In this enlightening episode of Speaking of Pets, we welcome back Dr. Rance Gamblin, a renowned veterinary oncologist and new associate professor at Mississippi State University College of Veterinary Medicine. Join hosts Alice and Janet as they dive deep into the complex landscape of pet cancer, exploring the latest advancements in diagnostics, treatments, and preventative care.
The episode kicks off with a charming introduction to Dr. Gamblin’s adorable nine-week-old puppy, setting a light-hearted tone as they discuss the importance of routine veterinary care. Listeners will learn about essential blood tests, the significance of monitoring trends in lab results, and the potential of emerging cancer screening tests. As the conversation unfolds, Dr. Gamblin shares his expertise on various types of tumors, including melanoma and mast cell tumors. He emphasizes the importance of early detection, the nuances of treatment options, and the unpredictability of cancer outcomes in pets. The duo also tackles the role of vaccinations in managing cancer and discusses the latest research on hemangiosarcoma and its treatment options.
With heartfelt anecdotes and practical advice, this episode serves as a vital resource for pet owners who want to be proactive about their furry friends’ health. Tune in for a blend of expert knowledge, personal stories, and an unwavering commitment to improving the lives of pets everywhere. Don’t miss out on this essential conversation; your pet’s health could depend on it!
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All footage is owned by SLA Video Productions.
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Listen to the Podcast here
Discussing New Developments In Canine Cancer
Are you keeping him?
Yes. This is the pick of the litter.
He is fabulous. This is your first TV show. Look at him. He’s a smart one. Look how smart he is. Are you cute?
We had a big morning. We went out. We were retriever training with all the big dogs.
He’s probably going to sleep now.
That is certainly is the hope.
If anyone wants to know about how cute this dog is, this dog is owned by Dr. Rance Gamblin, our favorite veterinary oncologist and new Associate Professor at Mississippi State University College of Veterinary Medicine. Welcome, Rance. Thanks for coming back on the show.
Thank you.
Preventative Diagnostics & Monitoring
By the way, my co-host Janet is off somewhere. She apologizes. She needed a note to be excused. We want to talk to Dr. Gamblin with so much cancer going on with our pets. Are there any blood tests like a serum profile or what shows up in a CBC? What can we do preventatively? That little guy that you had in there, what are your plans for him, Rance, to keep him healthy?
Obviously, I think the best thing is to have a good relationship with your primary care veterinarian and following their recommendations. A lot of the stuff, quite honestly, on the referral side, I think that sometimes the primary care veterinarians maybe sometimes hear about that stuff before we even do, quite honestly.
I certainly feel like it’s a good idea on even on your younger dogs probably having complete labs and that type of thing checked on these guys at least probably once a year or so as they’re younger. Maybe bumping that up to maybe even every six months, as they get to be in their prime of life and then on into other geriatric years. I think just routine monitoring of complete blood count, chemistry panel, urinalysis, thyroid, that type of stuff is a very good idea.
There are certainly are some new diagnostic blood tests that are being out there that are touted by some of the laboratories as being cancer screening tests and that type of thing. A lot of those were coming out about the time that I was retiring. I don’t necessarily have a lot of experience with them myself as far as being able to tell you exactly how I feel about them. I hope that they are going to end up having a place as being able to non-invasively screen these guys over time.
That’s how I feel too. I’ve read about those. I’m thinking it’s like when color TV first came out. I’m waiting for the perfection of it. Having said that, as a nervous and OCD pet owner and a veterinarian, like you, I can run blood work anytime I want. I’ve got these 3 and 4-year-old. They’re rescues. I did blood work as soon as I got them. I do it now every year. When they get a few years older, they’re going to have it every six months.
I think it’s a good idea.
Yeah, don’t you agree?
Yeah, I do. Quite honestly, I think sometimes it comes down to just being able to look at that laboratory work and really interpret it. Certainly, that’s not necessarily something that we expect an owner to be able to do, but I think it’s important to look at trends, to really look at the values. Just because it’s not flagged as being abnormal doesn’t mean that you may not glean some information that may help you head off a problem.
It’s important to look at trends and values over time. Just because something isn’t flagged as abnormal doesn’t mean you can’t glean information that might help prevent a problem. Share on XIf you’re seeing that your dog’s red cell count is slowly ticking downward or our calcium, certainly, if that’s starting to slowly tick up, those types of things. It doesn’t mean that you do have a problem, but at the very least it should be an indication that maybe this is something we should be watching more closely. Is this an anomalous lab value or is this actually a real abnormality that we need to be concerned about?
I agree with you about the trends. The other thing, too, that I’ve never failed to be amazed, sadly, is I can have a dog right here with normal blood work that has cancer, has a big tumor somewhere. The complete blood count or what we call CBC and serum profile, which is potassium, sodium, kidney, liver, it tells us stuff, but doesn’t tell us everything.
