VetInfo Digest     August 2001

This Month:

Cancer Therapy...

    Definitions

    Mast Cell Tumors

    Soft Tissue Sarcomas

    Melanomas

    Lymphoma

    Squamous Cell Carcinoma

    Basal Cell Tumors

    Nasal Adenocarcinoma

    Mammary Tumors

This month's VetInfo Digest is devoted entirely to a discussion of various types of cancer and the treatment of cancer. This is one of the most difficult subjects in veterinary medicine. There are many people that can not imagine treating a pet for cancer due to the perception that it is inevitably fatal and that treatment is miserable for the pet. Despite this, the reality of cancer is that it is actually one of the most curable of chronic illnesses and most of our clients who chose to treat for cancers find the quality of life during therapy acceptable for their pet.

Many cancers can be completely cured with surgery. In addition, some cancers respond completely to chemotherapy or radiation therapy. Oncologists are discovering the benefits of combining surgery with other therapies to hit tumors harder. This is especially helpful when it is not clear if the surgery completely removed all remnants of the tumor. Better diets, better pain control and better nursing care are helping many cancer patients. It is true that many pets do die from cancer. It is also true that not every pet is a good candidate for cancer therapy and that not every family can provide the support necessary for cancer therapy to work to its whole potential. Whether to treat or not treat for cancer is a question that many of us will face with our pets. There is still no absolute best answer to this question for most malignant cancers. It is definitely worth listening to all options before making any decisions, though.

Defining the Problem

Usually we try to present one or two diseases or disorders in some detail, to try to provide a better depth of understanding of the diseases. This month, we are going to provide a quick overview of a number of cancers that affect pets and the current recommended therapies. Each of these cancers could be the topic of an in-depth review but due to the rapid changes in recommendations and advances in cancer therapy it seemed best to try to cover them more superficially this time.

Just to make sure that the terms used in this newsletter are understandable, here are some definitions necessary to the discussion:

Grading of tumors is a process through which the pathologist attempts to give an estimation of the potential for a tumor to be malignant, based on the appearance of the cancer cells.

Staging of tumors is the process of figuring out how much they have already affected the patient. There may be several stages that vary from tumor to tumor, but the highest stage (most commonly Stage IV) is the point where the tumor has spread to a distant site, such as the situation in which a bone cancer has spread to the lungs. Staging starting with O or 1 normally pertains to tumors that that are small and have not spread. The stages in between cover local invasion and invasion to regional lymph nodes.

Chemotherapy is the use of medications to try to arrest tumor growth or to kill the tumor. Some chemotherapeutic agents are very broad spectrum, attacking most dividing cells, and other agents are very narrow in spectrum, such as mitotane (Lysodren Rx) which specifically attacks adrenal gland tissue.

Radiotherapy is the use of radiation to kill cancer cells. This can be from X-rays or from the implantation of radioactive material into the tumor itself. An example of the latter is the use of radioactive iodine to kill thyroid tumors.

Oncological surgery techniques refer to the removal of a block of tissue that contains the tumor plus all surrounding tissue for at least one to two centimeters in every direction and often larger margins for some tumors. This type of surgery is not the same as dissecting out a tumor and then going back to remove a small margin of tissue around it. It is a planned surgery in which the surgical margins are determined in advance and incisions are made to accommodate these margins in an effort to remove the tumor and sufficient normal tissue to prevent metastasis, without disturbing the tumor, if possible.

Response to therapy when used to describe cancer patients, means any indication that the tumor was inhibited, that that patient lived longer than would be expected without treatment or that course of the cancer was affected by treatment in some other manner. For this reason, it is pretty important to figure out what is meant by a "response to therapy" for any particular medication. After all, a five day improvement in survival time justifies saying that there was a response to therapy, but that wouldn't make most people eager to pursue the option of chemotherapy with that medication. Some articles on cancer use terms like partial response and complete response. It is important to note that complete response rarely means "cured", it just means that the tumor is no longer detectable through examination after treatment. A complete response in the case of lymphoma, for instance, only very rarely means a cure was obtained.

