Canine Lymphosarcoma

Re: Canine Lymphosarcoma

Rob Loxley — Sun, 24 Mar 2013 17:10:58 GMT

[quote user="Hanna Bennett"]choice between spending money on staging or treatment, and after discussion with owners we almost always go for treatment, which can be started asap on the back of an fna result, rather than waiting for results and then any biopsy wounds to heal[/quote]

FYI, you can do b/t typing by flow cytometry on FNA aspirates: http://www.dwrdiagnostics.com/tests-and-profiles/flow-cytometry.aspx

Re: Canine Lymphosarcoma

Hanna Bennett — Sun, 24 Mar 2013 13:11:18 GMT

i understand the theory behind t/b cell differentiation but have (anecdotally) found that this does not play out in the real world. I've also found that in my experience most lymphoma owners are not insured so then i have a choice between spending money on staging or treatment, and after discussion with owners we almost always go for treatment, which can be started asap on the back of an fna result, rather than waiting for results and then any biopsy wounds to heal.

Re: Canine Lymphosarcoma

Christopher Saul — Sun, 24 Mar 2013 12:50:14 GMT

[quote user="Emily Herskind Nightingale"] I am aware that pred tx before hand reduces efficacy of chemo, but he is only on 5mg BID (he weighs 28.5kg) so hopefully this isnt going to influence things massively. (I hope??!!) [/quote]

Exactly how long it takes to for prednisolone treatment to significantly impact upon chemosensitivity is not currently known, so I don't think one can answer this question precisely, however I think you had no choice but to give pred so I wouldn't beat yourself up about it

Before I go on I'd like to say that you have worked this case up perfectly appropriately and I see little else that should have been done. You did not give this dog LSA and this is NOT your fault. The initial assumption of a hotspot pyoderma seems perfectly reasonable to me.

There is little I would have done differently to be honest, other than maybe to have biopsied the skin lesions (or did you do this ?) - The only reason I think this is relavent is that if the LSA is truely epitheliotrophic then the recommendation for treatment is a little different from that for mutlicentric LSA. In general for epitheloptrophic LSA I would use lomustine as my first line Tx rather than a CHOP -type protocol (which I would use for most LSAs)

Having said the above I doubt this is epitheliotrophic LSA from the history - it sounds more likely to be multicentric with skin involvement to me.....

Might be interesting if you could post the histo/cyto results you have....

Chris

Re: Canine Lymphosarcoma

Rob Loxley — Sat, 23 Mar 2013 17:02:20 GMT

[quote user="Robin Grimmer"]Saw a cat this week that had alimentary lymphoma confirmed by biopsy 9 months ago and is still doing well on preds alone.[/quote]

High grade or low (small cell)?

Re: Canine Lymphosarcoma

Robin Grimmer — Sat, 23 Mar 2013 13:57:10 GMT

Saw a cat this week that had alimentary lymphoma confirmed by biopsy 9 months ago and is still doing well on preds alone.

Re: Canine Lymphosarcoma

Bob Russell — Sat, 23 Mar 2013 11:56:25 GMT

Some of these cases can look amazingly good with prednisolone alone and for some owners this may be enough! It only prolongs life by delaying the need for euthanasia on welfare grounds!

Every lymphoma patient I have treated has gone into remission for a time bar one. This had to be my own collie, at the start of this year!!

Re: Canine Lymphosarcoma

Emily Nightingale — Sat, 23 Mar 2013 10:05:42 GMT

Thank you all for your very helpful and interesting input.

The staging and chemotherapy choices are the bits I'm most interested to hear views on at present..especially with regards to prognostics.

7d ago, the patient was admitted as an emergency case to our OOH provider and was in such a state of collapse/dysnpnoea that the owners seriously considered euthanasia there and then, and the vet attending agreed (I would have done too). However he responded so well to treatment of diuretics and supportive care (IVFT etc) that the next day he was much improved and the owners were so pleased that they hadnt pulled the trigger so to speak. However, this DOES mean, having seen him in dire straits, they have a lower threshold for what they will tolerate in terms of deterioration before they put him to sleep. The very sensible Mr Owner, has said if he is suffering at all, then knowing where this is going, we will call it a day whilst the going is still good.

So at the moment, as he is so well and his quality of life is very good I will elect to wait until the staging comes back from Idexx, before giving the owner options of which chemotherapy protocol would be best. I am aware that pred tx before hand reduces efficacy of chemo, but he is only on 5mg BID (he weighs 28.5kg) so hopefully this isnt going to influence things massively. (I hope??!!) Also, the tachycardia (<160bpm at rest, grade 4 heart murmur etc) needs to be investigated before I can make any decisions.. so I'll update you more on Tuesday when we are doing and ECHO and ECG... The owner is aware that "every day is a bonus" but they are so pleased they have had this last week with him and it truly has been a very good week.

