Nasal Cavity Tumors

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Article Written by Dr. Daniel A. Degner, Board-certified Veterinary Surgeon (DACVS)

Key Points

Nasal tumors are locally invasive and have a lower tendency to spread early in the course of the disease

Radiation followed by surgery seems to provide the longest survial times

Chemotherapy may be an option if radiation therapy is not an option


Introduction

  • Cancer of the nasal cavity accounts for 1% of all cancers in the dog.
  • About 80% of all nasal tumors in dogs are malignant.
  • Nasal cavity cancer tends to be a locally invasive disease. Late in the course of the disease, the cancer can spread to other parts of the body, with the lungs being the most common site. In one study, 0 to 12% of cases were found to have metastatic disease at the time of diagnosis; however, at the time of death, 46% of the dogs had evidence of spread of the cancer to lymph nodes and lungs.
  • The most common type of cancer that affects the nasal cavity in dogs is the carcinoma. This type of cancer includes nasal adenocarcinoma, squamous cell carcinoma and undifferentiated carcinoma and consists of 2/3's of all types of nasal tumors.

Clinical signs

  • The average age of dogs with nasal cavity cancer is 10 years and males are slightly more affected by this tumor than females. Medium to large breeds more commonly develop nasal cavity cancer than small breeds.
  • Clinical signs of nasal cancer include bleeding from the nose, white, yellow or green nasal discharge, deformity of the face and tearing from one or both eyes.

Diagnosis

  • Although the aforementioned clinical signs can be due to intranasal cancer, other causes may include high blood pressure, fungal infection and allergies. If your pet has depigmentation of the nose and nasal discharge, fungal infection is likely to the be cause versus cancer.
  • The first tests that are run include blood work such as a complete blood count, biochemistry profile, urinalysis and clotting profile.
  • Chest radiographs (x-rays) are made to evaluate that patient for spread of the tumor to the lungs.
  • Radiographs of the nasal cavity are generally of little diagnostic value to the clinician, therefore CT scan is recommended. This diagnostic modality will give the veterinarian a very good idea as to the type of disease process present (cancer vs. fungal infection) and the extent of the disease.
  • Definitive diagnosis of a nasal tumor is based on the evaluation of a biopsy of the tumor and is typically performed at the time of a nasal CT scan. Anesthesia is required for both procedures.

Treatment options

  • No treatment is an option, however survival times following diagnosis of a malignant intranasal cancer is quite short. One study showed a median survival time of 95 days. Dogs that had bloody nasal discharge had a median survival time of 88 days versus those dogs that did not have blood in the nasal discharge had a median survival time of 224 days.
  • Surgery alone results in median survival times that are less than six months, therefore is not recommended as the sole treatment.
  • Surgery followed by orthovoltage radiation therapy resulted in a median survival time of 23 months in one study, however other studies have not been able to reproduce these results. The type of radiation therapy seems to play a role in patient survival. One study which included 42 dogs, showed that surgery and orthovoltage radiation therapy was inferior to megavoltage radiation therapy reported in other studies.
  • Radiation therapy followed by surgical removal of the contents of the nasal cavity has given the longest survival times. In Adam's study (2005) of 53 dogs, the median survival time was 19.7 months with radiation alone and 47.7 months with 10 doses of 4.2 Gy per dose and subsequent surgery. Currently, this seems to be the best treatment for dogs that have intranasal tumors.
  • Photodynamic therapy (injection of the patient with a special light sensitizer and illumination of the site with a special light) has been reported in 4 cases and resulted in clinical remission of the cancer in the patients that had epithelial tumors, but not the dog that had a sarcoma.
  • Chemotherapy (carboplatin, adriamycin and piroxicam) has been reported in a series of 8 cases, in which 75% responded to treatment. Disease free intervals in the responding patients ranged from 150 to 510 days. This treatment may be a consideration if radiation therapy is not an option.