 

Mast Cell Tumors (Mastocytoma)

Mast cell tumors are the most common skin cancer of dogs. Approximately 20% of all malignant skin tumors in dogs are mast cell tumors. They can occur at almost any age but are more common in dogs over 9 years of age. Boxers and Boston terriers seem to be affected more than other breeds in our practice but we see these tumors in all breeds. Mast cell tumors of the skin occur in cats much less commonly and are not usually malignant in cats. Mast cell tumors affecting the spleen and abdominal organs in cats are much more likely to be malignant and can be associated with the presence of skin tumors in some cats.

Mast cell tumors are hard to recognize based on physical appearance and justify considering biopsy for almost any lump on dog skin that doesn't have the typical appearance of another lump. Fine needle aspiration or even an impression smear of the tumor surface often provides a sample that is sufficient to make the diagnosis. Mast cells produce histamine, which is what makes skin itch, so itchiness associated with a tumor of the skin is suggestive of this cancer. Histamines also contribute to the formation of gastric ulcers, so this is another problem than can occur in dogs that have mast cell tumors.

Mast cell tumors are graded with several schemes and it is important to figure out which one is being used. The most common grading scheme is Grade I to Grade III, with Grade I being a low malignancy potential and Grade III being a high malignancy potential.

At the present time there is good evidence that complete surgical excision of a mast cell tumor of Grade I or Grade II and Stage 0 or 1 (no spread to the lymph nodes) is sufficient to provide a good prognosis and chemotherapy or radiation therapy are not thought to be necessary in this case. However, if there is any question about the surgical margins, especially in areas such as tumor affecting a foot, in which adequate removal of tissue without amputation is difficult, radiation therapy in combination with surgical removal gives a prognosis equal to that of surgery in which wide tissue margins are possible. In both cases, the long term survival rate approximately 85%. Mast cell tumors located in the oral cavity have a worse prognosis than when they are located in the skin and it is considered best to use radiation therapy as a follow up to surgery, when possible, for tumors in the oral cavity.

For tumors that require additional therapy the best adjunct to surgery is thought to be radiation therapy, at the present time. When this is not possible the chemotherapeutic protocol with the best long term success rate is a combination of prednisone and vinblastine, which results in greater than two year survival rates in approximately 45 percent of patients treated. Prednisone alone, or in combination with cimetidine, has about a 4% chance of producing similar long term survival. Other chemotherapy options are still being explored but these are the best of the current treatments.

It is hard to determine when surgery alone is sufficient and when it is best to utilize radiation or chemotherapy. This is a decision that has to be based on the tumor grade, stage, surgical success in removing sufficient margins and availability of treatment options for the patient. If the surgeon who removes the tumor believes that at least a 2cm, and preferably a 3cm, margin, was obtained around the entire tumor then it is reasonable to rely on the surgery alone for Grade I and Grade II tumors. For Grade III tumors it is probably best to consider additional therapy and radiation therapy is more effective than chemotherapy, where it is available.

 

Soft Tissue Sarcomas -- Spindle Cell Sarcomas --- And More Specific Names

There is a group of tumors with similar behavior that are identified by a number of names, depending on the site of the tumor, the tissue it originated from and the ability to differentiate between the tumor types at the time the histopathology sample is obtained. The individual tumors that fit in this category, when they can be identified, include nerve sheath tumors, hemangiopericytomas, synovial cell sarcomas, liposarcomas, myxosarcomas, leiomyosarcomas, rhabdomyosarcoma and lymphangiosarcomas. There may be more of these and some of these tumors have more than one name. For the most part these tumors behave about the same in cats as they do in dogs. The exception to this are the feline vaccine associated sarcomas and fibrosarcomas, which will be discussed separately.

When these tumors are well differentiated and can be identified as a specific cell type, they tend to be less malignant. When the best the pathologist can say is that the tumor is a soft tissue sarcoma or that it is of spindle cell origin, the tumors are more likely to be malignant.

These tumors tend to be highly invasive in surrounding tissue. They form a structure known as a "pseudo-capsule" around themselves and it is very easy for a surgeon to find these tumors, assume they are encapsulated and neglect to get wide tissue margins due to this. The pseudo-capsule is actually just a band of very compressed tumor cells around the outside of the tumor resulting from the growth of the tumor. For this reason, there are usually also tumor cells outside the pseudo-capsule and seeded in surrounding tissue. Soft tissue sarcomas metastasize to distant sites around 20% of the time, although this varies from one type of tumor to another. Therefore, prior to surgical removal it is best to X-ray the chest to look for metastasis (spreading) of the tumor.