Thank you for all your help. (sorry for waffly rambling style but been up since 1am with teething baby who has only just gone down for a nap... Think I might follow suit.. )

Thanks again.

Re: Canine Lymphosarcoma

Rob Loxley — Sat, 23 Mar 2013 08:53:19 GMT

[quote user="David Mills"]Re preds and reducing cytotoxicity, this is written all over the place but does anyone have a link to the evidence of this?[/quote]

IIRC it is due to upregulation of P-glycoprotein, an efflux pump responsible for multidrug resistance in tumor cells. There are papers looking at this in tumor cells, and an interesting one in lymphoma dogs looking at correlation between p-GP levels and eventual outcomes.

[quote user="Braden Collins"] I think soon we will have different protocols for B and t cell lymphoma[/quote]

I once went to a lecture where they were keen for MOPP as a 1st line for t-cell lymphoma. Likewise CCNU in EL.

Re: Canine Lymphosarcoma

Braden Collins — Sat, 23 Mar 2013 01:01:49 GMT

Pred can give a great remission for 4-6 eeks, but that's as long as it normally lasts. Pred can reduce responses to other treatments but the trade off is keeing the dog healthy enough to still be a viable chemo candidate.

I tend to only offer immunohistochemistry if the difference in survival times will influenc the owners decission - if a 7 month median survival with T cell is not long enough for them, it may be worth doing, otherwise I crack on with treatment ASAP. I think this is something to watch for the future - I think soon we will have different protocols for B and t cell lymphoma.

Re: Canine Lymphosarcoma

David Mills — Fri, 22 Mar 2013 21:46:28 GMT

[quote user="Hanna Bennett"]

i no longer bother with t/b cell differentiation - have had b cells pts within a month and t cells live two years. tbh if they are simple multiple lymphadenopathy i rarely bother beyond fna to confirm lymphoma - decision of what chemo to do is based on owner preference and individual animal personality for me - does all the other stuff really do anything to change your treatment plan?

[/quote]

No, possibly not, but all the options should be made available. Simply to say 'i no longer bother...[anecdote]' is to ignore the higher evidence out there. Emerging evidence is that B or T cell staging is useufl for prognostication, and subtyping even more useful - it may not change your treatment plan but it can help answer that which is probably most important to the owner - how long has he/she got? I'm always bemused by the strange logic of not bothering with prognosticating.

Here are a few:

http://www.ncbi.nlm.nih.gov/pubmed/23444036

http://www.ncbi.nlm.nih.gov/pubmed/21295720

http://www.ncbi.nlm.nih.gov/pubmed/11518416

Ms N, PM me if you want the actual articles.

Generally, low grade T carries best prognosis (>600d), whereas high grade T and all B are pretty poor (100-200 days). If I was an owner, with a low grade T I'd go full throttle with chemo - otherwise I wouldn't bother. That would definitely change treatment options.

Re preds and reducing cytotoxicity, this is written all over the place but does anyone have a link to the evidence of this? Genuinely interested.

Re: Canine Lymphosarcoma

Hanna Bennett — Fri, 22 Mar 2013 21:11:16 GMT

Re: Canine Lymphosarcoma

Gillian Mostyn — Fri, 22 Mar 2013 20:17:19 GMT

Trying not to rain on your parade, but as the other poster said, they tend not to do so well on a lot of the chemo protocols if they have already been on steroids. Also, in my experience, (pure anecdote) the ones that respond so well to steroids seem to quickly and suddenly stop being responsive and there is usually a rapid deterioration. I am sure you are on top of this, but do be careful not to be too optimistic with the owners just because the dog is doing well at the moment.

Sorry!

However,

Re: Canine Lymphosarcoma

Rob Loxley — Fri, 22 Mar 2013 19:56:51 GMT

[quote user="Emily Herskind Nightingale"]I am still awaiting B T cell differentiation which will determine chemo options and prognosis, however currently this seems uber steroid responsive[/quote]

Previous steroid treatment can increase the rate of resistance to cytotoxic drugs and has been shown to negatively affect the prognosis for subsequent chemo treatment. As per previous, how is t/b phenotype going to determine chemo options?

Re: Canine Lymphosarcoma

Emily Nightingale — Fri, 22 Mar 2013 14:02:23 GMT

Well just to update you..