Complications

  • Recurrence of the tumor in most cases is expected.
  • Chronic nasal discharge and recurrent infection in the nasal cavity is a common problem following radiation and surgery of the nasal cavity, thus intermittent treatment with antibiotics may be needed.
  • Side effects of radiation include:
    • loss of hair over the bridge of the nose
    • chronic nonhealing wounds over the bridge of the nose
    • mucositis (sores in the mouth)
    • brain damage
    • blindness due to cataracts or damage to the eyes
    • oronasal fistulae - a hole that develops in the mouth that communicates with the nasal cavity

Summary of prognostic factors in dogs

  • Dogs afflicted with a nasal cavity tumor tend to have a shorter life span with
    • bloody nasal discharge
    • age greater than 10 years
    • sex: males
    • metastasis of the cancer at the time of diagnosis
    • failure of resolution of clinical signs following radiation therapy
    • please note that just because your dog may have one or more of these factors does not mean that treatment will not extend quality of life

Specifics about cats and nasal cavity tumors

  • Ninety-two percent of all nasal cavity tumors are malignant.
  • Lymphoma is the most common cancer that affects the nasal cavity in cats. In a study of 123 cats afflicted with nasal cavity cancer, the second most common cancer was carcinomas (adenocarcinoma and squamous cell carcinoma). Older cats are generally affected with a median age of 9 months in one study.
  • The most common clinical signs include nasal discharge, sneezing and vomiting. Other signs include loss of appetite, breathing difficulty and decreased activity.
  • On study showed that lymphoma may be localized to the nasal cavity (in about one third of the cases) and radiation therapy may be the treatment of choice. Cats that are infected with Feline Leukemia Virus or Feline Immunodeficiency Virus generally do not do as well and development of lymphpoma in other parts of the body are quite possible. Almost all cases are B-cell lymphoma. Nasal lymphoma tends to be more resistant to chemotherapy than other forms of lymphoma.
  • In a report of 19 cats that had stage 1 intranasal lymphoma, treatment with radiation and chemotherapy resulted in a disease free interval of 31 months and a median survival time of 31.4 months. Based on the fact that 17.6% of the cases had recurrences in distant locations, radiation therapy is not recommended as a sole treatment and chemotherapy should be also used.
  • In a series of 8 cats with nonlymphomatous intranasal tumors treated with course fraction megavoltage radiation (4 to 6 treatments) the median survival time was 382 days.

References

  1. Malinowski C. Canine and feline nasal neoplasia. Clinicial techniques in small animal practice 2006; 21:89-94.
  2. Demko JL, Cohn LA. Chronic nasal discharge in cats: 75 cases (1993- 2004). J Am Vet Med Assoc
    2007;230:1032–1037.
  3. Rassnick KM, Gldkamp CE, Erb HN, et al. Evaluation of factors associated with survival in dogs with untreated nasal carcinomas: 139 cases (1993-2003). J Am Vet Med Assoc 2006;229:401–406.
  4. Mukaratirwa S, van der Linde-Pipman JS, Gruys E. Feline nasal and paranasal sinus tumours clinicopathological study, histomorphologial description and diagnostic immunohistochemistry in 123 cases. J Fel Medicine and Surgery 2001; 3: 235–245.
  5. Mellanby RJ, Herrtage ME, Dobson JM. Long-term outcome of eight cats with nonlymphoproliferative nasal tumours treated by megavoltage radiotherapy. Journal of Feline Medicine and Surgery 2002;4:77–81.
  6. Litle L, Patel R, Gldschmidt M. Nasal and nasopharyngeal lymphoma in cats 50 cases 1989 to 2005. Vet Pathol 2007;44:885–892.
  7. Adams WM, Bjorling DE,McAnulty JF, et al, Outcome of accelerated radiotherapy alone or accelerated radiotherapy followed by exenteration of the nasal cavity. J Am Vet Med Assoc 2005;227:936–941.
  8. Geiger T, Rassnick K, Siegel S, et al. Palliation of clinical signs oin 48 dogs with nasal carcinomas threated with coarse-fraction radiation therapy. J Am Anim Hosp Assoc 2008;44:116-123.
  9. Lucroy MD, Long KR, Blaik MA et al. Photodynamic therapy for the treatment of intranasal tumors in 3 dogs and 1 cat. J Vet Intern Med 2003;17:727–729.
  10. Sfiligoi G, The'on AP, Kent MS. Response of 19 cats with nasal with nasal lymphoma to radiation therapy and chemotherapy. Vet Radiology & Ultrasound, Vol. 48, No. 4, 2007, pp 388–393.
  11. Northrup NC, Etue SM, Ruslander DM et al. Retrospective study of orthovoltage radiation therapy for nasal tumors in 42 dogs. J Vet Intern Med 2001;15:183–189.
  12. Henry CJ, Brewer WG, Tyler JW, et al. Survival in dogs with nasal adeoncarcinoma 64 cases 1981 to 1995. J Vet Intern Med 1998:12:436-439.
  13. Langova V, Mutsaers AJ, Phillips B, Straw R. Treatment of 8 Dogs with Nasal Tumours with Alternating Doses of Doxorubicin and Carboplatin in Conjunction with Oral Piroxicam. Australian Veterinary Journal 2004;82(11):676-680.