The local recurrence rate reported for soft tissue sarcomas varies really widely from one study to the next. The most likely reason for this is the lack of standardization of surgical technique from one study to the next and the difficulty in positively identifying the exact tumor type when these tumors are present. In some studies the recurrence rate is about 75% and in others it is as low as 25%. The study that reported a 25% recurrence rate specified that there were at least 3cm margins around the tumors after removal in the study, which means that in most cases in which these tumors occurred on a limb, amputation was required to obtain adequate tissue margins. Surgery is the best hope for eliminating these tumors but doing it properly to obtain adequate tissue margins may mean making some difficult decisions about amputation or other disfigurement.

When complete surgical removal is not possible, the combination of surgical removal of as much tumor as possible and following surgery with radiation is the next best option. If it is possible to get to the point where there are only microscopic remnants after surgery, radiation has a very good success rate, with about 60% of dogs making it at least two years prior to recurrence of the tumors with radiation of skin tumors and a lower success rate for oral tumors. Radiation alone doesn't provide a good long term prognosis.

Chemotherapy is generally considered to be palliative at best for soft tissue sarcomas. Vincristine, doxorubicin and cyclophosphamide are the chemotherapy agents that have been able to produce at least a partial response to therapy. Local infusion of cisplatin has been attempted with some success, as well. Due to constantly ongoing research in chemotherapy, it is always a good idea to check with an oncologist for the most recent information when faced with one of these tumors.

Vaccine associated sarcomas are a tumor group that only seems to occur in cats. At the present time, it appears that these might be more appropriately referred to as injection site sarcomas. There is suspicion that any injected substance that is irritating to the subcutaneous tissues might predispose some cats to these tumors. Despite this, the strongest evidence for a relationship between these tumors and a precipitating cause still points to rabies vaccination and feline leukemia vaccination as the most common initiating factors. The prevalence of this reaction is thought to be about 1 in 2600 vaccinated cats but in some areas the reported incidence is as high as 1 in 1000 cats. This has led to some speculation that there may be a genetic component to susceptibility to these tumors but I do not believe that has been proven. It does help to explain why some practitioners don't seem to see any of these tumors and other see them more frequently. The breeding population in one area may be more prone than in the other.

The one thing to remember about vaccine associated sarcomas is that there is only one really good chance to remove these tumors surgically and it occurs when the first surgery is done. Whenever possible, this type of tumor should be carefully diagnosed, studied to determine the extent to which it has spread and then removed in a block of tissue that has at least 3 cm (1.5 inch) margins around anything that might be tumor tissue. Very few general practice veterinarians have the resolve to remove these tumors and an adequate amount of surrounding tissue. Doing so almost always requires removing underlying bone, including portions of the spinal vertebrae. The best way to visualize these tumors prior to surgery is to have an MRI scan utilizing dye that makes the tumor stand out. This is obviously not an available option in all areas of the country but it may be worth considering a trip to a facility with this capability, if an all-out effort to remove the tumor is contemplated.

To give you some idea of the difference between a "normal" veterinary practice and one in which an oncologically trained surgeon practices, the median time to return of these tumors when they are removed by general practice surgeons is reported to be 2 months. The median time until tumors reoccur when aggressive surgery is performed is 9 months (Hershey, 2000). The percentage of patients who remain cancer free is estimated to be about 20% for less aggressive surgical techniques and about 50% for very aggressive surgical techniques. When a second surgery is attempted, the time to recurrence is shorter and the cancer free percentage is much lower. It is absolutely imperative to make sure that the first surgery done on these patients is carefully planned. If it is not possible have MRI imaging of the tumor in advance of surgery it is necessary to take much wider margins for this type of tumor, as "fingers" often extend out from the portion of the tumor that can be observed, for as far as two or more inches. For most patients, the best option for surgery is going to be a visit to a surgical specialist or an oncologist trained in surgery.

Radiation therapy is considered to be a useful adjunct to surgery, especially when it is clear that incomplete removal of the tumor has occurred or when it was difficult to get adequate tissue margins. Chemotherapy has not been helpful in studies, so far.

