Every veterinarian who has treated a dog with HSA wishes for better early diagnostics and more effective therapies to stop the growth of the HSA tumors. “The wish list for every veterinary oncologist starts with trying to find some way to deal with hemangiosarcoma,” says Rodney Page, DVM, MS, Professor of Oncology, Director of the Flint Animal Cancer Center, and Principal Investigator for the Golden Retriever Lifetime Study. “It’s a tumor that’s relatively unique to dogs and has completely evaded all attempts to understand what’s going on in a way that’s able to be modified in the patient. It’s a rapidly fatal cancer and one that desperately needs better diagnostic tools and treatments.” (Quoted from “Cancer Research: Looking Back, Moving Forward,” morrisanimalfoundation.org, March 27, 2019.) Fortunately, research on HSA is taking place in many locations: 

• Ethos Veterinary Health’s Canine Hemangiosarcoma Molecular Profiling (CHAMP) project is a multi-faceted prospective study of canine splenic HSA. One of its first undertakings was to assess the value of personalized medicine in dogs with HSA and then validate the usefulness of a potentially prognostic test. Through a collaboration between Ethos and the Translational Genomics Research Institute (TGen), the molecular characterization of genomic alterations in HSA was recently completed. CHAMP hopes to identify dogs with distinct prognoses and develop molecularly targeted therapies for each patient.
• Ethos Discovery (a division of Ethos Veterinary Health, LLC) is evaluating Rapamycin to determine whether it can improve treatment outcomes for dogs with HSA and to gain an understanding of which HSA genotypes may benefit most from its use. Rapamycin is known to have an immunosuppressive that provides significant anticancer activity and has been approved for use in treating several human cancers.
• At the Flint Animal Cancer Center at Colorado State University in Fort Collins, researchers are evaluating the effectiveness of VDC-597 administered orally to dogs with Stage I and II splenic HSA who have undergone splenectomy. VDC-597 is an oral agent that has antitumor and antimeta-static activity in human and mouse cancer models as well as in canine HSA cell lines.
• The Veterinary Clinical Investigations Center at the University of Pennsylvania in Philadelphia, in partnership with NovaVive, are in the follow-up stage of a study on the efficacy of treating canine splenic hemangiosarcoma with intravenous Immunocidin, the mycobacterial cell wall fraction derived from non-pathogenic Mycobacterium phlei, stimulating anti-tumor activity. It is currently approved for the treatment of mammary cancer in dogs.
• The University of Minnesota Veterinary Medical Center, Purdue University, and University of Pennsylvania are collaborating on a study to determine whether propranolol (a blood pressure medication) used in combination with standard-of-care doxorubicin chemotherapy can improve outcomes for dogs with HSA. Propranolol can kill HSA cells in the laboratory; it has also been effective in reducing disease progression and increasing survival time in humans with angiosarcoma (which is similar to canine HSA).
• A study at the New York State College of Veterinary Medicine at Cornell University aims to find and test new drugs that can prevent tumor growth. The long-term goals of this project are to identify better procedures and drugs to treat canine HSA as well as to test the ability of newer targeted drugs in preventing tumor growth or recurrence.
• The Shine On Project, led by Jaime Modiano, VMD, PHD, at the University of Minnesota College of Veterinary Medicine, is designed to detect HSA cells in the blood at the earliest onset by way of a new, targeted drug called eBAT. The drug was developed at the University of Minnesota with the goal of destroying the cells responsible for tumor formation, thereby stopping the formation of malignancies. The process “will use a blood test to look for the cells responsible for establishing and maintaining the disease, and then use an experimental drug treatment that attacks those same cells in order to prevent development of the tumor.” Researchers at the college have been studying the biology and the behavior of HSA for more than 10 years.
• A recent retrospective multicenter observational cohort study of 406 dogs determined that the risk of HSA diagnosis in dogs presenting with blood accumulation in the abdomen could be predicted using a simple risk score modeled on four predictors: body weight, total plasma protein, platelet count, and thoracic radiograph finding. This evaluation process could aid in identifying and treating dogs at lower risk for this diagnosis. (“Development and validation of a hemangiosarcoma likelihood prediction model in dogs presenting with spontaneous hemoabdomen: The HeLP score,” Schick et al, Journal of Veterinary Emergency and Critical Care, Volume 29, Issue 3, 17 April 2019.)
• Michigan-based Metta Pets is currently enrolling dogs at select referral centers around the United States for a clinical trial, “Investigation of a traditional Chinese medicine herbal therapy protocol for treatment of dogs with Stage II splenic hemangiosarcoma after splenectomy.” They will evaluate the impact of a standardized bupleurum-based herbal formula administered with vitamin D supplementation, Yunnan Pai Yao, and coriolus mushroom granular extract in canine patients diagnosed with stage II splenic HSA following splenectomy. To date, no toxicities from the treatment have been noted, including one dog who received a significant repeated overdose due to client non-compliance. Preliminary data suggest improved survival times when compared to chemotherapy treatment and an increase in the number of patients living to one year or more. This study will assist in determining if these promising findings are repeatable when a larger number of patients are evaluated.

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Hemangiosarcoma in Dogs
You can’t help it: Reconsidering past decisions after a devastating diagnosis
Making the Most Out of the Time You Have

It’s been nearly 2 1/2 years since we lost our precious dog Linus to hemangiosarcoma. He was a sweet, silly, athletic Portuguese Water Dog and was just shy of his 10th birthday. 

