Transcript Indezine Template

Managing Lymphoma in
Small Animal Practice
Wendy Blount, DVM
Lymphoma
• aka lymphosarcoma (LSA)
• Other than euthanasia in shelters, cancer is
the #1 killer of dogs
• LSA most common cancer in dogs & cats
• Most common cause of hypercalcemia in
dogs and cats
• 30% of cats with cancer have lymphoma
• 24% of dogs with cancer have lymphoma
• Most common spinal cord tumor in the cat
• Most common brain tumor in the cat
• Most common nasal tumor in the cat
• Most common liver tumor in the cat
Lymphoma
Juan Carlos Garza – Houston TX
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Etiology
• GI lymphoma can be preceded by IBD in cats
• Helicobacter spp increase risk of GI
adenocarcinoma in people, and are often
present in gastric LSA histopath in cats
• FeLV predisposes to LSA in cats
• Lymphoma respects age less than other
tumors
Clinical Signs
Vary tremendously by tumor location
Multicentric lymphoma most common
• Multiple painless enlarged lymph nodes,
hepatomegaly, splenomegaly in dogs
• Enlarged mesenteric lymph node, hepatomegaly,
splenomegaly in cats
• Fever
• Other locations
Ocular lymphoma
• Third eyelid or conjunctival mass in cats
• rapidly enlarges
• Anterior or posterior uveal infiltrates and/or uveitis
Clinical Signs
Clinical Signs
Clinical Signs
Clinical Signs
Clinical Signs
Clinical Signs
Clinical Signs
Clinical Signs
Vary tremendously by tumor location
• GI lymphoma (focal or diffuse)
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Vomiting, diarrhea, steatorrhea, melena
Hematochezia, mucoid feces, tenesmus
Mass on rectal palpation
Anorexia, weight loss, lethargy
Abdominal pain or effusion
Palpable abdominal mass, thickened loops of
bowel
• Pallor, anemia if GI bleeding
• Icterus if obstruction of bile duct
Clinical Signs
Nasal lymphoma
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Unilateral or bilateral nasal discharge
Epistaxis, Sneezing
Dyspnea, stertor, nasal stridor
Facial distortion and ocular discharge
Intermediate to large cells
Clinical Signs
Nasal lymphoma
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Unilateral or bilateral nasal discharge
Epistaxis, Sneezing
Dyspnea, stertor, nasal stridor
Facial distortion and ocular discharge
Intermediate to large cells
Clinical Signs
Nasal lymphoma
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Unilateral or bilateral nasal discharge
Epistaxis, Sneezing
Dyspnea, stertor, nasal stridor
Facial distortion and ocular discharge
Intermediate to large cells
Neurologic signs if invasion of the cribriform plate
– anterior forebrain
• Seizures
• Behavioral changes, obtunded, head pressing
• Blindness, circling
• CP deficits worst in rear
Clinical Signs
Spinal cord lymphoma
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Extramedullary tumor
Onset chronic or acute
More common in cats than dogs
Localized severe spinal pain
• Extramedullary tumors seem to be more
painful than medullary
• More pain receptors in these areas
LMN signs (flaccid weakness) 2 vertebrae caudal
to the area of spinal pain
UMN signs (spastic paresis) caudal to that
Usually part of multifocal disease
Younger cats, up to 2 years of age
Difficult to diagnose, CSF often not diagnostic
Clinical Signs
Brain lymphoma
• Symptoms caused by
• Displacement of brain tissue
• Disruption of blood brain barrier
• Disruption of CSF and blood flow
• Seizures the most common symptom in dogs
(cerebral)
• Lethargy, weight loss, obtunded
• Circling, behavior changes, head pressing
• Contralateral CP deficits worse in rear
• Head tilt and ataxia in cats (caudal brain stem)
• Brain herniation in the late stages
• Coma, dilated pupils, death