Frequently Asked Questions After Surgery

When should my dog have the first bowel movement after surgery?

  • Many dogs will not have a bowel movement for the first 4 to 5 days after surgery
  • Reasons that a dog will not have regular bowel movements after surgery include:
    • The dog has been fasted prior to surgery
    • Dogs do not eat well during the hospital stay
    • They frequently do not eat well when they go home
    • They are fed highly digestible food that produces little stool
    • Pain medication that contain narcotics (such as morphine, fentanyl patches, and tramadol) can be constipating
  • If a pet does not have a bowel movement on the 5th day of being home, a stool softener such as metamucil can be fed
    • Dose of metamucil is 1 tsp per 25 Kg mixed in with each meal (canned dog food); feed immediately after mixing, as the metamucil will gel the food and may make it less palatable

My pet had surgery and will not eat.  What can be done?

  • Dogs
    • Most pets will not eat their regular dog food after surgery, especially if it is kibble.
    • Offer a cooked diet having a 1:1 ratio of a protein source and carbohydrate source.  The protein source can be any meat (example: chicken breast, turkey breast, lean hamburger) that is low in fat and should be cooked (drain off all fat after the meat has been cooked).   The carbohydrate can be pasta, potato or white rice.
    • Try canned dog food; to enhance the flavor sprinkle a very small amount of garlic powder or chicken or beef broth (Chicken-in-a- MugTM or Beef-in-a-MugTM products)
    • Try Gerber strained meats for babies such as the chicken, beef, turkey, or veal
    • Try Hill's A/D diet available at most veterinary hospitals
    • Hand feeding: place a small amount of food in the mouth so that your dog gets the flavor
    • Warm the food slightly in a microwave, as the food will be more aromatic; stir the food before feeding and test the temperature on the bottom side of your wrist; it should only be luke warm.
    • Remember that most pets will not eat the first day or two after they get home from surgery
  • Cats
    • Offer smelly foods that contain fish such as tuna or smelly cat foods
    • Try Gerber strained meats for babies such as the chicken, beef, turkey or veal
    • Hand feeding:  with your finger place a small amount of food on the roof of your cat's mouth; use a syringe to get soft food into the mouth
    • Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature; it should be only luke-warm
    • Some cats will only eat dry food, try kibble if your cat normally has been fed that food
    • Petting and stroking your cat frequently will help to stimulate appetite
    • Remember that most pets will not eat the first day or two after they get home from surgery
    • Appetite stimulants such as cyproheptadine may be helpful
    • If your cat refuses to eat anything for 7 days a stomach tube or nasogastric tube should be placed to provide nutrition so that a serious liver problem (hepatic lipidosis) does not develop

My pet is vomiting.  What can be done?

  • The first thing for you to discern is whether your pet is vomiting or regurgitating.  Both will result in fluid or food being brought up.  Vomiting always will have heaving or retching of the abdomen prior to expulsion of the vomitus.  Regurgitation is not associated with heaving and the pet usually just opens the mouth and fluid or food will be expelled.  Usually the regurgited material will be clear or brown colored fluid. 
  • Next is to identify the cause of the vomiting or regurgitation.
  • Causes and treatment of vomiting after surgery
    • When some pets return home after a stay in the hospital they may drink excessive amounts of water at one time and then vomit; if this appears to be the case, the water should be limited to frequent smaller amounts.
    • Medications such as antibiotics, narcotics or nonsteroidal anti-inflammatory medication commonly cause vomiting after surgery.  In order to see which medication is causing the problem, the administration of each drug should be separated 2 hours apart.  Usually the pet will vomit or appear nauseated (drooling and sick look) within 1 hour of administration of the medication that they are sensitive to.  The antibiotic in some cases may be changed to a different one, or may be discontinued. 
    • Stomach upset from anesthesia is a potential cause of vomiting and will pass within a couple of days. 
    • An uncommon cause of vomiting after surgery is internal organ failure.  Blood testing will confirm this problem. For this reason vomiting should not be ignored if it persists for more than 24 hours.
    • If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it may indicate that infection of the abdominal cavity, called peritonitis, is present.  Do not ignore this sign.
    • Symptomatic treatment of vomiting involves withholding food for 12 to 24 hours, then introducing small amounts of bland food such as rice and lean cooked hamburger, if your pet does not vomit after that then gradually wean him/her back onto the regular diet after 3 days.  In order to decrease the acidity of the stomach, Pepcid AC 0.5 mg/kg can be given by mouth twice daily for 5 days.  Metoclopramide and Cerenia are good anti-vomiting medications for dogs and cats.  You should always consult a veterinary healthcare professional before administering medication.
  • Causes and treatment of regurgitation after surgery
    • The most common cause of regurgitation is reflux of acid from the stomach into the esophagus while your pet is under anesthesia.  Acidic fluid from the stomach can cause a chemical burn of the esophagus and result in a bad case of heart burn, called esophagitis.  This results in poor motility of the esophagus, therefore water and food will accumulate in this structure.  In most cases, esphagitis is self-eliminating and will resolve within two or three days. 
    • If the esophagitis is severe the esophagus may develop one or more strictures.  A stricture is a narrowing or stenosis of the esophagus and does not allow passage of food down the esophagus, in regurgitation that lasts longer than one week.  This problem should be brought to the attention of your pet's doctor within the first two weeks so that it can be treated by ballooning the stricture (minimally invasive procedure, as it is done with the aide of an endoscope).  If an esophageal stricture is chronic surgery is needed.
    • Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland food, and administering a coating agent (sucralfate) and an acid blocker (omeprazole or other).  Consult a veterinary health care professional if the regurgitation continues for more than a couple of days.