There is no question that vaccination has greatly improved the quality and quantity of life that cats can expect. However, due to the potential for tumors, vaccinations should be carefully chosen based on estimated risk factors and it is reasonable to try to use longer intervals between vaccinations where it seems reasonable to do so. In addition, some thought should be given to placement of vaccinations. If you would consider amputation of a limb to treat this cancer, which is a good way to get adequate tissue margins, it may be better to vaccinate as low on a rear leg as is practical. Some vets have seriously suggested giving vaccinations in the tail so that if a tumor formed it could be easily removed. We have given vaccinations in the flanks in our practice for a long time. In the cases of vaccine associated sarcoma that we have seen in cats vaccinated at our practice, it has been possible to remove good tissue margins, so far, due to the location of the tumors on the flanks. We have been lucky in this regard, having only seen approximately 5 to 7 cats with tumors that seemed to be vaccine related and having vaccinated only 2 or 3 of those cats in our practice. It may be helpful to use non-adjuvented vaccines, such as Merial's PureVax (Rx), although there have been clinical reports in which this vaccine was still suspected of contributing to the formation of a vaccine associated sarcoma. These are unproven at this time to the best of my knowledge, though.

Cats have fibrosarcomas, which are very similar in composition to the vaccine associated sarcomas, as well. For this reason, it is sometimes hard to determine if a tumor is vaccine related in a cat, since the "background" cases that would have occurred anyway are hard to separate from the induced tumors. In any case, both types of cancer are very aggressive and it is best to follow the same practices in dealing with the tumors.

 

                                                                        Melanomas

Melanomas occur in both dogs and cats. There are several types of melanotic tumors, from the benign melanocytoma to malignant melanomas. These tumors are pretty common in dogs but are less common in cats. Melanomas are more common in older pets. Most melanomas occur in haired skin or in the oral cavity. There is a marked difference in their biologic behavior based on where they originate. The typical appearance of a melanoma is a black dome shaped tumor, but they may be non-pigmented, especially in the oral cavity. In dogs with black or dark colored oral mucosa, as is common in rottweilers, the presence of a white colored tumor should make a person wary of an amelanotic (not pigmented) melanoma.

Melanomas that arise from areas of haired skin tend to be benign in nature, with less than 15% of these tumors exhibiting metastatic behavior. If the tumor surface is ulcerated or the tumor is very large it is more likely to be malignant. In this case, it is prudent to consider checking for metastasis of the tumor to sites such as the lungs (with X-rays), prior to doing surgery.

Miniature poodles are the exception to the rule that melanomas arising from skin are likely to be benign, as the tumors are commonly malignant in this breed. When melanomas occur in the oral cavity they are often very aggressive and prone to metastasizing to distant sites.

Malignant melanomas are generally not responsive to chemotherapy. Oral melanomas are responsive to radiation therapy based on studies, but a cure (no future occurrence of melanoma) is uncommon. Once this tumor starts to spread it is very difficult to control. Therefore, it is reasonable to remove melanomas when they are present, even though the majority of them are likely to be benign. In the oral cavity, removal of the tumor with follow up radiation therapy is the best option, when it is possible.

 

Lymphoma

Lymphoma is common in both dogs and cats but the disease process associated with the cancer is different in the two species. Lymphoma in dogs tends to be generalized (multicentric), with all peripheral lymph nodes enlarged and easy to find by palpation (feeling for them). Other forms exist, such as cutaneous and intestinal lymphoma, but these are not especially common in dogs. On the other hand, intestinal lymphoma is the most common form of this cancer in cats and must be ruled out when inflammatory bowel disease is suspected in cats, if possible. In addition, in cats the feline leukemia virus makes it easier for lymphoma to occur, making it necessary to test for this virus prior to making treatment plans. There may also be a weak correlation between feline immunodeficiency virus and lymphoma in cats. Mediastinal lymphoma (in the chest) is also common in cats so looking for specific sites for problems is important in this species.

In a major switch from the cancers we have been discussing so far, chemotherapy is the most effective form of therapy for lymphoma. There are many chemotherapeutic agents that have some effect on lymphoma and there are a number of combination protocols for these agents. At the present time, the "Wisconsin Protocol" seems to be the most commonly used of these protocols for canine patients, although there are lots of variations used by individual practitioners. In general, all of these protocols revolve around the use of several chemotherapeutic agents. These include prednisone, vincristine, asparaginase, cyclophosphamide, adriamycin in the initial protocols. When there is a relapse, many other chemotherapeutic agents have been tried with some success, including doxorubicin, mitoxantrone and actinomycin-D.