No, and in fact, that always was a very common conversation that I would have with clients in the exam room. They can’t believe that their dog has cancer because they just had laboratory work done three weeks ago or a week ago and their laboratory work’s all normal so they can’t have cancer. I think I’ve even said this before. Quite honestly, if my patient is not doing well and their laboratory work is normal, I’m actually more concerned about them.
Quite honestly, if my patient isn’t doing well but their lab work is normal, I’m actually more concerned. Share on XI actually became more concerned about it because I’m sitting here, certainly finding problems like with kidney disease or liver disease or whatever else, while that’s not something that you necessarily want to find, it at least answers the question of why are we having problems. Everything is down the line normal, my index of suspicion goes up rather than down, I guess is the best way to put it.
I also think anything out of the norm for that pet, they’re creatures of habit. I remember I adopted from Golden Treasures, at age eleven, a golden retriever, Cindy. She was a great walker and we walked Hinckley Lake almost every day. I remember about three years later, she just didn’t want to walk. We got out of the car, she just stood there. Everything else seemed fine. She ended up having a brain tumor. You can have such subtle signs. I would have never attributed not wanting to walk to a brain tumor. The moral of the story was it was something different from her regular routine. I think that is a red flag for all of us with pets.
For sure. Clients are typically or very in tune with their pets. If I had a client telling me that they’re just not right, there’s something not right here, I’m inclined to believe them. That does not necessarily mean that my job just got easier. At the very least, maybe the things that they’re telling me may give me some direction as far as what should be the next things that we start to look at to help us maybe narrow down where that problem really lies.
Clients are typically very in tune with their pets, so if a client tells me something isn’t right, I’m inclined to believe them. Share on XI think something you and I have in common is if there’s a skin bump, lump, or mass, it needs to be aspirated. Meaning a needle, it doesn’t even hurt. Stick it in there, suck some of the cells out. That’s not a biopsy. It’s called a cytology or an aspirate. You got to find out what that is.
I agree, for sure. Looking at every one of those little lumps and bumps is probably not a bad idea and just making sure that you aren’t dealing with a problem. I actually had to laugh. I was actually at a hunt test and my veterinary kit, as you might imagine, is a little bit different than most people’s. I’m getting called over to look at a friend’s dog, saying, “What do you think about this lump,” or whatever else. Actually, I’ve got a slide case in my truck right now that I need to drop by Metro and stain it and go look at it and see what’s going on. I’m doing it on the tailgate of a truck.
I met a fellow dog walker at the park and he had a golden and another breed, their heads were sticking out the back window. I said, “They’re so cute.” I’m petting and I felt this lump, and I said, “How long’s that been in there? You need to have that aspirated.” “Yeah, I was going to do that.” I said, “Okay, when are you going to be here next?” You’re right. I did it in the trunk of my car. I brought the aspirate and I said, “What’s your phone number? I’m going to take it home and stain it and call you.” No charge.
I was telling somebody I think I did more veterinary medicine this past weekend than I’ve had since I retired. I’m going to actually have to restock my medical bag with a wide variety of items after doing that little test.
Let me tell you, you can get a personal account with MWI if you haven’t already done that.
I have not done that. Maybe I need to.
Yes, I have one, that way, I can buy microscope slides and heartworm preventative and all that stuff. Make sure you do that. Just a little retiree-to-retiree info.
Yeah, get with me later.
Melanoma: Sites, Appearance, & Prognosis
I will. Now, I want to talk about specific skin tumors. Let’s start with melanoma. For example, melanoma, where on the body should I be most concerned or everywhere, and what breeds do you think you see it the most in?
As far as sites, my general rule has always been if it’s on haired skin, I am a lot less concerned. Seemed like just seeing a lot of melanomas in practice, maybe about once or twice a year, I would have a haired skin melanoma that I was actually concerned about from a biopsy standpoint. Most of the time, those were biologically pretty benign.
You’d go surgically take them off then?
Right. Yes, surgically taken off, that type of thing, and you get your biopsies back. There are special stains and stuff that the pathologist will go through and look at things like proliferation indices and mitotic count, and all that business. That gives you an idea of is this a fairly benign melanoma or is this one that you should be more concerned about. Thankfully, most of the time, if it is haired skin, they usually are pretty biologically benign.
Where I start to become a lot more concerned is when I start seeing them arise on mucous membranes or where haired skin meets mucous membranes. Certainly, the number one site would be the mouth. Anywhere in or around the mouth, those are the ones that I worry a lot more about. It seems like really just about any location, whether that’s the gingival tissue, the tongue, the roof of the mouth, the tonsil, the inside of the cheek or even the lip margins. Those guys, I’m a lot more worried about. Probably right behind those would be nail beds.
