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Neurosurgery in the 21st Century
Jay McDonnell, DVM, MS, DACVIM-Neurology
CNS tumors
Brain tumorl Brain tumor treatment in
companion animals?l Aging of companion animalsl Incidence 1-3.5% Calo
Dudley
Benny
Brain tumor
l Symptoms – clinical complaintsl History, clinical signs - PE & NE
Cats and dogs
Brain tumor – biology
l Meningioma 90% in cats, 40-60% in dogsl Gliomas 5-8% in cats, 30-50% in dogsl Choroid plexus papillomas 5-10% in bothl Other tumors likely 2%
****** Pituitary Adenomas are typically not considered “brain tumors” in necropsy studies
Brain tumor Biology
l Slow growingl Metastatic potential is lowl CNS compensatory mechanisms
Brain tumorDiagnosis
l Historyl Clinical signs - PE & NE
Neurolocalization
Brain tumorDiagnosis
l Historyl Clinical signs - PE & NEl Minimum database
l CBC, serum chemistries and urinalysisl other tests based on results
l Metastatic screening
Brain tumor Advanced Imaging
Brain tumor Advanced Imaging
Brain tumor Advanced Imaging
l Magnetic resonance imaging (MRI, MR)
Dudley 7 yr, 8 mo, MNGold. Ret
Brain tumor Advanced Imaging
l Computed tomography (CT, CAT scan)l Magnetic resonance imaging (MRI, MR)l Ultrasoundl Angiographyl Sinus venographyl Scintigraphyl PET, SPECT
Brain tumorEarly recognition
and treatment increases
survival times
Treatment Options
l Palliativel Surgeryl Radiationl Chemotherapy
Treatment Options
l Palliativel Surgeryl Radiationl Chemotherapy
Treatment optionsl Surgical
considerationsAccessibility – Surgical
approaches
Treatment options …..
l A special note about cats!
Miss Parker, 15 Jan 201516 yr old FS DSH
Ax T1W post C Ax T2W Ax FLAIR
Sagittal T1W post contrast
Treatment options
l Surgical considerations for “cure”l Tumor typel Completeness of excisionl Post-operative morbidity/mortality
Treatment Options
l Palliativel Surgeryl Radiationl Chemotherapy
Treatment Options
l Radiation
Stereotactic Radiotherapy
Thanks to Dr. Siobhan Haney @ Veterinary Cyberknife Center Center, Malvern, PA
Before and After SRT….
© Siobhan Haney 2018 22
Pre-RT MRI
7 months post-RT
1 year post-RT
Thanks to Dr. Siobhan Haney @ Veterinary Cyberknife Center Center, Malvern, PA
Treatment Options
l Palliativel Surgeryl Radiationl Chemotherapy
Treatment Options
l Chemotherapy
Brain tumor Treatment options and survival
l Palliative - 5-56 daysl Chemotherapy - 5-310 daysl Radiation - 150-360 daysl Surgery - 40 - 410 daysl Surgery & radiation – 462-864 dayslSurgery & chemotherapy (CCNU) 538 days
Spinal Cord Tumor
l Presentationl Signalmentl Minimum Database
Spinal Cord Tumor
l Work-up and rule-outs
l Treatment options
Spinal cord tumor Advanced Imaging
Treatment Options
l Palliativel Surgeryl Radiationl Chemotherapy
l Multimodalcombination therapy
Brain and Spinal Cord tumor Treatment: What’s Next?
l Animals as models of human diseasel Spontaneous, availablel Biologically and clinically similarl Mutually beneficial
• Treatment overview (timeline above)• Vaccines – autologous tumor lysate, imiquimod (adjuvant) & CD200 inhibitor• PE, blood for PBMC & serum, MRI – postop day 0, 4, 8 & 12 months• Outcome measures
– Adverse reactions– Tumor volume on MRI– T and B cell responses (flow cytometry and Western blots)– Progression free and overall survival
10 d 28 d 42 – 56 d
Surgery - day 0vax
7 d 7 d
vax vax vax vaxvax vax vax
28 d28 d 42 – 56 d
MRI MRIMRI
Repeat once (months 8-12 months)
Vaccine-based immunotherapyDr. Liz Pluhar – University of Minnesota
Autologous tumor lysate vaccines
Surgical removal of the tumor -pathologist & lab for expansion
In vitro expansion of tumor cells
Tumor cells lysed and irradiated
Tumor specific antigens
+
Toll-like receptor 7 agonist
(imiquimod)Inject lysate + TLR7 to activate antigen presenting cellsStimulate local B and T cell response
Our Experience:15 patients enrolled in trial since 2017
1 cat recurrent intracranial meningioma1 canine spinal cord recurrent meningioma
3 gliomas10 meningiomas
Vaccine-based immunotherapyDr. Liz Pluhar – University of Minnesota
Our Results:3 Gliomas – 3, 8 and 12 months
12 Meningiomas 6 still alive
Average survival 16 months
Vaccine-based immunotherapyDr. Liz Pluhar – University of Minnesota
Brain tumor: clinic take backs
F Disease mostly of older animalsF Seizures OR mentation changes are most common
clinical signsF Early recognition and diagnosisF Imaging, imaging, imagingF Meningiomas are potentially curable with surgery and
radiation or vaccine
l Gliomas –l Univ of Minn - Novel combined immunotherapeutic
strategies for glioma: pet dogs as a large animal spontaneous model
l Virginia Tech - Molecular Combinatorial Therapy for Canine Malignant Gliomas
l Univ of Georgia - The treatment of canine brain tumors with Cetuximab administered using convection enhanced delivery (CED)
From AVMA Animal Health Studies Database
Brain tumor: other clinical trials