Some of the same chemotherapeutic agents are used in cats but there is a greater tendency to use doxorubicin in this species, sometimes alone and sometimes in combinations with prednisone, cyclophosphamide and vincristin. Reactions to chemotherapy are more common in cats but usually the use of lower dosages and careful attention to nursing care results in an acceptable quality of life. For cats with intestinal lymphoma the use of prednisone or methylprednisolone alone seems to work well for some cats for several months and is sometimes an acceptable alternative when multidrug protocols can not be used due to side effects or financial constraints.

Variations in the protocols produce small differences in the time to first remission, percentages for response and survival times, but in general the majority of patients with lymphoma will respond to chemotherapy, with a median survival time in dogs of 13 to 14 months. In general, dogs tolerate chemotherapy very well and side effects that seriously impact on the quality of life are not common. Some dogs do develop reactions, such as severe persistent diarrhea, that require stopping the medications to retain a reasonable quality of life. Sometimes, though, even the initial few weeks of chemotherapy, without continuing on, will cause several months of remission --- so even some of the patients who had serious reactions still ended up having several months of good quality life after getting over the diarrhea. Cats do not respond as well to chemotherapy and even multidrug protocols often only cause a four to six month remission in cats, although some cats do well for much longer periods of time.

Many of our clients are reluctant to consider chemotherapy, but most of our clients who do decide to try chemotherapy for lymphomas are satisfied with the decision in retrospect.

 

Squamous Cell Carcinoma

Squamous cell carcinomas (SCC) occur most commonly in white cats, on the tips of their ears or on their noses. They can occur in any color cat and also occur in dogs. This is also a fairly common tumor in the oral cavity and upper airways of both dogs and cats. As with other tumors, there is a significant difference between a tumor of the skin and a tumor of the oral cavity or upper airways.

Squamous cell carcinomas of the ears and face in cats, and of the skin of the trunk of dogs tend to be very slow to metastasize but are very invasive locally, often leading to significant loss of tissue in the region surrounding the tumor. This is especially true of SCC of the nose in cats. Squamous cell carcinomas of the oral cavity, especially the tonsils, are much more likely to metastasize quickly and have a much worse prognosis, due to this. Squamous cell carcinomas also have a predilection for occurring in the nail bed of both dogs and cats and are often very destructive of surrounding bone, necessitating amputation of the toe in affected pets. Approximately 30 to 50% of pets who have toe amputations due to squamous cell carcinoma will eventually have a recurrence or the tumor will develop at a metastatic site.

There has been a lot of experimentation with treatment for SCC. Due to the location on the ear and nose, cryosurgery (freezing of the tissue), photodynamic therapy, superficial radiation and injection of chemotherapeutic agents directly into the lesions have all been successfully used to control small localized incidences of squamous cell carcinoma. For more extensive lesions surgery is the best option and it usually curative when tissue margins can be obtained. Removal of the nasal planum (the fleshy part of the nose) seems to be a sticking point with many of our clients but it produces better cosmetic results than most people think it will and it is estimated to have greater than 50% long term cure rate. Don't rule out this surgery without looking at pictures of cats who have been through the surgery or talking to owners of cats who have had this procedure done. Unfortunately, this surgery does not produce good long term results in dogs nearly as often, so it may not be an acceptable option unless the SCC lesion is very small.

Chemotherapy does not work well for squamous cell carcinoma that has metastasized and radiation therapy has limited usefulness for most of the areas that SCCs tend to metastasize to.

 

Basal Cell Tumors

I just thought that basal cell tumors should be mentioned because they are the most common skin tumor in cats and occur occasionally in dogs. For the most part, basal cell tumors are benign and are easily removed surgically. In cats these tumors have a varied appearance making them hard to distinguish from less benign condition. Most commonly they are a small raised lump on the skin with no hair over them and a smooth appearance. They can be ulcerated, pigmented or lumpy, in some cases, though.

 

Nasal Adenocarcinoma

Bleeding from the nostrils, excessive sneezing and pus or mucous drainage from the nostrils in older pets is often a sign of a nasal tumor. Nasal adenocarcinomas occur in both dogs and cats. In dogs, adenocarcinoma and squamous cell carcinoma account for the majority of nasal tumors. In cats there is probably a more equal distribution between nasal adenocarcinoma, lymphoma and squamous cell carcinoma. Lymphomas respond better to treatment than the other tumor types, so this is an important difference in cats.