Nail beds are a big one and footpads, and then probably farther down the list be like the perianal ones, that type of thing. Those tend to be a lot less common, but that dog whose nail flakes off and then the nail just starts to grow an abnormal nail or it the nail doesn’t regrow or whatever else, my index of suspicion of whether that’s a melanoma or some other tumor of the nail bed goes way up.
Are they always black, these melanomas?
They aren’t. In fact, actually, some papers would suggest that somewhere in the neighborhood of about a quarter, so 25% or so of melanomas have a very specific mutation where they don’t make melanin or make very little melanin. Those guys may actually appear pink, that type of thing and so not be black or purple at all. The color does not necessarily point you in the right direction. Certainly, the black purple classic mass in the mouth or the lip or whatever you can pretty much bet, those are melanomas. When you see those pink ones, it doesn’t mean it’s not. For sure.
What’s sad about an oral lesion is nobody really looks in their pet’s mouth.
With the advent of dentistry and how prevalent doing dentals and dental cleaning and all that stuff has become, I think we spend more time in their mouths now than we used to, for certain.
With the rise of veterinary dentistry, we now spend more time examining pets’ mouths than ever. Routine dentals aren’t just about cleaning—they let us thoroughly check the oral and pharyngeal health of our dogs. Share on XThat is good.
Absolutely. I think it’s a great thing. I think that is as probably as good of an of a rationalization for doing routine dentals or regular dentals on your dog as much as anything, is just being able to get a good oral and even pharyngeal exam and certainly, if you see something, biopsy it.
When you mentioned tonsil, I totally forgot about that. My girlfriend in New Jersey had a little rescue Sheltie and the dog just wasn’t eating well. Not eating well, odor from the mouth, salivation. We had a feral cat that was our office cat. I adopted it because I knew it wouldn’t make a good pet. I went upstairs and I said to Jackie, “How come little Jerry’s not eating? What’s all this canned food sprayed all over the walls?” He ended up having a big tumor in his mouth, but we had to sedate him to see it. Anything different around the mouth needs to be checked out.
It’s one of the most common sites of malignancies in dogs. Certainly, paying close attention to their breath and that type of thing. Everybody just assumes if they’ve got bad breath that they need a dental cleaning, but in a lot of times, that’s all it is. Really, your nose tells you a lot of things. When you’re getting that smell that will roll up wallpaper, there’s a reason for it.
Also, change of habit. Doesn’t want to eat well, that thing.
I was going to ask you too about the melanoma vaccine because you and I had a client together, a honey-colored chow that would see me for derm reasons and saw you. I think that dog was like two years out with using the vaccine, if I’m not mistaken.
Melanoma Vaccine
The melanoma vaccine’s been around now for probably twenty-plus years. It’s a really interesting and unique product. I guess my experience with it having vaccinated hundreds of dogs, probably at this stage of the game. Most people, when they think about a vaccine they think about something that is a preventative. This is truly as a therapeutic and not a preventative.
As I used to tell clients, how I would sum up my experience with the melanoma vaccine is pretty easy and one sentence. Nothing works for everybody. That is the maybe the best way to put it because I have certainly had dogs that I would have said were ideal vaccine candidates. They had a relatively small melanoma, they staged negative everywhere that we looked, couldn’t find any evidence of spread. Their tumor was completely removed surgically and then we followed them with vaccine and they developed metastatic disease and died within 6 to 9 months.
By the same token, I would have these dogs that really shouldn’t have done well that were like what you were describing here where they’re getting like their two-year melanoma vaccine booster, that type of stuff and going pretty phenomenal. The only thing that we were doing therapeutically for them was the vaccine. They were dogs who probably should have passed away within 6 to 9 months that didn’t.
Do you use the vaccine when it’s a small growth or do you use it after you take the big tumor out and then after that?
The answer is yes. It seems like the ideal indications I would say is if you have good local control, so you’ve done surgery, you’ve got clean excision, you don’t have any obvious evidence of metastatic disease, so you don’t have any obvious evidence of spread, that type of thing, that’s your ideal situation. We know that the vaccine will take somewhere in the neighborhood of anywhere from 2 to 4 months before you really see maximal immune response.
That’s why these dogs that come in with more advanced disease, it doesn’t mean that you can’t vaccinate them. It just means that we’re now trying to play immunologic catch-up in terms of treating. I always caution people, that doesn’t necessarily mean the vaccine’s not working. It just means that we’re maybe getting into the game late. We try to use it as best we can in the postoperative setting.
There is one paper out there that did talk about the importance of clean margins. It was interesting. There were dogs that had all of their gross tumor removed so they had no visible tumor, but they were not necessarily microscopically clean excisions. They actually still had better than expected outcomes when following with the vaccine.
