Hypofractionated radiation therapy for invasive thyroid carcinoma in dogs: a retrospective analysis of survival

Canine thyroid carcinomas: A review with emphasis on comparing the compact subtype of follicular thyroid carcinomas and medullary thyroid carcinomas

Canine thyroid carcinomas are relatively common malignant endocrine neoplasms in dogs derived from either thyroid follicular cells (forming follicular thyroid carcinomas) or medullary cells (parafollicular, C-cells; forming medullary thyroid carcinomas). Older and recent clinical studies often fail to discriminate between compact cellular (solid) follicular thyroid carcinomas and medullary thyroid carcinomas, which may skew conclusions. The compact subtype of follicular thyroid carcinomas appears to be the least differentiated subtype of follicular thyroid carcinomas and needs to be differentiated from medullary thyroid carcinomas. This review includes information on the signalment, presentation, etiopathogenesis, classification, histologic and immunohistochemical diagnosis, clinical management, and biochemical and genetic derangements of canine follicular and medullary carcinomas, and their correlates with human medicine.

99m-Technetium-Pertechnetat- und 99m-Technetium-Sestamibi-Szintigrafie zur Darstellung von hypofunktionellem Schilddrüsengewebe und Staging bei einem Hund mit Schilddrüsenkarzinom

Eine 10-jährige Mischlingshündin wurde aufgrund einer zervikalen Umfangsvermehrung zur Schilddrüsen-Szintigrafie vorgestellt.

Aufgrund einer zusätzlichen Hypothyreose, die einen „kalten“ Knoten vermuten ließ, und zur Metastasensuche, erfolgte neben der 99m-Technetium-Pertechnetat (Tc-Pertechnetat)-Szintigrafie eine zweite Szintigrafie mit 99m-Technetium-Sestamibi (Tc-MIBI).

Zwanzig Minuten nach intravenöser Gabe von 38 MBq Tc-Pertechnetat waren ein „heißer“ zervikaler und ein intrathorakaler Knoten mit einem „Uptake“ von 8,40 und 0,25 % sichtbar. In der zweiten Szintigrafie 20 Minuten nach intravenöser Gabe von 364 MBq Tc-MIBI und 70 Minuten nach der ersten Szintigrafie zeigten die Knoten nach Abzug der Pertechnetat-Aktivität und Zerfallskorrektur einen „Uptake“ von 0,99 und 0,03 %. Zudem stellten sich in der Schilddrüsenloge beide Schilddrüsenlappen mit einer geringen Tc-MIBI-Aufnahme dar. Das Verhältnis Tc-„Uptake“/Tc-MIBI-„Uptake“ betrug für beide Läsionen 8,48 bzw. 8,33.

Nach Exstirpation des zervikalen Tumors ergab die histopathologische Untersuchung atrophisches Schilddrüsengewebe, das von einem expansiv wachsenden gut differenzierten follikulären Schilddrüsenkarzinom fast vollständig verdrängt wurde.

Dieser Fallbericht beschreibt Durchführung, Nutzen und rechnerische Korrektur einer aufeinanderfolgenden Pertechnetat- und MIBI-Szintigrafie, die eine Darstellung von hypofunktionellem Schilddrüsengewebe ermöglichte. Die beiden heißen Knoten waren daher und aufgrund ihrer gleichen MIBI-Stoffwechselaktivität als dystopes Gewebe/Metastasen zu werten, wodurch die Hündin in das prognostisch ungünstigere WHO-Stadium IV klassifiziert werden musste. Anders als beim Menschen sollten beim Hund zur Vermeidung einer erneuten Narkose beide Szintigrafien kurz hintereinander durchgeführt werden. Eine qualitative/visuelle Beurteilung des MIBI-Szintigramms ist daher nicht sicher möglich, sodass eine quantitative Beurteilung über den „Uptake“ nach rechnerischer Korrektur der Pertechnetat-Aktivität erfolgen muss.

