weeks thereafter
Palladia Administration
• GI side effects common
– Make sure owner knows to STOP drug if
anorexia, vomiting, diarrhea
• Dispense Cerenia and metronidazole at
the first visit to have on hand
• Administer H1 and H2 blockers
Palladia Study – Bergman & Clifford, 2009
• Dogs with progressive disease on the
blinded phase could enter open-label
phase at any time
Palladia Study – Bergman & Clifford, 2009
• Statistically significant improvement in
objective response rate
Palladia Study – Bergman & Clifford, 2009
• 57.2% did not respond
• Among responders, median duration of
response was 12 weeks (3 months)
• Median time to non-response or death was
18 weeks (4-5 months)
• 82% of dogs with C-KIT mutation responded
• 54% of dogs without mutation responded
• There was a placebo response
– Likely due to spontaneously resolving
• Clin Cancer Res 2009; 15:3856-3865.
Palladia Side effects
Palladia Side effects
• Dec. albumin – 13% Palladia, 8% Placebo
• Palladia given long term leads to
glomerular disease and renal failure
• While this side effect is severe, it is
balanced against the grave prognosis of
high grade MCT
Palliative Drug Therapy
• Alone, or accompanying chemo and/or
• Prednisone 40 mg/m2/day
– Wean gradually to 0.5 mg/m2/day
• Antihistamines daily
• H2 blocker or proton pump blocker
– Cimetidine, ranitidine, famotidine
– Omeprazole, esomeprazole
• sucralfate if ulcerated
– Hematemesis, melena
Radiation Therapy
• Curative
– Low grade II non-resectable MCT without
distant metastasis
– Grade II Stage 0 MCT with dirty margins
• Disease free interval is increased compared to no
• Similar outcome to re-excision (95% cure)
• Palliative
– Non-resectable high grade MCT
– Regional lymph node metastasis
• No indication to irradiate grade II MCT
with clean borders
Treatments Not Recommended
• Deionized water injections
– At one time recommended for cytoreduction
prior to surgery
– Subsequent studies have proven ineffective
– Risk causing degranulation
– Pain on injection
• intralesional Vetalog or DepoMedrol
– Historically for those dogs who have too many
dermal MCT to remove and no evidence of
systemic disease
– replaced by TKI or palliative drugs
• Stage and grade much more important for
MCT and than for LSA
– Grade I with clean borders are cured by surgery
– Low grade II clean borders usually cured by
surgery and/or radiation
– High grade II clean borders should probably have
adjunctive chemo and/or radiation
– High grade II with dirty borders should definitely
have adjunctive chemo and/or radiation and may
have poor prognosis
– Virtually all of grade III die of their disease, often
within a few months, unless very small with clean
Indicators of poor prognosis
• Dirty borders after re-excision
• High grade, advanced stage, MI >5
• Breed- Shar pei
• Systemic signs due to degranulation
• Size and growth rate
• Location – perineum, scrotum, nail bed,
mucocutaneous, muzzle
• C-kit mutation and other histopath
prognostic indicators (MSU/AMC panels)
Indicators of better prognosis
• Clean borders on excision
• Low grade, low stage, MI <5
• Breed – Boxers and Pugs
Indicators of better prognosis
• Clean borders on excision
• Low grade, low stage, MI <5
• Breed – Boxers and Pugs
Indicators of better prognosis
• Clean borders on excision
• Low grade, low stage, MI <5
• Breed – Boxers and Pugs
Multiple primary mast cell tumors do not
necessarily worsen prognosis
• Dogs who tend to get one dermal MCT
tend to get more, simultaneously or
• Warn owners to look for more when you
remove the first
MCT prognostic panel
• Not indicated for grade I or III
• gives more information for grade II
• Do chemo/radiation if high grade II
• Amputate or radiate non-resectable low
grade II
• Cost is about $210 plus shipping
• Send MCT histopath to MSU or AMC, so you
can add the prognostic panel if grade II
• Save center of tumor in formalin to send to
MSU /AMC for panel later if grade II
• Can be difficult to get unstained paraffin
sections from the first lab (except TVMDL)
Client Handouts
Mast Cell Tumors
Chemo agents discussed Sunday
• Philip J. Bergman, DVM, MS, PhD, DACVIM
VIN Consultant, CMO BrightHeart Vet Centers
• Louis-Philippe de Lorimier, DVM, ACVIM
VIN Consultant, U of Ill Urbana-Champaign
Visiting assistant professor, medical oncology
• Karri A. Meleo, DVM, ACVIM (Oncology), ACVR
VIN Consultant, Vet Onc Serv, Edmonds, WA
• Robert C. Rosenthal, DVM, BS, MS, PhD
VIN Consultant
• Kurt R. Verkest, BVSc, BVBiol, MACVSc (Small
VIN Associate Editor, Univ Queensland, Australia
• Claudia Barton, DVM, ACVIM (Internal
Medicine, Oncology)
• Craig Clifford, DVM, MS, ACVIM (Oncology)
VIN Consultant
• Zachary Wright, DVM, ACVIM (Oncology)
Animal Diagnostic Clinic, Dallas TX

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