I always just caution people that it was a relatively low number of cases and so I don’t know if those stats would bear themselves out in bigger studies etc. Just because of the nature of where those tumors want to grow in the mouth, sometimes it may be very difficult or very disfiguring or whatever else to be able to get a clean excision because of the location of the primary tumor. However, that does not necessarily mean that surgery isn’t indicated. You may be able to do a really good taking it down to minimal disease and then following the vaccine. It’s just realize that you’re taking a little bit of a gamble.
Where does it metastasize in dogs when they have melanoma?
Melanomas are weird from the standpoint that they could do whatever they want to do, but the ones that obey the rules, it seems like lymph nodes usually are your first. For most of our oral lesions, we think about like the submandibular lymph nodes so right here at the base of the jaw. Deep pharyngeal lymph nodes or deep cervical lymph nodes, so back here close to the larynx, etc. Tonsil’s definitely is a big one, depending on location. From there, usually your next step is lungs.
Melanomas are our oddballs. They can do whatever they want. Share on XMelanoma, like I say, are oddballs from the standpoint that they can do whatever. I’ve seen all kinds of unusual sites of metastatic disease with those guys so things like bones, central nervous system, thyroid, spleen, you name it. Cats are fairly notorious. Cats don’t get melanomas nearly as frequently as dogs do. It’s probably one of the few things that where dogs may actually outrank cats in terms of a malignancy.
Where do cats get them on their body?
They get them in a lot of the same places but as far as sites of metastasis, one of the weird things is a lot of times, cats oftentimes will get actually more like abdominal metastasis, so like spleen, liver, that type of thing as opposed to pulmonary. They certainly get that too.
We just had Dr. Karen Trainer, the pathologist, and she was telling us she biopsied a cat that had a lesion here, a bump, and another one here. This one turned out to be a papilloma. This was a meningioma. She said, “I couldn’t believe it. I phoned a friend, many of them, for them to look at it.” Dr. Gross looked at it and said, “Those are meningioma cells.” Never bothered the cat. They thought that during the development of the cat, a couple of those cells broke through. Who knew? I was going to ask you too, what’s the new thing they’re using in squamous cell?
I remember you sent me that article and now I’m trying to remember what it was. I want to say that it was one of the small-molecule inhibitors. It may have been like Trametinib or one of those.
Yes, I think you’re right.
I believe you’re right. I’m going to have to go back and pull that now because it’s going to bother me.
The reason I asked about squamous cell because our little Jerry the cat had one and there again, it was this huge mass in his mouth. We couldn’t look in his mouth because he was feral, but there’s not much, and that just stays in that area, correct?
Oral Squamous Cell Carcinoma In Cats Vs. Dogs
To me, that is a very interesting difference in dogs and cats. Squamous cell carcinomas in most dogs, you can usually fix with surgery. Every long once in a while, you will deal with one that spread. Dogs tend to tolerate aggressive or fairly radical oral surgeries really well. Cats, on the other hand, it seems like the squames that they get in their mouth, whether that be under the tongue or associated with the mandible or whatever, just tend to be just crazy aggressive in terms of local destruction.
Thinking about it, I can’t say for sure that I can ever really remember seeing a cat who had spread of an oral squamous cell carcinoma. They all uniformly died of local disease almost regardless of what we did, whether that was surgery or radiation or whatever else. It just seems like cats, it’s just so much more of a crap shoot in terms of how well they tolerate those big oral surgeries. Taking a quarter of a half of a jaw.
There’s not much of an oral cavity in a cat. Unless you get bit.
Yeah, exactly. There’s plenty of it in there. Usually with the worst teeth in the world sunking into the meat of your thumb. Even some of these dogs that have such short jaws or whatever else, they still figure out just how to deal with having very little jaw left postoperatively. I used to have the conversation with clients that if you’re really seriously considering an aggressive oral surgery in a cat, you really probably in the back of your mind need to be prepared for and dedicated to some type of long-term interventional feeding.
If you’re seriously considering aggressive oral surgery in a cat, you need to be prepared for—and committed to—some form of long-term interventional feeding. Share on XAn E-tube or a gastrotomy tube or something along those lines because so many of those cats just don’t eat again. That’s why Steve Withrow, basically the father of veterinary oncology as far as I’m concerned, his always comment was is that was the bane of veterinary oncology, oral squamous cell carcinomas in cats.
The bane of mine was Mycosis fungoides.
Yeah, there’s another fun one.
Cutaneous lymphoma. There is no good treatment for that. Yet in humans, they’re like, “CTCL, here, put a little steroid ointment on it or go for light therapy.” in dogs, they can be dead in three months. It’s just absolutely horrible.
Dr. Elpiner and I have had that conversation over and over again. That’s just another one of those diseases that’s just so frustrating to deal with. How I managed them, anytime there is that many different options for managing something, it’s a good indication that none of them work. How I managed them really just seemed to depend so much on how bad were they when they started.