Pilot study evaluating the tolerability of a 3 Gy × 10 daily fraction 3D-conformal palliative radiation therapy protocol plus toceranib for the treatment of measurable carcinomas in the dog

The use of radiation therapy in conjunction with small molecule inhibitors is an appealing treatment combination for non-resectable carcinomas, which tend to be locally invasive with variable risk of locoregional metastasis. This prospective, pilot study aimed to evaluate the tolerability and adverse event profile of concurrent toceranib and palliative-intent radiation therapy (PRT) in dogs with measurable carcinoma and to secondarily evaluate short-term measurable tumor response. Fifteen dogs with measurable carcinoma received toceranib and 3D-conformal PRT in 3 Gy/fraction for 10 daily fractions. Adverse events were graded using standard schemes and tolerability was followed via quality-of-life questionnaires during the 12-week treatment period. Thirteen dogs (87%) experienced acute radiation toxicity, graded as severe in three dogs. All dogs experienced toceranib toxicity, graded as severe in one dog. Seven dogs (47%) completed the 12-week study protocol; four were withdrawn due to toxicity and/or associated poor quality of life and four developed progressive disease. Based on these preliminary results, this 3D-conformal chemoradiation protocol should be considered with caution and only with proper owner education on potential toxicity. More conformal treatment planning techniques or alternative protocols should be investigated for improved tolerability.

Response of canine thyroid carcinomas to radioiodine

Radioactive iodine (¹³¹ I) has previously been reported to prolong survival in dogs with thyroid carcinoma. This study aimed to describe tumour response and progression-free interval (PFI) in dogs with thyroid carcinomas treated with ¹³¹ I. Secondary aims were to describe overall survival time (OST) and prognostic factors. A bi-institutional retrospective review of records identified 66 dogs with thyroid carcinoma treated with ¹³¹ I from January 2010 to April 2020. Response was described using RECIST or a subjective response assessment where specific tumour measurements were not available. Forty-eight dogs (72.7%) were treatment naïve and 18 dogs (27.3%) had received prior therapy at the time of ¹³¹ I treatment. Objective responses were available for 34 dogs and subjective responses for 58 dogs. The overall response rate was 35.3% (four complete and eight partial responses). Improvement of clinical signs was seen in 76.2% of dogs (32/42). Kaplan-Meier-estimated median PFI (95% confidence interval [CI]) was 301 (217-578) days and OST (95% CI) was 564 (421-865) days. Prior therapy was associated with a lower hazard for progression (hazard ratio [HR] 0.260 95% CI 0.123-0.548, p = .0004). Treatment of thyroid carcinoma using ¹³¹ I can effectively alleviate clinical signs and reduce disease burden in a proportion of dogs.

Clinical features and outcome of functional thyroid tumours in 70 dogs

OBJECTIVE

To describe the clinical features and outcome of functional thyroid tumours in dogs.

MATERIALS AND METHODS

Retrospective multi-institutional study of 70 dogs diagnosed with thyroid mass and concurrent hyperthyroidism. Clinical data regarding presentation, treatment, outcome and functional thyroid status were retrieved.

RESULTS

Overall median survival of dogs with functional thyroid tumours was 35.1 months and 1- and 3-year survival rates were 83 and 49%, respectively. Median survival time was 72.6 months for dogs treated with surgical excision and 15.7 months for dogs that did not receive surgery. Of the 50 dogs treated by surgery and for which thyroid status was known following treatment, 64% developed hypothyroidism after surgery. Histopathologically confirmed metastasis was identified in 3% of dogs.

CLINICAL SIGNIFICANCE

Dogs with functional thyroid tumours may survive a long time after surgical excision, although post-operative hypothyroidism is common.

Safety and efficacy of stereotactic body radiation therapy (SBRT) for the treatment of canine thyroid carcinoma