Clinical Signs
Acute Lymphoblastic Leukemia (ALL)
• Usually non-specific signs
• May have coagulopathy of thrombocytopenia
• Petechiae
• Epistaxis, bleeding from the gums
• Primary hemostasis disorder
• Often part of multicentric disease
• Usually “atypical cells” in circulation, but not
always
• “Aleukemic leukemia”
• Cytopenias prompt bone marrow sample
Clinical Signs
Lymphomatoid granulomatosis
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aka eosinophilic pulmonary granulomatosis
aka lymphoid granulomatosis
aka lymphoproliferative angitis
aka granulomatosis
Destructive angitis in the lungs
Atypical T-cell lymphoma
History of treated heartworm disease
May progress to lymphoma
Symptoms of pneumonitis
Clinical Signs
Renal lymphoma (feline)
• Bilateral large, bumpy kidneys
• The many signs of renal failure
Mediastinal lymphoma (feline)
• Dyspnea, coughing
• Regurgitation
• Horner’s Syndrome
Hepatic lymphoma
• Marked hepatomegaly, liver failure
• Large cell in dogs, small cell in cats
Clinical Signs
Cutaneous lymphoma
• Usually diffuse in the dog
• Intense pruritis, resistant to treatment
• Sometimes follows atopy
• Two forms in cats
• Epitheliotropic – diffuse
• “Mycosis fungoides”
• Intradermal nests of 5-10 cells
• Usually large but sometimes small T
cells
• Non-epitheliotropic
• Large B cells deeper in the dermis
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Clinical Signs
CBC
• Neutrophilia if gross disease
• Lymphocytosis
• atypical lymphocytes if ALL
• May not have atypia with CLL
• Anemia
• Anemia of chronic inflammatory disease
• Mild nonregenerative anemia
• Iron deficiency anemia if GI bleeding
• Regenerative or non-regenerative
• Pancytopenia if leukemia is present
Clinical Signs
Panel
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Hypercalcemia
Elevated ALT, SAP, GGT if hepatic LSA
Icterus – GI, hepatic, pancreatic LSA
Low albumin
• PLE due to intestinal LSA
• GI bleeding due to GI LSA
• High globulins – B cell lymphoma
• Low globulins – GI bleeding due to GI LSA
• High BUN
• Pre-renal - dehydration
• Pre-renal - GI bleeding due to GI LSA
• Feline - renal LSA
Clinical Signs
Panel - icterus with normal liver enzymes
• A unique presentation in the cat
• Differential diagnosis:
• Pancreatitis – elevated fPLI
• Lymphoma – cytology or histopathology
• FIP – histopathology or diagnostic trifecta
• Lymphopenia <1500/ul
• Titer 1:160 or greater
• Globulins >5.1 g/dl
• Positive predictive value 89%
• Negative predictive value 99%
• Histopath and fluid analysis supportive
• Fluid analysis chart
Clinical Signs
Abdominal Imaging (rads)
• Abdominal mass – gut or lymph node
• Hepatomegaly, splenomegaly
• Gut obstruction
• Abdominal effusion
• Chyle or modified transudate
• Thickened gut wall (muscularis)
• Pneumoperitoneum if GI perforation
• Mucosal craters
• Soft tissue calcification if hypercalcemia
• Bilateral renomegaly in cats
Clinical Signs
Bilateral renomegaly in cats
Clinical Signs
Cat with mid-abdominal mass and ascites
Clinical Signs
Hepatosplenomegaly due to multicentric
lymphoma in a dog
Clinical Signs
Abdominal Imaging (US)
• Enlarged mediastinal lymph node
• Hepatomegaly
• Hypoechoic focal to multifocal lesions
• Generalized hypo- or hyper-echogenicity
• Normal to nodular hepatic sonogram
• Splenomegaly
• Nodular to diffuse
• hyper or hypoechoic
Clinical Signs
Lila
• 1.5 year old female Rottweiler
• Acute onset of abdominal pain and tachypnea
• Has not eaten for 2 days, no vomiting, mucus
in the stool
• Abdominal splinting on palpation
• Fever – 103.8F
• CBC, panel – NSAF
• cPLI – abnormal (>400)
• Fecal float negative
• No response to treatment with IV fluids and