How do I know that my dog is in pain following surgery?

  • Signs of pain include
    • crying
    • biting if you get near the surgical site
    • grimacing (lips are pulled back and the the dog looks anxious)
    • tragic facial expression
    • panting
    • restlessness and unable to sleep; pacing
    • if abdominal surgery was done the pet will not lie down on the incision, or will continually sit up in spite of appearing very tired
    • the worst pain will be for the first 2 to 3 days after surgery

What can I do to control my dog's pain?

  • Narcotic medications that control pain: tramadol, butorphanol, Duragesic (fentanyl patch)
  • Anti-inflammatories used to control pain: Deramaxx, Rimadyl, Previcox, or Etogesic
  • If an orthopedic surgery has been done cold packing the surgical site may be helpful
    • A cold pack may be a pack of frozen peas, crushed ice in a Ziploc bag, or a cold gel pack; place a thin barrier between the skin and the cold pack.  An alternative to a cold pack is to freeze water in a styrofoam cup; after frozen cut the bottom of the styrofoam cup out. Cool the surgical site around the incision by rubbing the exposed ice directly on the skin in a circular pattern.  Cooling the surgical site helps to numb the area.

How do I know that my cat is in pain following surgery?

  • Pain is more difficult to assess in cats versus dogs, as signs can be more subtle and they usually do not vocalize when in pain
  • Signs of pain in a cat include the following:
    • biting if you get near the surgical site
    • growling or deep cry
    • not wanting to eat
    • hiding and not wanting to be near owner (remember that this could also be caused by the cat just being upset about leaving home and coming back)

What can be done for pain at home for my cat?

  • Pain medication such as buprenorphine or a Duragesic (fentanyl) patch
  • Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver
  • Anti-inflammatories can be used, but the dose is much less than dogs

Is it okay for my pet to lick the incision?

  • If a dog licks the incision, the healing process may be delayed.
  • Licking can remove stitches and cause the incision to open
  • Licking can become a severe habit that is difficult to break
  • Licking can cause infection as the mouth has many bacteria
  • Dogs will frequently lick the incision when the owner is not watching such as at night time; if the skin looks red or excoriated the most common cause is from licking.
  • To stop your pet from licking the following can be tried:
    • Elizabethan collar can be placed on the neck; this will not help stop your pet from scratching at the region
    • Cervical collar (bite not collar) is a less awkward device and can be effective at stopping a pet from licking the surgical site
    • A tee shirt can be used to cover an incision on the chest or front part of the abdomen; gather the waist of the shirt up over the dog's back and wrap an elastic band around this part of the shirt.
    • A bandage or sock can be used to cover an incision on a limb; fasten the top of the sock to the dog's limb with tape.
    • Bitter apple can be applied around the incision; many dogs will continue to lick  after application of this topical
    • Bitter Apple and Liquid HeetTM (obtain this from a drugstore...it is used for sore muscles) mixed in a 2:1 ratio can be applied around the skin incision
    • Antipsychotic medication in some cases is needed

Board-certification by the American College of Veterinary Surgeons

What does it mean?

  • Four years of advanced training in surgery beyond the Doctor of Veterinary Medicine Degree

  • Experience in the development of new surgical treatments

  • Rigorous examination by the American College of Veterinary Surgeons to ensure competency in advanced surgical techniques

  • Assurance that a veterinarian is a surgical specialist

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