Thyroid carcinoma develops spontaneously in dogs, with only 25% to 50% of cases amenable to surgery at diagnosis. Local control for unresectable tumours can be provided with external beam radiotherapy. The aim of this retrospective study is to describe the safety and efficacy of stereotactic body radiation therapy (SBRT) for treatment of canine thyroid carcinoma. Twenty-three dogs met inclusion criteria; median tumour volume before SBRT was 129.9 cm³ (range, 2.7-452.8 cm³ ). Sixteen patients (70%) had unresectable tumours. Pulmonary metastasis was present or suspected in 10 patients (44%) before SBRT. Patients were prescribed 15 to 40 Gy to targeted tumour volume in one to five fractions. Twenty patients evaluated had overall response rate of 70% (complete response, n = 4; partial response, n = 10). Thirteen out of sixteen (81%) symptomatic patients had clinical improvement within a median time of 16 days (range, 2-79 days). Median progression free survival (MPFS) was 315 days. Median survival time (MST) was 362 days. Nine patients (39%) had grade 1 acute radiation toxicity. Three patients had grade 1 late radiation toxicity (two leukotrichia and one [4%] with intermittent cough). Responders had significantly longer MPFS (362 vs 90 days; HR 4.3; 95% CI 1.4-13.5; P = .013) and MST (455 vs 90 days; HR 2.9; 95% CI 1-8.4; P = .053). Presenting with metastasis was not a significant negative prognostic factor (MST 347 vs 348 days without metastasis; P = .352). SBRT is a safe and effective treatment modality for non-resectable canine thyroid carcinoma.

Canine Thyroid Cancer: Molecular Characterization and Cell Line Growth in Nude Mice

Thyroid cancer is the most common endocrine malignancy in dogs. Dogs and humans are similar in the spontaneous development of thyroid cancer and metastasis to lungs; however, thyroid cancer has a higher incidence of metastasis in dogs. This study developed a preclinical nude mouse model of canine thyroid cancer using a canine thyroid adenocarcinoma cell line (CTAC) and measured the expression of important invasion and metastasis genes in spontaneous canine thyroid carcinomas and CTAC cells. CTAC cells were examined by electron microscopy. Short tandem repeat analysis was performed for both the original neoplasm and CTAC cells. CTAC cells were transduced with luciferase and injected subcutaneously and into the tail vein. Tumors and metastases were monitored using bioluminescent imaging and confirmed with gross necropsy and histopathology. Invasion and metastasis genes were characterized in 8 follicular thyroid carcinomas (FTCs), 4 C-cell thyroid carcinomas, 3 normal thyroids, and CTAC cells. CTAC cells grew well as xenografts in the subcutis, and they resembled the primary neoplasm. Metastasis to the kidney and lung occurred infrequently following subcutaneous and tail vein injection of CTAC cells. STR analysis confirmed that CTAC cells were derived from the original neoplasm and were of canine origin. Finally, 24 genes were differentially expressed in spontaneous canine thyroid carcinomas, CTAC, and normal thyroids. This study demonstrated the usefulness of a nude mouse model of experimental canine thyroid carcinoma and identified potential molecular targets of canine follicular and C-cell thyroid carcinoma.

Toceranib phosphate in the treatment of canine thyroid carcinoma: 42 cases (2009-2018)

Thyroid carcinoma is the most common endocrine malignancy in dogs. Thyroidectomy and radiation therapy control local disease, yet are not always feasible, and efficacious medical therapies need to be identified. Toceranib phosphate has been reported to provide clinical benefit (CB) in dogs with thyroid carcinoma, while its role in treatment-naïve thyroid tumours has not been well-described. The objective of this study was to describe the use of toceranib in the management of thyroid carcinomas in dogs in both the naïve-disease and prior therapy- settings. A medical record search identified 42 dogs diagnosed with thyroid carcinoma and treated with toceranib, of which 26 and 16 dogs were in settings of naïve-disease and after prior therapy, respectively. Twenty-three (88.4%) and twelve (75%) dogs experienced CB in the naïve and prior therapy settings, respectively. The median [95% confidence interval] progression free interval (PFI) for dogs in the naïve and prior therapy settings were 206 [106,740] and 1015 [92,1015] days, respectively. The median overall survival time (OST) for dogs in the naïve and prior therapy settings were 563 [246,916] and 1082 [289,1894] days, respectively. Overall, the data provided no evidence for differences in overall PFI (P > .20) or OST (P = .15) between settings. However, when asymptomatic at the time of diagnosis, dogs in the naïve setting showed poorer survival prognosis (estimated hazard ratio 17.2 [1.8, 163]) relative to dogs in the prior therapy setting. This study characterizes PFI, OST and CB with minimal AE in dogs with thyroid carcinoma treated with toceranib in both the naïve and prior therapy settings.