antibiotics for 2 days (began vomiting)
Clinical Signs
Clinical Signs
Ileus and abdominal effusion
Clinical Signs
Lila
• Abd US declined due to financial limitations
• Elected diagnostic surgery
• Generalized peritonitis, serosanguinous
abdominal fluid
• No obstruction or foreign body
• Fluid analysis
• Modified transudate
• Neoplastic very large lymphoid cells
• Cytology says “suspicious of lymphoma”
• Histopathology of mesenteric lymph node
confirms large cell lymphoma
Clinical Signs
Lila
• Responded to chemo within a few days
• Remission 6 months
• End – recurrence of initial clinical signs
Owner failed to “pay as she went” as promised,
and never paid her balance of >$1,500
Clinical Signs
Abdominal Imaging (US)
• Abdominal effusion
• Soft tissue calcification if hypercalcemia
• GI lesions
• Gut obstruction – dilated fluid filled bowel
• Thickened gut wall (muscularis)
• Obliteration of gut layers
• Pneumoperitoneum if GI perforation
• Mucosal craters
• Decreased motility
Clinical Signs
Renal lymphoma in a cat
Clinical Signs
Renal lymphoma in a cat
Clinical Signs
gastric lymphoma in a cat with ascites
Clinical Signs
Abdominal effusion and infiltrated omentum
in a cat
Clinical Signs
Hypoechoic liver - lymphoma
Clinical Signs
Hyperechroic liver - lymphoma
Clinical Signs
Stomach & duodenum in a dog with
lymphoma
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Clinical Signs
Thoracic Imaging (rads)
• Enlarged perihilar lymph nodes
• Interstitial nodular pattern
• Enlarged sternal lymph node
• Mediastinal mass
• Pleural effusion
• Soft tissue calcification if hypercalcemia
• Lymphoid granulomatosis
• Soft tissue masses in the lungs
• Interstitial to alveolar pattern
• Enlarged lymph nodes
• Pleural effusion
Clinical Signs
Clinical Signs
Enlarged
mediastinal lymph
nodes and
chylothorax
in a cat with LSA
Clinical Signs
Enlarged mediastinal, sternal and perihilar
lymph nodes in a dog with LSA
Clinical Signs
Clinical Signs
Interstitial pulmonary nodules in a dog with
lymphoma, enlarged lymph nodes
Clinical Signs
Pleural effusion in a dog with lymphoma
Clinical Signs
ECG
• VPCs if splenic mass
• Possible arrhythmia if hypercalcemia
• Prolonged PR interval (>0.14sec)
• 1st degree AV block
• 2nd degree AV block
• P wave not followed by QRS
• Ventricular fibrillation if severe
• Calcium (>18)
Hypercalcemia of Malignancy
aka Pseudohyperparathyroidism
aka HHM (humoral hypercalcemia of
malignancy)
• HHM is most common cause of
hypercalcemia in the dog and cat
• 67% of dogs with hyperCa have cancer
• 33% of cats with hyperCa have cancer
• Dogs with HHM most often have
• Anal sac adenocarcinoma
• LSA
• multiple myeloma
• Cats with HHM most often have LSA or SCC
Hypercalcemia of Malignancy
• 90% of dogs with anal sac tumors have HHM
• >50% are hypercalcemic at diagnosis
• 10-35% of dogs with LSA have HHM
• 15-20% of dogs with multiple myeloma have
HHM
• Cats with LSA and HHM are most likely to
have cranial mediastinal lymphoma
• >90% of dogs with LSA and HHM have
enlarged lymph nodes
Hypercalcemia of Malignancy
• Some tumors release PTH-rp
• Parathyroid hormone related protein
• Stimulates osteoclastic bone resorption
• Increases renal tubular reabsorption of
calcium
• Made in low amounts by normal tissues
• Thought to regulate calcium transport
during gestation and lactation
• Other humoral factors are involved in HHM
• Bony invasion can contribute to HHM
Hypercalcemia of Malignancy
• Clinical Signs of HHM
• PU-PD
• Weakness, lethargy
• Anorexia, weight loss
• Vomiting, diarrhea
Hypercalcemia of Malignancy
Diagnosis
1. Rule out lab artifact
• Fasting prevents lipemia
• No hemolysis
2. Confirm hypercalcemia is real