The best therapy for nasal adenocarcinomas is radiation therapy. There are variations in the types of radiation therapy and these differences can be important in the case of this tumor. Radiation therapy without surgery may work best when using megavoltage radiation but surgery may be necessary prior to radiation therapy when using orthovoltage radiation. The median life span in dogs after tumor diagnosis with all forms of therapy except radiation and for no therapy is somewhere between three and six months. With radiation therapy it is somewhere between 8 months and 2 years, which is a significant improvement.

For cats the survival times are similar for nasal adenocarcinoma but longer for lymphoma, so in this species obtaining an exact diagnosis of the tumor type is more critical, even though it is always a good idea.

 

Mammary Cancer

Mammary tumors are a common problem in female dogs who are spayed after the second heat period. Approximately 25% of dogs who have experienced at least two heat periods will develop mammary cancer at some time in their life. Fortunately, mammary tumors in dogs are less likely to be malignant than in either humans or cats and even when they are malignant they tend to spread more slowly. Only about 50% of mammary tumors in dogs are malignant and it is likely that only about half of these have spread at the time of surgery. For this reason, surgical removal of mammary tumors in dogs provides a high degree of success. In cats, the situation is much different. At least 85% of mammary tumors in cats are malignant and many of these have spread at the time they are diagnosed. Siamese cats have a higher risk for mammary tumors than other cat breeds. While mammary tumors in dogs can be considered to be a local disease in many patients, they must be considered to be a systemic disease in cats.

It is hard to stage mammary tumors in cats. Checking regional lymph nodes for spread of the tumors is not especially difficult but looking for spread to the lungs can be hard. Cats often develop many small metastases rather than a few large lumps. It can be very hard, or even impossible, to recognize this type of metastasis in X-rays. If fluid can be obtained from the chest it can be analyzed for tumor cells and this may be the most reliable method of looking for metastatic cancer in cats, when it is possible to obtain fluid. In dogs, there is a stronger tendency for tumors that have spread to the chest to be visible on ordinary X-ray films.

In dogs, lumpectomy, or removal of only the visible tumor and sufficient margin around it, is often sufficient. It is usually considered to be reasonable to do a lumpectomy first and then to do more aggressive surgery if a malignant tumor is identified by the pathologist. In cats there is good evidence that radical mastectomy, with removal of the entire chain of mammary glands on the affected side, plus regional lymph nodes, offers a better prognosis. The best long term survival rates in cats occur when the initial tumor is less than 2cm (about 1 inch) in diameter and radical mastectomy is performed.

Chemotherapy is not highly successful in cats and dogs with mammary tumors but some response in cats occurs to the use of doxorubicin alone or in combination with cyclophosphamide. It is reasonable to attempt chemotherapy as an adjunct treatment after surgical removal of the tumors. Radiation therapy has not been shown to be helpful in the treatment of mammary tumors in cats. There is some evidence that radiation therapy can be a useful adjunct procedure in dogs with tumors that are difficult to remove entirely, but this has not been confirmed through scientific studies that I know of, yet.

 

Just a last thought-

There is a saying among people who treat cancer, which goes like this: "Cancer does what cancer wants". I know of no one who honestly feels they are capable of predicting the specific outcome of a tumor in any particular patient. Averages just don't always apply to an individual patient, since there are major variations on both sides of "the average". I think that every veterinary hospital has a few owners who bring pets year after year for physical examinations and say, each time, "Do you remember when you told me Spot was going to die from cancer within a year?". It is good to be wrong, sometimes. If your vet suspects cancer, or any terminal illness, it is reasonable to get a second opinion prior to making the decision to euthanize and if your pet feels good, acts fine and just doesn't show signs of being ill, it is most reasonable to keep going in the face of a bad prognosis, at least until symptoms occur that become a burden for your pet.

 

Thanks for Your Support!

The VetInfo Digest is published by TierCom, Inc., P.O. Box 476, Cobbs Creek, VA 23035. 

The opinions expressed in this newsletter are those of Michael Richards, DVM., author. Please send email for Dr. Richards to mervet@inna.net

Copyright 2001, TierCom, Inc.