Volumetric Modulated Arc (Radio) Therapy in Pets Treatment: The "La Cittadina Fondazione" Experience

Volumetric Modulated Arc Therapy (VMAT) is a modern technique, widely used in human radiotherapy, which allows a high dose to be delivered to tumor volumes and low doses to the surrounding organs at risk (OAR). Veterinary clinics takes advantage of this feature due to the small target volumes and distances between the target and the OAR. Sparing the OAR permits dose escalation, and hypofractionation regimens reduce the number of treatment sessions with a simpler manageability in the veterinary field. Multimodal volumes definition is mandatory for the small volumes involved and a positioning device precisely reproducible with a setup confirmation is needed before each session for avoiding missing the target. Additionally, the elaborate treatment plan must pursue hard constraints and objectives, and its feasibility must be evaluated with a per patient quality control. The aim of this work is to report results with regard to brain meningiomas and gliomas, trigeminal nerve tumors, brachial plexus tumors, adrenal tumors with vascular invasion and rabbit thymomas, in comparison with literature to determine if VMAT is a safe and viable alternative to surgery or chemotherapy alone, or as an adjuvant therapy in pets.

Laryngeal chondronecrosis after radiation therapy in a dog

A 5-year-old pug presented with a soft tissue swelling on the ventral neck and moderate stridor with associated respiratory effort. This patient received hypofractionated radiotherapy for metastatic upper lip mast cell tumour and to the submandibular lymph nodes 6 months before presentation. Oral examination showed moderate elongation of the soft palate, stage III laryngeal collapse with only the right laryngeal saccule mildly everted and exuberant pale epiglottal and left pharyngeal mucosa. Staphylectomy, resection of the epiglottal mucosa and left arytenoid lateralisation were performed. One day after surgery, temporary tracheostomy was performed after respiratory distress due to the severe laryngeal and pharyngeal oedema. A third oral exam showed pale and redundant caudal pharyngeal mucosa obstructing the rima glottis, soft and collapsible arytenoid cartilage with pale mucosa and bilateral everted laryngeal saccules. Permanent tracheostomy was elected and laryngeal cartilage biopsies were taken. Histologic diagnosis showed cartilage necrosis and abundant tissue oedema. The patient was euthanased 1 week later.

Identification and preservation of the parathyroid gland during total thyroidectomy in dogs with bilateral thyroid carcinoma: a report of six cases

Simultaneous removal of bilateral thyroid tumors was performed while preserving the parathyroid gland in six dogs. At least one external parathyroid gland was identified in all dogs. In five cases, the external parathyroid gland and its blood supply were preserved intact. In one dog, the vessels supplying the external parathyroid gland had been invaded by the tumor, and the gland was thus removed and reimplanted into the sternohyoid muscle. That dog required postoperative treatment with oral calcium gluconate and vitamin D₃. Local tumor recurrence was not observed in any of the cases. The mean survival time was 920 days. We found that the external parathyroid gland could be identified and preserved in most dogs undergoing total thyroidectomy.

Hyperthyroidism and hyperparathyroidism in guinea pigs (Cavia porcellus)

Abnormal conditions of the thyroid and parathyroid in the guinea pig appear in the English-language scientific literature on an emerging basis. Although true descriptions of abnormal thyroid and parathyroid anatomy or morphology are not new findings, the clinical condition of abnormal thyroid or parathyroid function seems to be a more common observation by clinicians in recent years. This article is an overview of general clinical conditions and adequate diagnosis, and offers treatment options.