• Ionized calcium
• Follow reference lab handling guidelines
• Altered by temperature, pH and CO2
3. Look for tumors
• Rectal exam, LN palpation, imaging, CBC
• Sample bone marrow if cytopenias
4. Send PTH, PTHrp and iCa++ to Michigan
Hypercalcemia of Malignancy
Diagnosis
• If concurrent azotemia, it can be difficult to
distinguish HHM from renal hypercalcemia
• Hypercalcemia can cause nephrotoxicity
• Marked azotemia and mild hypercalcemia is
more consistent with renal disease
• Marked hypercalcemia with mild azotemia is
consistent with HHM
• Phosphorus often high with renal disease
• Phosphorus often low with HHM
• iCa++ high with HHM
• iCa++ normal to low with renal failure
Hypercalcemia of Malignancy
Differential Diagnosis Hypercalcemia
• H = Hyperparathyroidism (1°, 3°, hyperplasia), HHM,
houseplants, hyperthyroid (cats)
• A = Addison's disease, aluminum toxicity, vitamin A
• R = Renal disease, raisins/grapes (dogs)
• D = Vitamin D toxicosis (granulomatous dz), drugs,
Dovonex, dehydration, diet
• I = Idiopathic (cats), infectious, inflammatory
• O = Osteolytic (osteomyelitis, immobilization, local
osteolytic hypercalcemia, bone infarct)
• N = Neoplasia (HHM and LOH), nutritional
• S = Spurious, schistosomiasis, salts of calcium,
supplements
Hypercalcemia of Malignancy
Differential Diagnosis Hypercalcemia
Diagnostic Chart
• 16 conditions and 10 blood parameters
Treatment Algorhythm
• Clinically ill with high iCa++
• Chronic hypercalcemia without illness
• Idiopathic hypercalcemia in cats
Diagnosis
Cytology
• Avoid sampling the submandibular lymph
nodes, as they are most prone to
inflammation
• Use “core technique” – needle only with no
attached syringe for aspiration, then attach
10-12cc syringe full of air to squirt onto slide
• Vertical pull apart, as lymphoid cells are
fragile
• Horizontal smears destroy the cells (“smudge
cells”)
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Diagnosis
Cytology
• Normal lymph node
• Mostly small lymphocytes
• Smooth chromatin, scant cytoplasm, no
prominent nucleoli
• 1-1.5x size of RBC
• Fewer intermediate & large lymphocytes
• Occasional neutrophil, macrophage, plasma
cell, mast cell
• But pyramid of maturation is conserved
• Reactive lymph node
• Can have many blasts
• Many cell types present
Diagnosis
Cytology
• >80% lymphoblasts = large cell lymphoma
• 3-5x size of RBC
• More abundant cytoplasm, round to
slightly cleaved nucleus, pale chromatin,
prominent nucleoli
• Small cell lymphoma
• Other cells are largely missing
• Not many intermediate or large
lymphocytes
• Difficult cytologic diagnosis (often need
histopath)
Diagnosis
Cytology - cats
• Immunoblastic lymphoid hyperplasia
• Aka atypical follicular lymphoid hyperplasia
• Peripheral LN hyperplasia in a young cat
is more likely to be this than lymphoma
• Associated with FIV or FeLV positive
• Pyramid of maturation preserved
• Very large immunoblastic lymphoid cells
are present
• Prognosis after treatment with
corticosteroids is excellent in retroviral
negative cats (beware of latent infection)
Diagnosis
Normal lymph node
Diagnosis
Reactive lymph node
Diagnosis
Feline large cell lymphoma
Diagnosis
large cell lymphoma
Diagnosis
SI biopsy touch prep
Small cell lymphoma on histopath
Diagnosis
SI biopsy touch prep
Large cell granular lymphoma (feline)
Azurophilic granules
Diagnosis
FNA enlarged kidney diffusely hyperechoic
Large cell lymphoma (feline)
Diagnosis
Chylothorax – mediastinal mass
Thymoma
Diagnosis
Chylothorax – mediastinal mass
Mediastinal Lymphoma – large cell
Diagnosis
Liver aspirate
Hepatic Lymphoma
Diagnosis
Liver aspirate
Hepatic Lymphoma & fatty liver
Diagnosis
Is histopathology necessary?