We got up one Saturday morning in April with plans to play at the park, then give him a bath in preparation for his first therapy dog visit the next day. My husband, Paul, got up before me and I heard him say, “Hey buddy, are you okay?” Linus was laying down panting in the hallway. When we went out to the family room, Linus ambled out and dropped to the ground. We called the emergency vet to let them know we were on our way. 

I had to carry Linus to the car and into the veterinary hospital because he couldn’t stay on his feet. They took him back right away. After what seemed like an eternity, the veterinarian came out and said that Linus was in severe shock and appeared to be bleeding into his belly. I have a number of friends who have lost dogs to HSA, and I was terrified. I kept asking, “Do you think it’s hemangiosarcoma?” I remember thinking it was so surreal to be sitting in the vet office hoping that my dog had ingested poison, because at least there may be something to do about it. 

They did an ultrasound, which found multiple masses on Linus’ spleen and liver.

The veterinarian reviewed our options: surgery to remove whatever tumors he could (but it was likely that Linus wouldn’t survive surgery); try to slow/stop the bleeding and buy some time (likely a few days); or make no attempt at treatment and let him go. I just couldn’t believe that a few hours before we were making plans for the weekend and now were contemplating how to manage Linus’ final hours or, at most, days. I desperately wanted to get him home; I didn’t want him to die in a vet office. We decided to try to control the bleeding to see if he could improve enough to make it home. The vet called a couple hours later to say that despite transfusions and medication, Linus’ clotting function was non-existent and we needed to make a decision. We raced back.

We found Linus in so much pain and distress that we decided we needed to help him depart immediately. Another situation I never imagined – please, please hurry and euthanize my wonderful dog. Linus was gone in just a few minutes. My beautiful, funny, intelligent, loving dog who always lived life to the fullest was gone.

Second-guessing, so hard

I can’t count the number of times I’ve pondered the decisions we made over the course of Linus’ life. Did this or that contribute to his cancer? 

Linus had allergies that began before he was a year old. We tried everything under the sun: elimination diets, frequent baths, various medications, etc. He was on Apoquel for some time; it helped significantly with his itching. Sometime later he developed a nasty skin infection, which we treated with antibiotics and increased the Apoquel. A few months after that, I found some small black growths on the skin of his elbow. We had them biopsied, and while they weren’t harmful, the dermatologist said Linus’ immune system should have prevented them from growing; the Apoquel may have suppressed his immune system too much. We discontinued the drug; fortunately, what is now Cytopoint was newly available and we started that with success. Should we not have used the Apoquel? I have no idea. I do know that it gave him relief when nothing else seemed to help and made a drastic difference in the quality of his life.

Another event happened about 10 months before he died. He had ambled across a yellowjacket nest in the ground and a number of yellowjackets stung him. I’ve never seen anything like it. It was awful. His face puffed up like that of a prize fighter. The emergency vet treated him with antihistamines and a two-week course of steroids. Another immune suppressor – might that have opened the door to the cancer? The timing makes me think it’s possible. I’m not a fan of steroids, but for his situation, I think it was necessary to help him recover.

A month or two later he seemed not quite himself – a bit less enthusiastic about things he usually loved. Then he recovered. He had his annual physical a week or two later. Everything seemed fine. I told the vet that he had this period of a few weeks where he was a little subdued. I said, “You know I’m scared to death of hemangiosarcoma.” He said we could do an ultrasound if I wanted, but added that there wasn’t much that could be done for HSA. In the unlikely event that we had been able to detect HSA at that point, a splenectomy and chemo might have bought us just a couple more months. His last six months of life were great, and it would have been heartbreaking for us to have spent that time dealing with the discomfort of treatment that would likely accomplish little.

On the other hand, I was comforted by the fact that for most of his life we gave Linus a raw, fresh diet. I loved making his food, and he loved eating it! I hope it helped him live longer than if he had been on a different diet. 

The multitude of questions continue to swirl in my head and heart. In the end I try to remind myself that we made the best decisions we could at the time with the information we had, always with the intention of providing Linus the best life possible. And most importantly, we loved that wonderful dog and enjoyed a beautiful life with him. – Joanne Osburn

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Hemangiosarcoma in Dogs
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On the Horizon: Hemangiosarcoma Studies

Roo was a large, adventurous, mixed-breed dog belonging to my colleague and friend Tory. In August 2008, at about 13 years of age, Roo was experiencing what her veterinarian thought were small seizures. By pursuing this one seemingly small isolated symptom, further diagnostic tests revealed a mass on her spleen. 

A soft tissue specialist recommended exploratory surgery with removal of the tumor, if possible; this would provide the best chance for a diagnosis and treatment. Tory was hesitant: Roo was a senior dog; surgery seemed to be a lot of trauma to put her through – especially because at that moment she was perky and happy and appeared perfectly normal. It was only upon reflection that we realized this was periodic recovery from the small bleeds that intermittently depleted her body of red blood cells. 

The specialist reassured Tory that Roo was very stable and that the surgery shouldn’t be too taxing on her system. The vets suspected that the mass was more than likely some kind of malignant tumor – either hemangiosarcoma (incurable with a short survival time) or hepatocellular carcinoma (curable if completely removed).