Response rate and duration associated with a 4Gy 5 fraction palliative radiation protocol

The purpose of this retrospective study was to determine if 4Gy fractions over 5 consecutive days is an effective and safe palliative radiation protocol for dogs and cats. Eighty patients (22 cats, 58 dogs) with complete follow-up information were evaluated. Overall response rate (ORR) for all patients was 67%. Median progression free survival (MPFS) was 3.3 months and median survival (MST) was 4.2 months. Primary bone tumors were the most common tumors treated. The ORR for primary bone tumors was 66.6%, the MPFS was 3.5 months, and MST was 3 months. The most common tumor treated in cats was oral squamous cell carcinoma and ORR was 54.5 %, the MPFS was 1.8 months, and MST was 3 months. Soft tissue sarcomas were the second most common tumor treated in dogs (10). ORR was 80% and the two other patients had stable disease. MPFS was 5.7 months and MST was 7.9 months. Overall rate of toxicity was 18.4% in 65 sites that were evaluated for toxicity. Acute toxicities were all grade I or II and occurred in 16.9 % of patients evaluated. All late toxicity was grade I alopecia and leukotrichia. There appears to be a comparable response rate for this palliative protocol as compared to others historically. This response was seen over a wide range of tumors. We also documented a low toxicity profile in a shorter overall treatment time, making this protocol more attractive for some clients.

Veterinary radiation therapy: review and current state of the art

Veterinary radiation oncology became a recognized specialty in 1994. Radiation therapy is an important component of a multimodality approach to treating cancer in companion animals. It is important to understand the many aspects of radiation, including the equipment used in external beam radiation therapy, the basic mechanism of action of ionizing radiation, the results of irradiating various histopathological types of tumors, as well as the associated potential acute and late side effects of radiation. A comprehensive review of radiation therapy is timely and provides information for clients on cancers that may benefit from external beam radiation therapy.

Canine thyroid carcinoma

Malignant thyroid carcinomas are relatively common in dogs. The majority of tumors are unilateral and nonfunctional. Before deciding on treatment options, it is important to determine whether the tumor is freely moveable or fixed and invasive into adjacent tissues. Thyroidectomy is recommended for unilateral, mobile thyroid carcinomas. Radiation therapy or radioactive iodine therapy are recommended for dogs with invasive or bilateral thyroid carcinomas. The role of adjunctive chemotherapy is poorly defined, but should be considered in dogs with high-risk tumors, such as large or bilateral thyroid carcinomas. The prognosis is good following surgical treatment of mobile thyroid tumors and irradiation of fixed thyroid carcinomas, with median survival times greater than 3 years.

Thyroid Tumors in Dogs and Cats

The clinical presentation and biologic behavior of thyroid tumors vary widely among dogs, cats, and human beings. Although thyroid tumors in dogs are rare, they are most likely to be malignant. Clinical signs are usually the result of impingement on surrounding structures, and clinical hyperthyroidism is rare. In contrast, hyperthyroidism resulting from benign thyroid proliferation is relatively common among older cats. Malignant tumors are extremely uncommon but have high metastatic potential. Irrespective of the tumor's ability to produce functional thyroid hormone, scintigraphy is often helpful in the diagnosis and staging of thyroid tumors in all three species. Treatment with surgery is a reasonable treatment option for noninvasive tumors. Iodine 131 is a well-established treatment for thyroid nodules in cats, but its effectiveness in dogs is controversial. In dogs, external beam radiation therapy has produced more consistent results in affording local tumor control when surgery is not possible.

Nuclear Imaging and Radiation Therapy in Canine and Feline Thyroid Disease

The indications, techniques, and expectations for radionuclide diagnostic studies on canine and feline thyroid glands are presented. In addition, the considerations surrounding radioiodine or external beam radiotherapy for benign and malignant thyroid disease are reviewed. The intent of this article is to familiarize primary care veterinarians with the utility of and outcome of the ionizing radiation-based diagnostic and therapeutic techniques for assessing and treating canine and feline thyroid disease.

Sodium iodide I 131 treatment of dogs with nonresectable thyroid tumors: 39 cases (1990–2003)

OBJECTIVE

To determine outcome for dogs with nonresectable thyroid carcinomas treated with sodium iodide I 131 and identify factors associated with outcome.

DESIGN

Retrospective case series. Animals-39 dogs.

PROCEDURES

A definitive or presumptive diagnosis of thyroid tumor was made on the basis of cytologic or histologic examination, abnormal accumulation of sodium pertechnetate Tc 99m during scintigraphy, or both, and dogs were treated with sodium iodide I 131. Dogs with cervical thyroid tumors were evaluated 3 to 6 weeks after 131I therapy, and residual tumor was resected when feasible.