• Lymph nodes cytology by boarded oncologist
or pathologist is often sufficient
• Some circumstances might require biopsy
• Low grade lymphoma resembling mature
lymphocytes
• Feline lymphomas
• Small cell lymphomas in dogs
• Severe inflammation and necrosis
• GI lymphoma (full thickness biopsies)
• Hepatic lymphoma (Reno)
Diagnosis
Cell Size – Degree of anaplasia
• Most dogs have large cell lymphomas
• Most cats have large or intermediate cell
lymphomas
• Small cell lymphomas are more common in
the cat than in the dog
• Small cell more common in old cats
• Large cell more common in young cats
Diagnosis
Special tests for atypical sites
• Nasal rads in cats
• Open mouth, DV, frontal sinus skyline
• Soft tissue opacities
• Turbinate lysis
• Nasal biopsy in cats
• Anterograde and retroflexed behind soft palate
• blind biopsy yields diagnosis more often than
rhinoscopy guided
• Use radiographs as a guide
• Rhinoscopy – low yield
Diagnosis
Right nasal lymphoma in a cat
Diagnosis
posterior nares – small mass on the left
Diagnosis
posterior nares – large mass on the left
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Diagnosis
Nasal biopsy
• Platelet count and BMBT
• Anesthetize and intubate the dog
• Count 4x4 gauze use to pack off the
pharyngeal area
• Elevate the shoulders above the nares
• Absorbent pad on the floor
Diagnosis
Nasal biopsy
• Platelet count and BMBT
• Anesthetize and intubate the dog
• Count 4x4 gauze use to pack off the
pharyngeal area
• Elevate the shoulders above the nares
• Absorbent pad on the floor
• Wait 10 minutes after biopsies complete to
begin anesthetic recovery
• Hospitalize overnight – they sneeze blood
LSA - Stage
• Stage I – Single node or site involved
• No evidence of distant metastasis
• Stage II - Two or more lymph node
regions both on the same side of the
diaphragm
• Stage III - Two or more lymph node
regions on different sides of the
diaphragm
• Stage IV - Any lymph nodes PLUS liver or
spleen involvement
• Stage V - Involvement of extranodal
tissue
LSA - Stage
Substage – added to any stage
• Substage A – no clinical signs
• Substage B – illness caused by tumor
Histopathologic grade – MI
• Little effect on prognosis
Staging of limited prognostic value EXCEPT
• Stage V worse prognosis than others
• Substage B negatively impacts prognosis
Classification
Location
• 80% of dogs with LSA have multicentric
• Cat lymphomas not as likely to be multicentric
as in dogs
• GI most common in cats
• mediastinal 2nd most common
• Cats with multicentric LSA are less likely to
have peripheral lymphadenopathy than dogs
• Skin Lymphoma – different behavior than the
typical multicentric lymphoma in dogs
• T cell in dogs – resistant to treatment
• Both T and B cell in cats – variable
response to treatment
Classification
Immunophenotyping – immunohistochemistry,
flow cytometry, PCR
• B (CD79) or T (CD3) cell?
• Also null cell lymphomas
• Dog LSA – >70% B cell, <30% T cell
• Cat LSA – B cell more common than T cell
• More of a prognostic indicator in dogs as
compared to cats
• High grade B lymphomas have better
response and longer survival than high
grade T cell lymphomas
Classification
Colorado State University Testing
• Guide to Lymphoid Neoplasia Testing
• Flow Cytometry
• Immunocytochemistry
• Immunofixation
• PARR (PCR for Antigen Receptor
Rearrangement)
• $100-125 each test, plus shipping
Use these tests:
• To tell lymphoma from lymphoid hyperplasia
• To tell B from T cell – prognosis
• To tell if in remission – planning chemo
Treatment - Chemotherapy
Many protocols, and most have similar
prognosis and outcome
• CHOP – cyclophosphamide, doxorubicin,
Oncovin (vincristine), prednisone
• COPA – cyclophosphamide, Oncovin,
prednisone, Adriamycin (doxorubicin)
• VELCAP – vincristine, Elspar,
cyclophosphamide, Adriamycin, prednisone
Other induction protocols are out there, but
those including these 4 drugs are thought to
be most effective
Elspar is added for high tumor burden
Treatment - Chemotherapy
Examples of CHOP Protocols
• Wisconsin 19 Week Protocol (4)
• Wisconsin 25 Week Protocol (4)
• Same as above with 6 weeks off
• TAMU Canine Large Cell Protocol (2)
• TAMU Feline Large Cell Protocol (7)
• Tufts VELCAP-L (6)
• Final “L” distinguishes from another
shorter intermittent Tufts protocol
• Ohio State 3 Week Cycle (max)
Treatment - Chemotherapy
Ohio State 3 Week Cycle
• Week 1 - doxorubicin 30 mg/m2 IV
• 1 mg/kg in dogs under 15 kg
• Dispense prednisone 20 mg/m2 PO EOD
• Week 2, day 1 - vincristine 0.7 mg/m2 IV
• Week 2, day 3 - Cyclophosphamide 200
mg/m2 PO
• Week 3 – vincristine 0.7 mg/m2 IV
Repeat for 20-25 weeks (7-9 cycles), or until
out of remission
Doxorubicin reaches maximum lifetime dose
Treatment - Chemotherapy
Other protocols – with prednisone
See Rescue Handout for details
• Doxorubicin q3 weeks
