Case Report: Management Vaccine Associated fibrosarcoma in 2 persian cats
By: drh. Cucu Kartini Lie and drh. Diana Safitri
A single hard lump (diameter 4.5 cm) and elongated lump (2.5 cm x 8 cm) found in 2 persian cats in young –adult cats, both male intacts were developed hard masses and attached to the muscle of the top of the neck between inter scapulae area after 8 – 10 month vaccination against polyvalen vaccine contains panleukopenia, calicivirus and herpes virus
Owner notice that the lump enlarge within 1 month, but both cats do not show any abnormalities on health condition, except they’ll feel little pain when they’re not touched gently.
Citology evaluation from 2 cats showed that population of tumor cells potential as malignant cells which were suspected to be originated from mesenchimal. From that characteristics were assumed to be soft tissue sarcoma.
A vaccine-associated sarcoma (VAS) is a type of malignant tumor found in cats. These tumors have been commonly associated with Rabies and feline Leukemia virus vaccine that contained allumiunium adjuvant. However, recent information suggested that injection site sarcomas can occur with any types of vaccine (lappin, 2009).
The incidence of VAS is unknown and difficult to estimate due to various methods of reporting the tumors. However, it is estimated at 1 case per 1.000 to 1 case per 10,000 vaccine administered. The likelihood of sarcome development increases within years following an injection (grace,2006)
Treatment VAS of two cats was performed by surgical procedure. Followed with antibiotic cefadroxil 20 mg/kg bid for 7 – 10 days and Transfor factor advance once a day as anti oxidant. The previous evaluation from thorax radiograph were not revealed of metastase to the lung yet.
Histopathology diagnosis after removed the mass from two cats was fibrosarcoma.
Current adjuvant treatment after surgery, two cats under chemotherapy with AC protocol (combination of Doxorubicin and Cyclophospamide). Doxorubicin 20-25 mg/m2 IV day 1. At day 3, 4,5 and 6 took cyclophospamide 50 mg/m2/PO , and then repeat cycle every 21 days, total giving of 3 cycles.
Keywords: chemotherapy, feline, fibrosarcoma, vaccine
Two young-adult persian intack male, from different owner were presented to the PDHB Clinic when they found hard masses and attached to the muscle of the top of the interscapulae after 8 – 10 month vaccination against polyvalen vaccine contains panleukopenia, calicivirus and herpes virus. The owner notice those lumps are growing very fast within 1 month. From the two cats, We notice the single lump is round shape with 4.5 cm in diameter and another lump is elongated shape (2.5 cm x 8 cm )
Picture 1. Lump in Persian Cat
Initial clinical findings
The cats conditions during their presented were normal, except cats refuse when it grooms or strong palpation. Mucose membrane was normal, body temperature slight fever (39,6ºC), activity and performance status quite well (Grade 1/4 due to Modified Karnovsky’s ( p 1101, chapter 78. Small animal internal med 3 ed)
Differential diagnose consideration
The presence of lumps or swelling were suspected to insect bites and some bacterial infections are often result in acute focal onset (james P. Chapter 45,small animal medical diagnose). To confirm those diagnose of that lump, performing of citology (FNA/B)sample is the effective. Although FNA/B finding may provide a definitive answer, more often the surgical biopsy is nesessary, because sarcoma do not consistently exfoliate cell. selected neoplasia (chapter 84.Small animal internal med 3 ed, 1151 -1152)
Citology was performed by FNA/B staight forward to the nodular mass on Tobby. The citology contains lerge number of neoplasticcells, details round cells type, histolitic, spindle cells and multinucleated giant cells almost 30 nucleus. Tumor cells have variable cytoplasm from pink to amofofilic and vacoulation. From the citology were assumed as soft tissue sarcoma /Malignant fibrous histiocytoma.This tumor is malignant tumor originally from fibrocyts as a variant tumor are the most commonly implicated Feline Vaccine-associated fibrocsarcoma.
Picture 2. Citology Lump from Tobby
In cats, fibrosarcoma can be happen within 3 – 11 months post vaccinal, it can occure on young cats ( 3 years) and no sex predilection,. Unfortunately VAS unpredictable evidence, some reasearch assumed that relatively low evidence around 1: 1000. Reccurrence after completed removed is common, and potencial to be metastase
Citology result from Goldy originate from mesenchimal cells from soft tissue (soft Tissue Sarcoma) risk of reccurence post surgery will be happen as local invasive and metastasis to regional lymphnodes, mediastinum and lung
Picture 3. Histopatology Lump from Goldy
Base on blood work result, performance status that both cats were suitable for surgery and considered combined with chemotherapy and immunotherapy. Big,wide and deep incision ( 2 -5 cm incision remove from the margins site) were performed to anticipate of reccurency of tumors, the following treatment with antibiotic (cephalexin bid for 10 days and transfer factor advance ® bid for 3 months). After 10 days sugery, cats visiting for opening suture, unfortunately, the skin healing process were slower than usual, It may be happen due to technique of incisison (too large skin removed), delay healing of cell suround the tumors,or infection handling. Antibiotic oraly and topicaly to be continue for another 5 more days. Completely remove suture 2 weeks after surgery with nice skin healing.