I would see those that have fairly minimal lesions that just really weren’t that bad and they weren’t that rapidly progressive. I felt like some of those guys you could hold off with chlorambucil and prednisone or whatever else and hopefully they live long enough that something else gets them in trouble before that does.
You then see those guys that come in with the great big plaques and they’re starting to get lymph node enlargement, whatever else. You can correct me if I’m wrong on this one, but more often than not, whenever I saw those cases, whenever you really started drilling the client with questions is a lot of those dogs had lesions or some type of dermatological history that went back oftentimes years.
They’re usually misdiagnosed as a staph bacterial infection. They’ve been on eight antibiotics. I totally agree with you. They’ve had it for quite a while.
Exactly. It’s just finally they have rolled to the point that now they they’ve gone into the plaque stage or they’ve started developing like nodal lymphomas or whatever. By that time, you are really trying to push a chain uphill to gain ground.
Now I have to quote you from one of our favorite people for your next comment. “Never trust a mast cell tumor.”
Who would that be? Yes, and speaking of Guillermo, actually, I talked to him right before I retired. He is doing well. He’s alive and well.
I hear he’s a very happy grandfather, Dr. Guillermo Couto, who we all know and love. His words, I should have needlepointed them. We’re going to talk about mast cell tumors now, a mast cell lesion in a dog. The first words that came out of my mouth to the owner were, “We were taught we could never trust a mast cell tumor.” Which means anything I put your dog on works for some, but not for others. What’s your feeling on that?
To me, I think back to whenever I was very early in my career, the VCS mid-year meeting one year was about nothing but mast cell tumors. That just shows you how exciting we are. We sat around for two and a half to three days talking about nothing but mast cell tumor cases. I will never forget another one of my all-time favorite influential people in my career was Dennis Macy.
Mast Cell Tumors (MCTs): Prognosis & Management
Dennis had a slide that he popped up and it was the quote from I can’t remember which Dr. Seuss book it was but it popped up and it was it was “One of these is not like the other. I don’t know why, go ask your mother.” that is very much the truth. Actually, I was going through some of my old slides. This’ll date me a little bit. When I was cleaning out my office, I actually still had books of 2×2 Kodachromes.
Do not throw them out. I did and now I regret it. Do not throw them out. Take it from me. Another retiree-to-retiree.
One of my slides was mast cell tumors. Was it a malignant killer of dogs or was it much ado about nothing? Truthfully, I think both of those answers are correct. The hard part is knowing which one you’re dealing with when you start.
Shifty.
The one good thing I can say is I think we do so much better job now of being able to prognosticate on our mast cell tumors, “Is this one that I need to worry about or not?” than we used to be able to. That doesn’t mean that we get it right all the time but I think that we do a lot better job than we ever used to, you know, based off the two-tiered grading systems and all the information that we get off of our path reports about mitotic counts.
We do a much better job than we used to, thanks to the two-tiered grading systems and the information we get from pathology reports. Share on XIf you’re really are struggling the prognostic panels that are offered, the best one is the one through Michigan State. Even then, if you see enough of them, you are going to find one that does not do what you would expect it to do. I think those pieces of information at least start to give you a little bit more clarity and a little bit more comfort as far as is this something that I can send to surgery and monitor or is this something that you know we need to be looking for stuff that’s got letters and numbers behind it to throw something new at the problem in terms of management.
We see all of these dogs that I think are just chronic offenders with low-grade mast cell tumors. At some point, the owners get tired of cherry-picking them off. I get asked all the time about what can we do from a medical standpoint to prevent further mast cell tumor development. That whole area of chemoprevention, essentially. I have struggled with that one my whole career.
Do you believe in that?
I have had cases where I put them on, say, something like chlorambucil or something along those lines because if you’re paying attention to what you’re doing with that drug, it’s unlikely you’re going to hurt anything. I’ve had some of those dogs that they never developed another mast cell tumor and I’m always sitting here going, “Is that because I put them on chlorambucil or just that was just what they were going to do?” I’ve got others that it doesn’t matter what I put them on, every time you turn around, they’ve got three new ones. Most of those are Pit Bulls.
I was going to say, we used to laugh about Boxers and Pugs and all that type of stuff and don’t get me wrong, they still get it. Pit Bulls have eclipsed any and everybody from a mast cell tumor standpoint. The bad thing about it is that it seems like while they tend to get a lot of those multiple low-grade tumors that type of thing that are more of an aggravation than they are a real problem, but then all of a sudden, they may develop one that’s like a hot grade three. It comes in looking like a tomato. You’re going, “Alright, the game just changed.”
Way back in the day, Pat Breen and Gary Johnson, the pathologist, and I wrote up two cases of what we termed urticaria pigmentosa-like disease in two dogs. Urticaria pigmentosa in people are mast cells that when you do a Darier’s sign on them, in other words you go like this and then you get these lesions that pop up.