• Doxorubicin + cyclophosphamide
• Lomustine q3-4 weeks
Oral Chemotherapy
• Chlorambucil 6-8 mg/m2 QOD
• Prednisone 40 mg/m2 PO SID, then QOD
• CBC every 2-3 weeks
• Likely productive only for small cell LSAs
Treatment - Chemotherapy
• Most protocols last about 5-6 months (20-25
weeks)
• Older protocols continued chemo until the
patient came out of remission
• “Maintenance Therapy”
• Current thinking is that chemo beyond 25
weeks is not beneficial when in remission
• Maintenance chemo may increase drug
resistance at relapse
• If relapse occurs more than 2-3 months after
chemo stopped, 60-70% will respond again to
CHOP
• Maintenance chemo increases cost of chemo
and increases side effects
Treatment - Chemotherapy
• Maintenance therapy beyond 25 weeks
indicated only for indolent low grade tumors
Typical response to chemo for large cell
lymphoma in dogs:
• In remission within 4-8 weeks
• 5-6 months chemo
• 2-3 months remission after chemo
• Variable response to rescue therapy
• Minimal illness
• Each successive remission lasts as about
half as long as the last
• More than 3 remissions is unusual
Treatment - Chemotherapy
Common misconceptions
• My pet will lose his hair
• My pet will likely be ill as a trade off for
attempting a longer life
• It would be better for my pet to die of
cancer than to die of chemo treatment
Treatment - Chemotherapy
Things important to say
• You will likely think your dog is cured
• The probability of this is just about zero
• I can give you the averages, but whatever
happens to you is 100% for you
• If at any time you want to stop chemo, all
you have to do is say the word
• You know your pet best, and what is best for
your pet. Our job is to give you information
and help you manage your pet’s cancer as
you think best. You are in the driver’s seat
and we are here to help.
Treatment - Chemotherapy
Rescue Therapy
• Drugs used at the time of relapse are no
longer effective and should not be used
• Repeat CHOP if not being used at relapse
• Then maximize doxorubicin dose
• Then try either CCNU and MOPP, in either
order
• Then try various other rescue protocols
Treatment - Chemotherapy
Low Grade, small cell tumors
• GI lymphomas in cats
• CLL in dogs
• Chlorambucil 15 mg/m2 PO SID x 4d
• Repeat every 3 weeks
• Prednisone 40 mg/m2 PO SID, taper
• 70-75% remission
• Median remission 19 months
• Survival 1-2 years is usual
Treatment - Chemotherapy
ALL
• Can try large cell protocol, but expect more
myelosuppression
• Or Cytosine arabinoside 400 mg/m2 over 6-8
hours
• Administer weekly
• Monitor for sepsis and treat accordingly
• Blood transfusions as needed for RBC
• Platelet rich plasma for platelets
• Whole fresh blood for depleted factors
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Other Treatments
• Pulse chemo protocols
• Intestinal resection and anastomosis for
obstructive GI LSA
• Whole body radiation (1/2 at a time)
• Nasal cavity radiation
• Monoclonal antibodies
• Cerebral lesions
• Mannitol, furosemide, diazepam acutely
• Chemo long term
• Anticonvulsants (zonisamide or
phenobarbital)
• Natural alternatives
Other Treatments
Treatment of Hypercalcemia Handout
• Treat if >15-16 or symptoms
• IV 0.9% NaCl
• Increased GFR and calciuresis
• Decreases renal calcium reabsorption
• Furosemide 1-4 mg PO BID
• inhibits Ca++ reabsorption in ascending
loop of Henle
• Prednisone 1-2 mg/kg PO BID
• Inhibits VitD and GI calcium absorption
• Cytotoxic effect on LSA and myeloma
Other Treatments
Treatment of Hypercalcemia Handout
• >18 is a medical emergency
• Salmon calcitonin 4-8 U/kg BID-TID
• Pamidronate 1-2 mg/kg IV in 0.9% NaCl
over 2–4 hrs; repeat in 2-4 weeks)
• Zoledronate 0.25 mg/kg IV over 15
minutes q 4-5 weeks
Prognosis
Response to chemotherapy – canine large
cell multicentric lymphomas
• 70-80% achieve full remission
• 20-25% are partial or non-responders
• Average length of remission is 6-11 months
• Median survival 12 months
• 20-25% survive 2 years or longer
• Each remission is shorter lived and more
difficult to achieve
• Every tumor is expected to eventually
become responsive to all treatment
Prognosis
Response to chemotherapy – canine large
cell multicentric lymphomas
• Short term prognosis usually good, long term
prognosis is invariably dismal
• Staging doesn’t matter, except V is worse
• Grade doesn’t matter
• Things that worsen prognosis
• systemically ill (substage B)
• Hypercalcemia
• dyspnea on presentation
• Bone marrow involvement, especially if
cytopenias
• (T cell is worse than B cell)
Prognosis
GI lymphoma is more often T cell in dogs
• Median survival 13 days for SI LSA
• Colorectal LSA can have prolonged survival
• There can be a histopathologic gray area
between IBD and LSA
• Some Dx LSA behave as IBD
• Some Dx IBD behave as lymphoma
• Perhaps misdiagnosed?