Roo underwent a successful splenectomy. The tumor itself was found to be self-contained (a good sign), but additional smaller growths were seen on the liver (a not-so-good sign). The surgeon opted not to biopsy these growths as Roo’s blood pressure was fluctuating during the procedure. Furthermore, if the masses were HSA, bleeding could become a serious problem.

Sadly, the biopsy confirmed the mass was HSA and an oral metronomic chemotherapy protocol was added to her palliative treatment plan; she was also supported with supplements and special home-prepared meals. 

Roo spent weekdays with us at the office. She would spend time gazing out the picture window watching the city life of downtown San Francisco. She wandered from desk to desk in search of goodies. At my desk, she became quite adept at clearing everything off of it in search of treats. I may have contributed to this behavior. She knew when it was time for lunch; French fries were her favorite. Or maybe it was ice cream. She was enjoying life.

And then one day at about five months post-surgery, Tory noticed Roo seemed a little off. Bloodwork was promptly performed; the results were not good. Her time was nearing and she was watched very closely. 

A few days later, she had an episode similar to those that occurred at the beginning of the disease. She was carried to the car by a colleague and rushed to the veterinarian. She was failing fast and nothing more could be done – except take her home and let her eat out of a gallon container of ice cream while the vet sedated her. 

Tori remembers: “As she was laying there, I realized what was so special about her: She was the first being in my life to whom I was her number one. I was the single most important person to that dog. I’d never really experienced that before. My other dog, Scout, was kind of ‘everyone’s dog’ and all my other dogs before had been family dogs. So I thanked her over and over for choosing me!”

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Hemangiosarcoma in Dogs
You can’t help it: Reconsidering past decisions after a devastating diagnosis
On the Horizon: Hemangiosarcoma Studies

While a diagnosis of canine cancer is never good, there are few types worse than hemangiosarcoma (HSA). Like all cancer diagnoses, it’s frightening, shocking, and devastating. Often with this form of cancer there are no warning signs or symptoms; it can hit hard and fast and there may be little time to make decisions, much less research treatment options. 

HSA is a highly aggressive cancer of blood vessel cells that develops almost exclusively in canines. While the dermal form can sometimes be successfully treated, the visceral form can suddenly become evident with critical, and often fatal, symptoms. 

Jump to: Causes | Symptoms | Diagnosis | Stages of HSA | Treatment

Hemangiomas are benign clusters of blood vessels on or beneath the skin, such as the red birthmarks that occur on infants; sarcomas are rare cancers that develop in the bones and soft tissues, including the blood vessels. Hemangiosarcoma refers to a highly malignant disease that develops in the endothelial cells that line the surface membrane of blood vessels and then invades the blood vessels themselves. Because hemangiosarcoma affects blood vessels, it can develop in almost any organ, with the spleen being the most common anatomic location (40 to 50% of cases). 

HSA tumors affecting the atrium and the auricle of the heart were initially thought to be a result of metastasis but are now recognized as primary tumor locations comprising anywhere from 10 to 25% of cases; HSAs are the most common cardiac tumor found in dogs. In dogs with splenic HSA, 25% will also have a heart-based HSA. 

The dermal form of the disease comprises about 13 to 15% of the cases. Less common sites include liver, tongue, kidney, bladder, lung, muscle, and bone.

It is estimated that HSA accounts for 5 to 7% of all canine cancers. Any age or breed can develop the disease. It usually occurs in larger breed middle-aged and older dogs (ages 8 to 12 years), though it has been reported in dogs under one year of age. While traditionally there has been no sex predilection, recent reports are starting to show a slight increase in prevalence in males.

Types of Hemangiosarcoma

HSA is classified into three types based on anatomical location: dermal, hypodermal/subcutaneous, and visceral. 

Dermal Hemangiosarcoma: The dermal (cutaneous) form of HSA develops on the skin in areas that have minimal or no fur, appearing as black or reddish growths (can be singular or multiple masses) anywhere on the body, with the abdomen, rear legs, and prepuce the most common sites. 

In most cases, the cancer does not spread to the dermis tissue and can be treated (and potentially cured) with surgical removal. Because of the malignant nature of the disease, however, it can spread internally, which occurs in about one third of cases; early diagnosis and prompt treatment is vital. 

This form of HSA has a predilection for dogs with light or non-pigmented skin, sparse coats, and areas of white fur, and has been linked to excessive exposure to the sun. Thus, dogs with short white fur, such as Dalmatians, are predisposed to developing this type. It is believed that limiting sun exposure in dogs with thin fur and pale skin can help to prevent this form of the disease (there is no known preventive for other types of HSA).

Hypodermal Hemangiosarcoma: The hypodermal (just under the top layer of skin) form of HSA is more aggressive and invasive than the dermal form. This type is characterized by dark red to black growths just under the normal overlying skin; a soft or firm mass may be palpable (due to bleeding), and ulceration is common. Local control is challenging, as the disease may be extensive; more than 60% of these cases spread internally. 

Visceral Hemangiosarcoma: Visceral(internal) hemangiosarcoma affects the internal organs, primarily the spleen and heart. It is an invasive and rapidly spreading malignancy, often life-threatening as the tumors can break open and bleed – often without warning.

What Breeds Are at Risk for Hemangiosarcoma?