It’s not uncommon in little kids, especially around the abdomen. I had this black lab, probably about six years old, came in from Pittsburgh, and it would develop literally golf-ball-sized lesions that would come and go, that were full of edema. Also, other little nodules. The owner would go in the shower, take a shower, come out, the lesions would be gone.
When we biopsied them they came back as mast cell, but they’d and come and go. We had a cocker spaniel was our second case that we wrote up, this was in AJHA journal years ago. We called it urticaria pigmentosa-like disease in the dog. We didn’t have all of the techniques that they’re now looking at for grading and back then.
We put the dog on a combination of histamine one and histamine two blockers. Something like famotidine and Benadryl. The dog lived to thirteen and died of kidney disease. There you would have suspected, “This is a horrible aggressive mast cell. He’s getting all these nodules and these golf-ball-sized edema-filled,” but they would come and go. Anyway, I agree with you. Unpredictable, for sure.
I will have a sit-down with my clients whenever I would see them and I would say, “If somebody tells you that they know what’s going to happen with this case, they’re lying. I can tell you what I think is going to happen but I refuse to write a warranty card for a dog with a mast cell tumor.”
Couto’s words come back to you. You never trust them.
They’re going to do what they’re going to do and it probably is going to do it regardless of what I do, it seems like. As I said, I do feel like we’ve got better options for managing them now than we used to. The small molecule inhibitors, Palladia, changed the game. Probably some of the most profound responses I’ve ever seen in dogs with mast cell disease has been with Palladia. To a lesser extent, maybe with Gleevec or imatinib. Gleevec was the very first one of those small-molecule inhibiting drugs in people, going back in the ‘90s. It’s come off patent now, and you actually can get it compounded actually fairly cheaply, in all consideration.
Thank God for that. Look at chlorambucil now. That’s compounded, for sure.
The brand-name stuff is just crazy expensive.
I hate to sound like you and I are old but I remember $2 a tablet. It’s like $6,000 dollars now. I just did a talk on campus in cats and when I pulled up GoodRx, I almost had a stroke when I saw the price of it.
One of the things that I try to keep tabs on the whole compounding side of veterinary medicine from a pharmaceutical standpoint. If we don’t have good compounding, we’re going to quickly make it where we can’t hardly do anything. It’s the only way to get some of these drugs, quite honestly.
I try to keep tabs on the compounding side of veterinary medicine from a pharmaceutical standpoint. Without good compounding, we’d quickly reach a point where there’s almost nothing we can do. Share on XAnything new about hemangiosarcoma?
Hemangiosarcoma Research & Diagnosis
A couple of interesting things. Right now, at Metro, we were participating in Ethos’s push study.
I’ve been reading about that.
We were one of the study sites. Basically, dogs that come in for hemoabdomen that do not have obvious evidence of metastatic disease in liver or lung or anything along those lines end up getting some money towards their surgery and the histopath. If they are confirmed to be hemangiosarcoma, then they got randomized into different treatment groups. Just trying to determine is what we’ve been doing as long as I’ve been doing this, is that still the right way to handle it or should we be handling them differently?
The treatment groups that got picked were based off of what some historical information about genetic mutations and that type of thing but we’re not necessarily tailoring it to the individual patient. They’re just getting randomized to a treatment group. It was treatment groups that seemed to make sense based off of the information that we had.
It’s mostly large breed dogs you’re seeing?
Mostly, yeah. I can be very curious to see what comes of the final results of that study. Is that going to potentially start telling us that maybe we need to be looking at some of these additional other therapies so it’s not just doxorubicin-based chemotherapy post-splenectomy? It should we be looking at some of these some of these small molecule inhibitors, that type of thing in addition etc.
That’s probably one of the biggies. The Yale vaccine study, most of the attention that’s come from that has actually been towards osteosarcoma but they also were enrolling some hemangiosarcoma dogs in that study as well. It was directed against Her2. I think that is another potential avenue. Just like on the human side, so much of therapy is gone towards tailored medicine or personalized medicine, whatever terminology you want to use where they’ll genetically profile your tumor and that type of thing looking for potential targets and are there drugs out there that potentially are would fit in and be actionable.
I think we’re still are waiting to see the full potential of all of that. I think we’re very much on the steep portion learning curve as far as learning how to dose a lot of those drugs because most of those we’re borrowing out of the human pipeline. There’s not a ton of drug development along those lines in veterinary medicine.
Slowly becoming more and more, but it’s not like it is on the human side where there’s thousands of those drugs. The hard part is a lot of times, the pharmacokinetics may not have been worked out in dogs or at the very least, they were worked out in research dogs, not necessarily sick dogs and what’s the ideal dosing schedules. We’re learning that we have more questions is the best way to put it. I think those things are very exciting as far as possible.