Picture 4. One Week After Goldy Surgery
A week after removed suture, elongated lump cat start growing small hard tissue, suspected scar tissue or growing the tumor, one week after chemotherapy and immunotherapy treatment, the lump was disappeared. The treatment followed by chemotherapy Adriamycin (Doxorubicin) slow IV, following Cyclophospamid oral (cytoxan) on the day 3,4,5 and 6.
One cat (elongated lump) has nausea being the oral chemo, and decide to keep continue with combined with omeprazole for 7 days. Another cats, seems doing accepted to chemotherapy treatment. On the cylus 2, they was normal and body temperature stable, except slight shading their fur, appetite was normal, slight conjunctivitis, no evidence of lose whiskers. Blood work peformed One week after the third cyclus, it seem was an abnormality on globulin
Vaccine-associated feline sarcoma recommendations to help identify causes, and reduce the prevalence of VAS. Vaccines containing rabies antigen should be given as distally as possible in the right rear limb.Vaccine containing leukemia antigen should be given as distally as possible in the left rear limb. Vaccine containing any other antigent exclude rabies and leukemia, are given on the right shoulder, being avoid the midline or interscapular space. Vaccines should be given subcutaneously, rather than inramuscullary. Ensure medical records are kept of the date,site of injection, type, serial number and manufacture of vaccine
Principles of chemotherapy, chemotherapy as cytotoxic drug inhibit cell growth and division. Cyclophospamid as alkylating agent interferen with replication of DNA and transcription of RNA. Major toxicity of alkylating agent can effect the gastrointestinal tract (anorexia, vomiting and diarrhoea), alopesia or thining of the coat and loss of whiskers.
Safe handling of cytotoxic drugs:
1 tablet should never be broken or crushed and capsule should not be opened
2. disposable latex gloves should be worn when handling any drug/capsule
3. container should be labelled clear with the name of the agent . warning to keep out of reach of children.
4. staff and owner should be informed should always be worn when adminiter the tablet/capsul.
5. hand must always be washed following handling
6.all the excess or anwanted drugs should be disposed of by high-temperature inceneration. ( A.J Stell and J.M Dobson, Capter 3, Chemotherapy in the treatment of neoplasia. Pp 20 – 27)Feline medicine and therapeutic, 3 ed. E.A chandler, C.J. Gaskell and R.M. Gaskell ,BVSA,2007 .
Vaccines are most often associated with VAS particularly fe LV and Rabies, However, recent information suggested that injection site sarcomas can occur with any types of vaccine (lappin, 2009). Adjuvanted vaccines produce inflammation, stimulate fibroblasts to divide, and are responsible for free radical formation, witch results in oxidative damage to DNA. Apparently cats are unique species susceptibility to oxidative injury is one reason for the high vaccine –associated tumor rate. However, granulomas and inflammation occur in cat only 1- 5 in 10,000 develope sarcoma, it may depend on individual susceptibility to oxidative stress. Adjuvanted vaccined produce granulomas 3 weeks after vaccination but dissapear within 3 months, in that reason decition for removing any lump at vaccination site if it meets any one of the following 3 criteria are still present 3 months after vaccination, > 2 cm in size at any time after vaccination, growing in size 4 weeks after vaccination. (Dennis W.Macy, DVM. Vaccine risks 413-415,feline internal medicine secrets, Michael R. Lappin, DVM,PhD,DACVIM, hanley & Belfus,inc 2001)
- Morrison WB,2001. Vaccine-associated feline sarcoma.ASMA; 218:697-702
- Martin M, 2003. Vaccine-associated fibrosarcoma in cat. The canadian Veterinary journal; 44: 660-663 (pubmed)
- Grace SF, 2009. Sarcomas, injection site in the feline patient: 130. Third edition
- Lappin MR, 2009. Feline vaccine associated side-effects: local and systemic manifestations. Feline medicine and surgery: 25
- A.J Stell and J.M Dobson,chapter 3, chemotherapy in the treatment ofneoplasia.pp20-27) feline medicine and therapetic, 3 ed. E.A Chandler, CJ Gaskell and R.M> Gaskell, BVSA, 2007.
- Dennis W. Macy, DVM. Vaccine risks 413-415, Feline Internal Medicines secrets, Michael R. Lappin, DVM, PhD, DACVIM, Hanley & Belfus, inc 20010
- James P. Small Animal Medical Diagnose chapter 45
- Selected Neoplasia, Small Animal Internal Medicines 3 ed,chapter 84 pp 1151-1152