Large breed dogs appear to be at an increased risk, but especially Box-ers, Bully-type breeds, Dobermans, English Setters, Flat-Coated Retrievers, German Shepherds, Golden Retrievers, Great Danes, Labrador Retrievers, Poodles, Portuguese Water Dogs, Skye Terriers, and Whippets. The dermal form is overrepresented in Basset Hounds, Dalmatians, and Whippets and in dogs middle-aged (4 years) or older.

SIDEBAR: Making the Most Out of the Time You Have

What is the Cause of Hemangiosarcoma in Dogs?

The cause of HSA in dogs is unknown, but the breed association suggests a genetic predisposition. The dermal form is thought to be associated with excess exposure to sunlight as it is generally found in lightly-pigmented and/or thin-coated dogs. It has also been hypothesized that local irradiation may be contributing factor. Exposure to certain chemicals may also contribute to the development of the disease; though HSA in humans is extremely rare, exposure to vinyl chloride has been implicated. 

Symptoms of Hemangiosarcoma in Dogs

HSA tends to progress slowly at the beginning, usually without symptoms and without pain. As a result, a dog’s body can tolerate the disease until it reaches a critical stage. Symptoms may appear for only a limited duration and will depend on the type of HSA and the specific location in the body (see above for dermal form). 

Internal HSAs – both the hypodermal and visceral forms – may produce any combination of symptoms from general signs of illness such as lethargy, depression, dementia, inappetence, weight loss, constipation/unusual bowel movements, lameness, and decreased stamina, to more acute symptoms of fainting or weakness, lack of coordination, partial paralysis, intermittent collapse, seizures, abdominal swelling, nosebleeds, coughing, and increased panting. 

These malignancies are vascular by nature and develop their own blood supply; however, the blood vessels are formed with mutated cells, and they eventually leak blood into surrounding areas. This slow, chronic bleeding in small amounts can cause subtle transient symptoms with the dog recovering as new blood cells are produced. Eventually the tumors will rupture, resulting in a substantial hemorrhage with critical and obvious symptoms commonly involving difficulty breathing, increased heart and respiratory rates, pale mucous membranes, and collapse due to hemorrhagic/hypotensive shock requiring emergency veterinary care.

Hemangiosarcoma Diagnosis

If HSA is suspected, your veterinarian will perform a thorough physical exam, noting in particular any of the symptoms listed above. At times, abdominal tumors can be large enough that they are felt when palpated. A number of tests will likely be performed, such as a complete blood cell count (CBC), serum biochemistry profile, urinalysis, and coagulation profile. In dogs with HSA, abnormalities noted in the blood panel may include anemia, red blood cell fragmentation, low platelet count, and high number of neutrophils (the primary white blood cells that respond to bacterial infection). 

The coagulation profile will determine if there are clotting abnormalities suggestive of disseminated intravascular coagulation (DIC), which is present in about half of the dogs with visceral HSA. DIC is characterized by the development of small blood clots that block the blood vessels; this depletes the platelets and clotting compounds needed to control bleeding, which in turn can cause excessive bleeding. Heart arrhythmias are commonly associated with cardiac and splenic HSAs; accordingly, an electrocardiogram may be recommended.

Diagnostic imaging using radiographs or ultrasound are useful methods for locating, identifying, and characterizing masses in the abdominal and cardiac regions as well as providing possible evidence of free fluid or blood. When a mass on the spleen is detected, it may not be possible to determine if the mass is malignant prior to removal. 

A fine needle aspirate may be used to take a tissue or fluid biopsy; analysis of samples taken directly from the tumor (or from a surgically removed tumor) provides the most conclusive method for making a diagnosis. This procedure, however, is not without risk: not only does it have the potential to spread malignant cells during the process, it can also trigger bleeding of the fragile tumors. 

Imaging can also assess the extent of the malignancy (staging) and determine whether metastasis has occurred. This can be challenging because there may be multiple tumors and/or the primary tumor site may be difficult to determine. 

A recent study by Carloni, et al, published in the ACVIM Journal of Veterinary Medicine (“Prevalence, distribution, and clinical characteristics of hemangiosarcoma-associated skeletal muscle metastases in 61 dogs: A whole body computed tomographic study,” Volume 33, Issue 2, March/April 2019, Pages 812-819) found that clinical examination and traditional diagnostic imaging modalities missed the presence of skeletal muscle metastases. The authors recommend whole body computed tomography (CT) scans for accurate assessment and detection of metastasis to lungs, muscle, and other sites.

The visceral form of HSA is very aggressive and grows rapidly with local infiltration occurring early in the course of this disease. The likelihood that it has spread from the primary tumor by the time of diagnosis is very high, with about 80% of cases with metastasis upon initial presentation. The liver and lungs are common sites of metastasis, but the disease can spread to any location in the body due to its connection to the blood vessels. 

Because the symptoms associated with HSA can be subtle and non-specific, many cases are not diagnosed until a ruptured tumor results in catastrophic hemorrhage. While dermal HSA tends to have a lower metastatic rate and has the potential to be cured, it is important that a comprehensive assessment also be done in these cases because this form can still metastasize.

Stages of Hemangiosarcoma

Clinical staging is based on the results of the various diagnostic tests performed and can provide a foundation from which to explore and make treatment decisions. Two different three-stage classification systems are traditionally used for HSA.

Visceral HSA

• Stage I: Localized tumor; no other tumors seen in imaging or at time of surgery.
• Stage II: Ruptured tumor confined to the primary site, with or without metastasis present near the site of the primary tumor.
• Stage III: Ruptured primary tumor with invasion into adjacent structures plus local or distant metastasis.