I think more questions is a good thing because it promotes more interest and study into that. For the readers, I guess I should have mentioned hemangiosarcoma is a blood tumor that usually affects large breed dogs, spleen, liver, heart and sub-q. Actually, my first dog had that, including sub-q. We were walking to get the mail and he just keeled over. I’m like, “He’s dead.” this before I was a vet. In about a minute, he got up and started walking. It’s one of these blood-filled tumors broke and they get weak, but then he ended up having the surgery and it bought him three months because he had all those sub-q tumors after that.
I get a lot of cases that were sent to me for dermal and/or sub-q hemangiosarcoma. The question I ask myself whenever I would see those, “Is this the primary site?” That’s very different than if this is a metastatic site. It could be either. You literally you ended up working these guys up to the hilt just to make sure that what you were dealing with wasn’t the tip of the iceberg.
We had on Dr. Ed Breitschwerdt who has published where he’s finding Bartonella in those tumors. Now, is it a cause or an effect? When I read that, I got so excited because I’ve still been following hemangiosarcoma ever since I lost my first dog to it. It marks you for life. To be honest, I haven’t seen much in the way of anything great. I thought, “Wouldn’t it be interesting if this Bartonella organism, which is the cat scratch fever organism, was playing a role in this.”
It’s one of those tumors like the whole oral squama thing in cats. I think that survival statistics to me look better for hemangiosarcoma dogs for some hemangiosarcoma dogs than they used to because of the therapies that are out there now in addition to what we’ve been doing if you want to use the term standard of care which I’m not sure if there is. Whatever that is. Usually doxorubicin-based chemotherapy in addition of surgery.
It’s been one of those things that the advances that we have made have been small and slow in coming. I guess it’s the best way to put it. It’s just one of those just tough tumors. I think it will continue to be for while. Also, I think one of the other things is, is it a tumor that its reputation precedes itself even with a lot of clients? Whenever you start talking to people about it, unfortunately, they usually are trying to make decisions in a really bad time frame because it’s something that got forced on them. Your dog was fine a half an hour ago and now he’s not type of thing. I think they either had a friend or something else 10, 15 years ago that their dog had this. They did all this stuff and the dog was dead in a month and a half. Those are big hurdles that you have to overcome before you can really start to treat.
A tumor's reputation often precedes it. Unfortunately, clients usually have to make decisions about it under very stressful and unexpected circumstances. Share on XAlso, misinformation.
I don’t know if it’s necessarily, sometimes misinformation is much as it’s overwhelming information coming very rapidly at people.
You’re getting this news, the dog was fine in the morning. He keeled over two hours ago and now it’s cancer.
Exactly. You’re asking them to make big decisions in a really bad thing.
Advances In Lymphoma And Chemotherapy In Pets
Lastly, I’m going to ask you about lymphoma and what’s going on with that. Is there any light at the end of the tunnel for lymphoma dogs?
I definitely think there’s some interesting things going on. Since I’ve left Metro, I know Ethos has started actually a lymphoma study, so there actually is a funded lymphoma study going on at Metro right now, so put in a little plug.
He’s talking about Metropolitan Veterinary Hospital in Copley, Ohio.
Yes, in Highland.
My personal favorite.
I think the big thing is we talk about lymphoma so much like it is a disease and it really isn’t. It’s really a huge umbrella of a disease and no two lymphomas are exactly alike. I really think we’re starting to see the value in trying to subcategorize these a little bit better. We’ve known for a while that there were big differences. Is it a small cell lymphoma or a large cell lymphoma? Now with things like immunophenotyping, is it a B-cell lymphoma or a T-cell lymphoma? We know that that may have some significant prognostic bearing in terms of drug sensitivity, drug responsiveness, all that business.
I can remember many years ago, while I found T versus B cell to be academically interesting, it didn’t really change what I did. Whereas now, I would actually potentially treat very differently just because we’ve learned that some drugs don’t work as well as others in T-cell lymphoma. We start to tailor more to the to the patient and I think all of those are hopefully moving us in the right direction.
In people, the probably the biggest thing that changed the survival for people with non-Hodgkin’s lymphoma was a drug called Rituximab, which targets the CD20 molecule on the receptor of B cells. Any attempt that we have made on the veterinary side to specifically target CD20 or CD21 or CD3 in T-cell lymphomas, etc., unfortunately, we have really struggled to come up with something that works nearly as well as Rituximab. I think if we are able to find something that works that pathway, hopefully we’ll do a lot better.
I know we’ve talked about this before when you were on earlier. Our pet parents need to know that the goal of chemotherapy inventory medicine is different than in human medicine. We’re focusing on quality of life.