RESULTS

Prior to 131I therapy, 32 dogs had a solitary mass and 7 had metastases; 21 were hyperthyroid, 16 were euthyroid, and 2 were hypothyroid. Median survival time for dogs with local or regional tumors (ie, stage II or III) was significantly longer (839 days) than median survival time for dogs with metastasis (366 days). Tumor site (cervical vs ectopic), dose of sodium iodide I 131, age, body weight, treatment (131I therapy alone vs 131I therapy followed by surgery), and serum T4 concentration prior to 131I therapy were not significantly associated with survival time. Three dogs died of radioiodine-associated myelosuppression within 3 months after treatment, but no specific factor associated with development of toxicosis was identified.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that 131I therapy may result in prolonged survival times in dogs with nonresectable thyroid tumors, regardless of serum thyroxine concentration prior to treatment. Dogs undergoing 131I therapy should be monitored for signs of bone marrow suppression.

Acute severe hemorrhage secondary to arterial invasion in a dog with thyroid carcinoma

A 7-year-old spayed female Labrador Retriever was referred because of progressive swelling and bruising of the neck, hemothorax, a possible mediastinal mass, and stridor. At the time of admission, the dog was recumbent, mentally dull, tachycardic, and hypothermic. Fluid therapy with hydroxyethyl starch and a balanced electrolyte solution was administered because of presumed hypovolemic shock secondary to hemorrhage; multiple units of packed RBCs and fresh frozen plasma were also administered. On the basis of the computed tomographic images, extensive subcutaneous, subfascial, and cranial mediastinal hemorrhage; hemothorax; prescapular lymphadenopathy; and a contrast-enhancing mass in the left cranioventral aspect of the neck were diagnosed. Exploratory surgery of the neck was performed. All subcutaneous structures were encased in a large blood clot. During dissection of the clot, pulsatile bleeding was observed just caudal to and to the left of the larynx; ligation of the left common carotid artery resulted in immediate cessation of the pulsatile bleeding. Further surgical exploration revealed a 2.5 x 2.5-cm mass adhered to the left common carotid artery at the level of the branching to the left cranial thyroid artery. The mass was removed; the histologic diagnosis was thyroid carcinoma. Three weeks after surgery, treatment with a combination of radiation and chemotherapy (doxorubicin and carboplatin) was begun. Thirteen months after surgery, the dog continued to be free from clinical signs of disease.

Definitive radiation therapy for infiltrative thyroid carcinoma in dogs

The medical records of eight dogs with histopathologically confirmed infiltrative thyroid carcinoma treated with external beam radiation were reviewed and a retrospective analysis of survival and local tumor control were performed. The dogs received a definitive radiotherapy protocol of 46.8-48 Gray. All dogs had a reduction in tumor size to a clinically undetectable level on follow up examinations. Kaplan-Meier analysis indicated a median survival time of 24.5 months. Pulmonary metastasis was detected in three dogs and one of these dogs had concurrent bone metastasis. One dog had bone metastasis alone. Two dogs were alive at the censor. This study suggests that fractionated, definitive radiation therapy using multiple, moderate doses of radiation is an effective treatment for local control of invasive thyroid carcinoma in dogs.

Endocrine tumors

Because of the diverse nature of endocrine organs, and their vast range of physiologic functions, endocrine tumors encompass a wide range of origination sites and disease entities. The clinical picture of affected individuals is highly dependent on the tissue of origin, and the presence or absence of functional hormone secretions. Identification, localization, and therapeutic strategies, as well as prognosis can vary greatly. Many endocrine tumors have been described in human as well as veterinary patients. This article focuses on endocrine tumors of dogs and cats. Various tumors affecting the pancreas, thyroid, parathyroid, adrenal and pituitary glands are described, including insulinoma, gastrinoma, glucagonoma, and thyroid carcinoma, as well as parathyroid hormone- and growth hormone-secreting tumors. The syndrome of multiple endocrine neoplasia is also described.