Dermal / Subcutaneous HSA

• Stage I: Primary tumor confined to the dermis.
• Stage II: Primary tumor involving the hypodermis with or without dermal involvement.
• Stage III: Primary tumor with underlying muscular involvement.

Hemangiosarcoma Treatment

Because canine HSA tends to develop undetected until it has reached an advanced stage, the disease is often resistant to most forms of treatment. The modalities of surgery, chemotherapy, and radiotherapy can potentially have some effect.

Surgery

Surgery is typically the primary option for treatment for all cases of HSA. 

For the dermal type, it may be the only treatment that is necessary. Sunlight-induced and superficial dermal HSAs are sometimes considered cured following surgery; however, new tumors can develop elsewhere on the body independent of a previous occurrence. It is advised that dogs diagnosed with this form of skin cancer should avoid as much sun exposure as possible. Dermal and subcutaneous HSA surgery sites can be quite extensive due to the necessity of removing all affected tissues.

For visceral forms of the disease, surgery is usually recommended for all locations except those involving the heart. Cardiac surgery is inherently difficult, but vascular tumors are even more challenging. Depending on the size and involvement, atrial tumors may be considered for excision. Because HSA is associated with life-threatening hemorrhage and a dismal prognosis, the difficult decision of whether to pursue emergency surgery must often be made quickly at the time of diagnosis. 

For dogs with splenic masses, removal of the spleen (splenectomy) is recommended, even though it may not be known in advance if the tumor is benign or malignant. It is estimated that approximately 50% of splenic tumors are benign, but even if they are non-cancerous, the tumors can be dangerous because the spleen itself is very vascular and can rupture and cause substantial and serious bleeding. Removal of the spleen thus becomes both a diagnostic (by providing tissue for biopsy) and a therapeutic procedure. During the procedure, the entire abdominal cavity will be examined for evidence of metastasis and additional tumors with samples of any suspicious tissue taken for biopsy.

If there is time before the surgery, it can help to have a decision made and plan in place for what you want done, depending upon the findings made during the procedure. 

While surgery may be the best option available and provide the highest chance of increasing survival time, there are risks and concerns. Due to the inherent nature of the disease, there is a significant risk for severe hemorrhage during the surgical procedure. 

Dogs presenting with emergency HSA may already be compromised; stabilization prior to surgery usually involves fluid therapy and/or blood transfusions and intensive care monitoring. Cardiac arrhythmias can occur post-surgery and, while most occurrences resolve within 24 to 48 hours, some may require treatment. 

Removal of the spleen in deep-chested dogs may create more space in the abdominal cavity; as a result the dog may be more prone to gastric torsion and gastropexy (stomach tacking) may be warranted at the time of surgery.

Chemotherapy

Given the propensity for HSA to metastasize, chemotherapy is often recommended as an adjunct treatment to surgery, especially in cases of incomplete surgical removal, or as a primary treatment for heart-based HSAs (as surgery in the cardiac area can be very difficult). 

There are several chemotherapy protocols used, consisting of either a single agent or a combination of drugs; doxorubicin (Adriamycin), vincristine, piroxicam, cyclophosphamide, and methotrexate are the most common ones. Doxorubicin appears to reduce the gravity of the disease, yet it doesn’t necessarily extend the survival time beyond that of other protocols. 

Metronomic chemotherapy (a constant low dose of chemotherapy given at home in oral form) is being studied as an approach that not only reduces the chances of side effects but helps control the spread of disease and thereby increase survival time. Since HSA is not curable, the intention of chemotherapy treatment is to slow the cancer progression while providing a good quality of life. 

Radiotherapy

Radiotherapy (RT) has limited use in treatment of HSA because of where the disease forms in the body (sites tend not to be conducive to receiving radiotherapy) and the extremely high rate of metastasis. It may be considered as a treatment option for dermal forms where surgical removal from external surfaces did not achieve clear margins, as an adjunct to chemotherapy, and for cases with localized Stage II or Stage III disease. 

As a palliative therapy, RT can be beneficial in reducing pain and possibly extending survival time. Exploration of radiotherapy as a treatment option is continuing, however, and some recent – albeit small – studies have demonstrated that RT can provide clinical benefits to dogs with HSA.

SIDEBAR: You can’t help it: Reconsidering past decisions after a devastating diagnosis

COMPLEMENTARY REGIMENS

I’m-Yunity and Yunnan Baiyao are two alternative therapeutics that have been documented as having some success in treating HSA. While the research may be limited and in the early stages (studies are continuing), veterinary oncologists are incorporating these modalities into their treatment protocols.

I’m-Yunit. This is a poly-saccharopeptide (PSP) compound from the Coriolus versicolor mushroom, commonly known as the Yunzhi or turkey tail mushroom. It has been used for over two millennia in traditional Chinese medicine; Western researchers have recently begun exploring this mushroom treatment for hemangiosarcoma. It has been demonstrated to have antitumor activity in tissue culture studies and can boost the body’s own cancer-fighting abilities by improving the function of the immune system. 

In 2012, a small (15 dogs) clinical trial at the University of Pennsylvania demonstrated the efficacy of I’m-Yunity mushroom supplements in dogs with cancer. This double-blind randomized multidose pilot study featured a high-dose of PSP, which significantly delayed the progression of metastasis and increased the reported survival times for canine hemangiosarcoma. 