Lymphoid granulomatosis in dogs is highly
variable
• 6 days to 4 years
Prognosis
ALL has grave prognosis
• Days to weeks common
• Occasionally a few months
• Chemo may not prolong life
• ALL distinguished from Stage V LSA (bone
marrow) by immunohistochemistry
• The latter does not carry grave prognosis,
though not as good as lower stages
• Death usually by hemorrhage
Prognosis
Prognostic indicators in cats
• Retroviral status
• Anatomic location
• Initial response to therapy
• Stage & grade do not matter
• immunophenotyping matters less in cats as
compared to dogs
Some of the indolent low grade tumors can
have long survivals (2 years+)
• GI small Lymphoma in cats
• chronic lymphocytic leukemias in dogs
Prognosis
Nasal lymphoma in cats
• increased risk for kidney lymphoma
• Presence of anorexia worsens prognosis if
not treated with chemo or radiation
• Median survival 5 months if anorectic
• Median survival 11 months if eating
• Same prognosis for chemo alone, radiation
alone, or both together
• Median survival 1.5 years
• Much shorter MST if cribriform breach
(76 days)
Prognosis
Mediastinal lymphoma in cats
• Associated more with FeLV+ than GI
• Younger cats than GI LSA
Feline Hodgins-like lymphoma
• Not common
• Affect lymph nodes in head and neck
• Cells are of mixed phenotype
• Long term prognosis is good
Prognosis
Hepatic lymphoma in cats
• Associated more with FeLV+ than GI
• Younger cats than GI LSA
Cutaneous Lymphoma
• Better prognosis in cats - B cell
• 50% remission in dogs – T cell
• Average remission 4-6 months in dogs
• CCNU + Elspar in dogs
• Treated as multicentric in cats
• CHOP for large cell
• Chlorambucil + pred for small cell
Client Handouts
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•
•
•
Lymphoma in Dogs
Lymphoma in Cats
Skin Lymphoma
Acute Lymphoid Leukemia
• Drug and Chemotherapy Client Handouts
discussed under chemotherapy (Sunday)
Acknowledgements
• Philip J. Bergman, DVM, MS, PhD, DACVIM
(Oncology)
VIN, BrightHeart Veterinary Centers
• Louis-Philippe de Lorimier, DVM, ACVIM
(Oncology)
VIN, U Illinois Urbana-Champaign
• Karri A. Meleo, DVM, ACVIM (Oncology),
ACVR
VIN, Veterinary Oncology Services,
Edmonds, WA
Acknowledgements
• Mark Rishniw, BVSc, MS, ACVIM (SAIM),
ACVIM (Cardiology)
VIN, Clinical Research Coordinator
Ithaca, NY
• Kurt R. Verkest, BVSc, BVBiol, MACVSc
(Small Animal)
VIN, Univ Queensland, Australia
• Kari Rothrock, DVM, Tennessee
Acknowledgements
Linda Shell, DVM, DACVIM (Neurology)
• VIN Consultant
Nancy Johnstone McLean, DVM, DACVO
• U of Tennessee CVM
Amanda Podles, DVM
• Massachussets
Acknowledgements
• Robert J. Vasilopulos DVM, DACVIM
(Internal Medicine)
VIN Consultant, Vet Spec Ctr of Tucson
• Dennis J. Chew, DVM, ACVIM (Internal
Medicine)
The OSU CVM, Columbus, OH
•
Patricia A. Schenck, DVM, PhD
Mich State U, East Lansing, MI, USA
• Zachary Wright, DVM, ACVIM (Oncology)
Animal Diagnostic Clinic, Dallas TX