For sure. I think so much of the illness that we see associated with people and chemotherapies that they are pushing us really hard to try to cure us. We know, unfortunately, with most of our chemotherapy regimens and most of the diseases that we’re treating is that we’re probably unlikely to cure in a medical standpoint in veterinary medicine.
There are some exceptions, but I think the MD oncologist would say we’re using chemotherapy is a palliative measure. It certainly appears to improves survival. As I hate to say it. I think there’s a lot more emphasis on quality-of-life issues in veterinary medicine and most of our clients are just not going to put up with their dog being as sick as we are.
Chemotherapy can improve survival, but there’s now a much greater emphasis on quality-of-life issues in veterinary medicine. Share on XI have always tried to strive for to treat the disease as aggressively as I can get away with, with a reasonable level of complications. Having our appetite being off for a day or so, maybe a bout of soft stool or something along those lines, but the other six days of the weeks, we’re great, I can live with that. If you turn it around and we’ve got one good day of the week, I think we really need to think about what we’re doing.
I remember when my dad who had cancer of the appendix that then hooked onto the colon, and after his surgery, which bought him three years, it went to his liver then and he said, “What do you think I should do? They want to do chemo.” I said, “You know what, Dad, let’s do it. If for two minutes, you don’t feel good, then we’re done.” He did great. He had a little bit of sores in his mouth occasionally, but it was nice that it didn’t devastate him, which is sad. I know our goal injury medicine is let’s keep them eating and happy and running. As you said, if they go off their food for a day, I’d like to go off my food first day.
I probably could stay in, probably maybe more than.
One more thing before we go. I just thought of it. Anything new for bladder tumors?
On the nutraceutical side, I know Nutramax has brought out one of the broccoli extracts.
I had ordered that for my Skeeter. Skeeter Marie had bladder tumor and I ordered it before, it was available in veterinary. I ordered it from Life Extension. Sulforphane. That’s the active ingredient. I love that they’re making that.
That’s out there. Probably the biggest thing in my mind that probably has more to do with on the diagnostic side, the BRAF testing which is available. You can basically test on urine samples. It allows us to basically pick up genetic mutations in the urine which has been nice if you have a suspicious lesion on ultrasound or whatever else.
It used to be what we ended up doing was cystoscope and biopsy and that type of stuff to get answers. Now with a urine sample, we actually have a test that’s got really high sensitivity and specificity for the disease. That actually has been really nice for my diagnostic stuff I don’t know that it is necessarily 100% foolproof, but it certainly has made it a lot easier for us to answer questions for clients is this bladder cancer or not or what’s our next suspicion
What a nice non-invasive test. It’s easy to pee in a cup as opposed to open the dog up to biopsy whatever’s in there. Thank God for that.
I don’t know if I would say it’s necessarily uniformly across the board to be the way to diagnose it, but I tell you what, it’s another piece of information that if you got a negative, you start to feel a lot better that it probably isn’t a bladder tumor.
It’s pretty easy to get pets to pee in a cup. There are a lot of contraptions that we could probably take pictures of the clients. On that note, thanks so much for being here and thanks for introducing us to the new member of the family. I wish you a lot of luck. My advice to you, I already gave you two suggestions for retirement, my third is once you get to be our age, having a young dog around is a lot of work.
That has definitely has been the challenge. It’s essentially having a newborn back in the house. I’ve spent a couple of nights sleeping on the floor and that type of thing.
I think your beard got a little whiter since I’ve seen you with this new pup.
I got my fingers crossed he’s going to be like his daddy.
His daddy’s how old?
Eight and a half. My old guy’s still around too. He just turned fifteen.
He just had a birthday. I saw it on Facebook. Give him a kiss for me. Give Tracy a hug, too.
Exactly, will do.
All right, we’re signing off. Please tune in, like us, support us, we love you, we’re here for good information. We’re here with good evidence-based information for your pets and hope they stay healthy. Thanks, everyone.
Important Links
About Dr. Rance Gamblin
Diplomate ACVIM-oncology 1997
Residency: The Ohio State University, 1993 (oncology/hematology)
Internship: Colorado State University, 1992
BS in Biology: Mississippi State University, 1988
Areas of special interest: Lymphoma, Mast cell tumors, hemangiosarcoma, osteosarcoma
Originally from Jackson, Mississippi, Dr. Gamblin has been a medical oncologist in Northeast Ohio since 1997 and recently retired from Metropolitan Veterinary Hospital. He enjoys the multi-modality approach to cancer treatment, frequently collaborating with surgeons and radiation oncologists. In his time away from the hospital, Dr. Gamblin spends time with his family and furry friends, Pepper the cat, Roux, and Caje (chocolate labradors). He is an avid outdoorsman and volunteers for several wildlife groups, including Ducks Unlimited and Delta Waterfowl. He is currently an associate professor at Mississippi State University College of Veterinary Medicine.