The data suggest that PSP, as a single agent, might offer significant improvements in morbidity and mortality. For more information, see “Single Agent Polysaccharopeptide Delays Metastases and Improves Survival in Naturally Occurring Hemangiosarcoma,” in Evidence-Based Complementary and Alternative Medicine, Volume 2012.

Yunnan Baiyao. Yunnan Baiyao is also a Chinese herbal medicine and is known for its hemostatic (stops bleeding) and wound-healing properties. It is a protected Chinese traditional medicine and the exact formula is a trade secret, but labelling does identify its primary components. 

Yunnan Baiyao is frequently used in veterinary medicine to control bleeding in dogs by improving clotting and platelet function and veterinary oncologists are prescribing it to control or stop bleeding from cancerous vessels. 

In laboratory experiments, Yunnan Baiyao has been shown to kill HSA cells. Yunnan Baiyao appears to be of benefit to dogs with HSA, but documentation on efficacy and side effects is not yet available; clinical trials are still being conducted.

SIDEBAR: On the Horizon: Hemangiosarcoma Studies

Prognosis

HSA is a formidable disease, especially when compared to most other canine cancers. As with any form of cancer, statistics are presented as general guidelines and do not represent how an individual dog will respond to treatment.

The long-term prognosis for dogs with HSA is dismal, even when the disease is discovered at its early stages. For dogs who are receiving treatment, however, their quality of life usually remains good to excellent. Even as the disease progresses, it does not appear to cause much pain; instead, dogs may experience a return or increase of symptoms such as bleeding, anemia, or weakness. 

Overall, 6 to 13% of dogs with HSA who are treated with surgery alone will be alive one year post diagnosis; of those treated with surgery and chemotherapy, the one-year survival rate increases to 12 to 20%. 

• Survival time for dogs with dermal HSA that cannot be cured through treatment varies greatly and is dependent on such factors as location and stage. In cases where the dermal lesions invade the sub-cutaneous tissues, the survival times fall in the range of five to 10 months.
• The average survival time for dogs with hypodermal HSA is six months.
• Without treatment, most dogs diagnosed with HSA of the internal organs will die within one to two weeks of diagnosis, although some can survive for several months and others only a day.
• The prognosis for patients with splenic HSA treated with only surgery ranges from one to three months, while those treated with surgery and chemotherapy have an improved prognosis range of four to eight months. However, if extensive metastasis is present at the time of surgery, survival time is only about two months when followed with chemotherapy. 
• Clinical stage tends to be strongly associated with the prognosis for dogs with splenic hemangiosarcoma.
• The prognosis declines for dogs with splenic tumors that rupture; survival time tends to be shorter and unpredictable.
• Dogs with evident metastasis at diagnosis and who do not undergo surgery may respond to chemotherapy, which can provide a prolonged quality of life when compared with dogs who are not treated at all. 
• The prognosis for dogs with tumors that involve the heart, liver, and/or other internal organs is worse than for those with splenic tumors.
• Dogs with Disseminated Intravascular Coagulation (DIC) appear to have shorter survival times than dogs without the condition.
• Unfortunately, almost all dogs with HSA will succumb to the disease from tumor rupture or metastasis to the organs.

Reason for Hope

HSA affects thousands of dogs every year, but investigation into it has been limited, primarily because it is almost exclusively a canine disease. Most other types of canine cancers occur in humans as well and consequently have a greater impetus for research. 

It has been more than 40 years since chemotherapy was added to the standard of care for the treatment of HSA. While there has been little improvement in the prognosis for dogs since then, recent studies show promise for the development of new screening methods and early detection, which will allow for treatment to begin sooner and, we hope, a better outcome. See “On the Horizon: Hemangiosarcoma Studies” on the next page for more information about the latest research on this devastating disease. 

Eileen Anderson is an Arkansas-based author who also maintains the Dog Dementia website, a resource for people whose dogs have been diagnosed with CCD or are displaying symptoms of the disease. Anderson’s book Remember Me?: Loving and Caring for a Dog with Canine Cognitive Dysfunction, not only chronicles her experience caring for her dog, Cricket, who was diagnosed with CCD in 2011 at the age of 15, but also helps guide other dog owners through what they need to know to best care for their dogs with CCD.

“It breaks my heart that the vast majority of people who find my site have dogs who are in late stages,” Anderson says. “These owners are usually already grappling with the oncoming choices about euthanasia. I hope that more people can learn about CCD and begin to see the signs much earlier so they can take steps to slow the process.” 

Anderson has developed a printable checklist that includes an extensive list of CCD symptoms, designed to help dog owners recognize the signs and then keep records of behaviors their dog may exhibit, so they can remember to bring up these with their veterinarians. The checklist includes varied symptoms to watch for, including not responding to her name, seeking less attention, getting trapped under furniture, and being frightened of once-familiar people.

Anderson also encourages people to keep in mind that while CCD is very upsetting for dog owners to grapple with, it isn’t always as traumatic for our dogs. “We remember the dog’s former vibrancy,” she says. “But if we take a good look, dogs who pace may not be distressed. They don’t remember what they have lost. And if dogs still have pleasures in life, and guardians who are attentive and who can help provide those, they still may have good months or years ahead of them.” 

Keeping dogs with CCD comfortable is key. Anderson has become an expert in strategies for supporting aging dogs and ensuring their homes are safe. She has found that putting bathmats and yoga mats on floors can help dogs who are unsteady or disoriented. She also encourages people to put dog beds, food dishes, and water bowls in a number of locations in the house, so that disoriented dogs can find them while wandering. “I put water stations in corners because Cricket ended up in corners a lot,” Anderson says. She also advises that owners of dogs with CCD monitor and/or remove mobility ramps as well as access to stairs because the dogs may no longer have the cognitive ability to safely navigate them. 

Enrichment is key for all dogs, but especially dogs with CCD. Anderson offers the important perspective that even if activity doesn’t slow the progression of CCD for a particular dog, keeping these dogs mentally and physically active will help keep their overall quality of life as high as possible. 

Remember Me? won the 2016 Maxwell Award from the Dog Writers Association of America for a book on health, behavior, or general care.

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Nutritional Help for CCD

Food and supplements can play a part in maintaining optimal canine cognitive functioning and supporting an aging canine brain. Dr. Fry advises talking with your vet about adding antioxidant supplements that have shown benefits for the brain, such as Denosyl, which contains S-Adenosylmethionine (SAM-e), into your dog’s diet. The most advantageous time to do this, he says, is in your dog’s “middle age” –before she shows any signs of CCD. 

In addition, Dr. Tracy advises owners to feed diets high in omega-3 fatty acids (found in fish oil) and medium-chain triglycerides (found in coconut oil), which may be neuroprotective and even decrease the likelihood that a dog will develop CCD.

Both veterinarians recommend commercially available diets such as Purina’s Bright Mind 7+, Purina Pro Plan’s NeuroCare, or Hill’s Science Diet BD. These products include supplements and/or therapeutic levels of nutrients that studies have shown may support cognitive functioning in senior dogs. 

Editor’s note: The above-named products don’t generally have the characteristics we look for in a quality dog food. However, if a trial of a month or more of feeding one of these foods results in any improvement in your dog’s CCD, it makes sense to continue feeding the product! Or, owners may opt to discuss with their veterinarian how best to supply their dog with nutrients that may improve their senior dog’s cognitive function. These may include arginine, docosahexaenoic acid (DHA, an omega-3 fatty acid), eicosapentaenoic acid (EPA, another omega-3 fatty acid), and B vitamins. 

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She Wrote the Book on CCD

Mercury, my Chihuahua-mix, turned 17 years old this year, making him (by far) the oldest dog amongst all of my friend’s dogs. When people see him, I’m always proud that they can hardly believe he’s as old as he is. Despite his age, Mercury is still in great physical shape and maintains an active life. 

Though Mercury is still very active I can tell he is slowing down and there are days when, just for a moment, he seems a bit confused. Our vets indicate that this is a normal part of aging, but it has me worried. 

It’s been estimated that more than 14% of pet dogs over the age of 8 show some symptoms of age-related cognitive dysfunction – and a whopping 68% of dogs aged 15 to 16 years have symptoms of cognitive impairment. 

Some pet owners might joke about “doggie Alzheimer’s,” but it’s a real thing. The degenerative brain disease that is very similar to Alzheimer’s in humans is properly called Canine Cognitive Dysfunction (CCD). 

Gaemia Tracy, DVM, is a neurologist at NorthStar Vets in Washington Township, New Jersey. He says that dogs with CCD generally exhibit behavioral changes ranging from a loss of housetraining to aggression, and often appear confused or disoriented. All dogs are at an equal risk; there are no known associations between breed or size and the risk of developing CCD. Dr. Tracy notes that he generally sees signs of CCD developing in affected dogs after the age of 8 to 10. 

SYMPTOMS

Dog owners are usually the first to notice that something is wrong or different with their dogs. Common symptoms to watch for include pacing, turning in circles, staring into space, or seeming lost and confused. In many cases, the dog’s temperament changes. Dogs who have been generally friendly may begin to show aggression – and typically aggressive dogs may become unusually friendly! 

Dogs experiencing an onset of CCD may also start to have difficulty navigating stairs or seem confused about how to get around furniture. CCD may also lead to dogs isolating and seeking out less attention, or generally become more fearful or anxious.

Veterinarians use the acronym DISHAA to describe typical symptoms of CCD. This stands for:  

• Disorientation – Examples include getting lost in familiar places, doing things like standing at the hinge side of the door waiting for it to open, or getting “stuck” behind furniture.
• Interactions – Changes in how or even whether the dog interacts with his people. He may withdraw from his family, and become more irritable, fearful, or aggressive with visitors. In contrast, the dog may become overdependant and “clingy,” in need of constant contact.
• Sleep – Changes in sleep patterns (such as being wakeful or restless in the middle of the night), vocalization at night.
• Housetraining – Increased house-soiling and/or a decrease in signaling to go out are common. Or a dog goes outside for a while and then eliminates in the house right after coming inside, or soils his crate or bed.
• Activity level – Decrease in exploration or play with toys or family members, and/or an increase in aimless pacing or wandering.
• Anxiety – Increased anxiety when separated from owners, more reactive or fearful to visual or auditory stimuli, increased fear or new places. 

Recently, the letter “L” was added to the end of the acronym:

• Learning/memory – Decreased ability to perform learned tasks, decreased responsiveness to familiar cues, inability/slow to learn new tasks. 

Dylan Fry, DVM, Diplomate American College of Veterinary Internal Medicine (DACVIM), a neurologist at NorthStar VETS, also notes that it’s important to watch for new compulsive behaviors (such as pacing) from your senior dog, as these, too, could be symptoms of CCD. If your dog is exhibiting any of the above symptoms or has developed a behavior or personality change, it’s a good idea for your dog to be seen by a veterinarian so you can discuss your concerns about CCD and rule out any other conditions like arthritis or other pain, vision, or hearing changes that may cause similar symptoms.

HOW IS CCD DIAGNOSED

Before your veterinarian can diagnose CCD, he or she will discuss the symptoms you are seeing at home and possible alternate causes. Your veterinarian is likely to do a thorough examination and blood work to rule out other causes. 

“CCD is a diagnosis of exclusion,” says Laurie Bergman, VMD, Diplomate American College of Veterinary Behaviorists (DACVB), a veterinary behaviorist with New Jersey’s NorthStar VETS. “First we have to rule out possible medical causes of these changes, including endocrinopathies (thyroid disorders), pain, and changes in sensory function.” 

Dr. Bergman notes that the time it takes to get a proper diagnosis can be frustrating for dog owners, but warns that even if your dog shows what seems like clear symptoms of CCD, the symptoms could be tied to a different condition. Tumors, inflammation, and infection in the brain can mimic the symptoms of CCD; if a dog is showing symptoms of CCD that can’t be connected to other conditions, veterinarians may recommend using a magnetic resonance imaging (MRI) scan to confirm the diagnosis. MRIs can show specific changes in a dog’s brain, such as atrophy or shrinking, which can aid in the diagnosis. 

PROGNOSIS 

Like Alzheimer’s in humans, CCD is a progressive illness. Dogs who have CCD don’t get better, but the condition can be managed. While the condition will worsen over time, says Dr. Fry, “the speed at which this occurs is variable.” Many dogs who have CCD can continue to lead comfortable and enriched lives. 

That said, dogs with CCD will require careful supervision and specific management to ensure that they are kept safe. Dr. Loenser notes that dogs with CCD are particularly prone to accidents such as falling down stairs, wandering off, or being hit by a car. “As long as the dogs are kept safe,” she says, “their prognosis is fair.” 

TREATMENT

There is one medication that is widely prescribed for dogs with CCD: Anipryl (selegiline hydrochloride). It been shown to slow the progression of CCD and may improve an affected dog’s brain function. 

Your vet may also discuss additional medications to improve your dog’s quality of life. For dogs who struggle to maintain a normal sleep cycle, Dr. Fry encourages owners to try giving their dogs melatonin, a hormone that can be purchased over the counter in most grocery or health food stores. This can sometimes help dogs adjust their internal clock and sleep more soundly. 

Additionally, anti-anxiety medications have also been shown to be helpful for some dogs with CCD. As with all supplements and medications, ask your vet whether any of these might be helpful for your dog.

WHAT TO DO AT HOME

There are a number of things that you can do at home to support your dog as her condition progresses. The most important task is managing your dog’s personal and household routines to keep her comfortable and safe. 

SIDEBAR: Nutritional Help for CCD

Dr. Loenser specifically advises that guardians should try to limit the amount of change in a CCD dog’s life. It’s really helpful to stick very closely to known routines and to be slow to make any kind of changes to those routines – including everything from who is in the home to furniture placement, mealtimes, etc. 

In particular, if your dog has CCD, you need to protect her from things in your environment that can be dangerous, especially stairs, decks without railings, and other dangers in your yard, as she may have lost good judgment regarding heights. You’ll also need to be especially attentive to your dog when on walks in order to keep her safe; she may wade too deeply into swift water, or step into the path of an oncoming bicyclist. Even if her past behavior and training has long been so good that she has been able to walk with you unleashed in the past, she may no longer have the cognitive capacity to do this safely any more.

A breakdown in housetraining is a common symptom of canine CCD. When dealing with this condition, “understanding goes a long way,” Dr. Bergman says. It’s important to remember that your dog isn’t lazy, spiteful, or trying to be bad, he just doesn’t know better anymore. Belly bands (for male dogs) and doggie diapers (for females) may be needed to prevent house-soiling by a dog who just doesn’t realize that she’s “going.”

SIDEBAR: She Wrote the Book on CCD

ENRICHMENT

It’s tempting to pamper older dogs, but this must include keeping them active. Making the comparison to how it is commonly accepted that “brain games” such as crossword puzzles can slow the onset of dementia in humans, Dr. Bergman advises that regular mental enrichment may slow the progression of CCD in dogs. Any kind of training, exercise, and social engagement can support the mental fitness of aging dogs. 

Of course, you should also be attentive to your older dogs’ physical condition; don’t push them to do anything too strenuous. Low-impact sports like scent work and trick training can be great ways to keep your senior dog’s mind active. 

Food-dispensing toys and puzzles are particularly good for senior dogs, who may not have as much interest in playing any more, but still enjoy their food! For older dogs at risk of CCD, Dr. Dylan suggests trying to keep them awake during the day, if possible, in order to establish and maintain a healthy sleep/wake cycle. 

That sounds challenging – and with multiple senior dogs in my home I’m abundantly aware of exactly how challenging it can be to keep them healthy and safe. CCD is concerning, but it’s comforting to know there are treatment options available to slow the progression of the disease.