The patient has made a miraculous improvement! Currently on 60mg Furosemide BID to manage ascites, still on AB as before, 5mg pred BID and remarkably (REMARKABLY) is brighter, eating better, wanting walks and most of all the LNN have shrunk back by 80%!!!! The SMLN are now small prune sized, and the prescaps which were bigger than my hand, are now walnut sized.

Where to go from here?? I am still awaiting B T cell differentiation which will determine chemo options and prognosis, however currently this seems uber steroid responsive.. He is tachycardic with grade 4 murmur (suspect mediastinal lnn causing this ) so he is coming in for Echo and ECG on Tues.. Good news though on the whole so am much happier now!! Thank you for the kind responses =)

Re: Canine Lymphosarcoma

Braden Collins — Fri, 22 Mar 2013 13:30:18 GMT

Sounds to me like the case was worked up well. I don't think you can kick yourself over ones like this.

Make sure you deal with the hypercalcaemia promptly, as this can cause problems with multiple organs which in turn makes treatment mre difficult,

I'd get started on treatment before getting the immunohisochemistry results as it doesn't greatly affect treatment protocols, but more prognosis. With an epitheliotrophic form you may be better off considering a lomustine based protocol, though this can affect the bone marrow quite severely so if there's any evidence of myelophthesis I'd recommend a boe marrow aspirate. With significant bone marrow involvement a COP protocol or another protocol with less bone marrow suppression may be worth starting with then changing protocols once you have some degree of control. Cutaneous forms also have a higher level of being t-cell, so this may be a poorer responding form.

The skin may be a genuine hotspot or part of a paraneoplastic syndrome, so worth a biopsy to confirm as this may influence treatment options. If the dog is really sick it may even be worth biting the bullet and hitting it with some doxorubicin straight up - it has risks doing that but sometimes you just have to go hard early.

Also consider referral for a case like this if at all possible - a complicated lymphoma case is best dealt with by a specialist and this certainly doesn't sound straigh forward.

Sorry if that's not clear. i can spend an hour talking to clients about treatment options, so if referral isn't an option try phoning a friendly oncologist as their advice will eb very valuable.

Re: Canine Lymphosarcoma

James Laidlaw — Thu, 21 Mar 2013 09:57:09 GMT

How high was the hypercalcaemia out of interest?

Re: Canine Lymphosarcoma

Rob Loxley — Wed, 20 Mar 2013 23:56:01 GMT

Why is it always the nicest dogs? (we've diagnosed 3 splenic masses in the last week in lovely old dogs)

[quote user="Emily Herskind Nightingale"]Does anyone have any words of advice/encouragement/critique???[/quote]

Ref the ascites, did you get to look at the liver/spleen/guts; did you biopsy the skin lesions? I only ask since that these affect the staging, and EL is reported to have a poorer prognosis (likewise mediastinal LN and hepatic involvement IIRC). Sadly likewise hypercalcaemia :(

[quote user="Emily Herskind Nightingale"]Am awaiting tcell/bcell differentiation and if looking favourable I will start chemotherapy.[/quote]

If the owners are happy for chemo (and given survival times are so variable even if you know phenotype how much does estimated prognosis affect this?), how does T/B determination affect whether you start chemo? Obviously some stabalisation of a sick dog prior to starting chemo may be needed.

Re: Canine Lymphosarcoma

Emily Nightingale — Wed, 20 Mar 2013 21:47:39 GMT

So kind. Thank you.

Re: Canine Lymphosarcoma

Busybee — Wed, 20 Mar 2013 21:44:42 GMT

I honestly don't see that you've done anything wrong with this case, I doubt I would have done anything differently to you and I think this is just one of those horrible 'bad things happen to the nicest patients' cases.

The skin lesions - have faith that you're skilled enough (and by the sounds of it, you are!) to have noticed enlarged lymph nodes at the first exam. The dog improved, everyone was happy, case progressing nicely. The dog had a good 14 days of antibs for pyoderma which is a good enough duration for surface pyoderma.

You had the foresight to carry out pre-op bloods and detected an abnormality that you then followed up on, thoroughly. The work up sounds text-book and although the diagnosis is a sad one, you have a diagnosis and a plan for the dog and owner.

I had a similar case a few months ago where I saw an old-ish lurcher cross with a small skin lump. Discussed FNAs, biopsies, removal etc but the O wanted to monitor for now, which I didn't think was unreasonable with the presentation. Few weeks later, dog comes back with huge pre-scap LNs - confirmed lymphoma, owners rejected chemo and opted for prednisolone-only treatment. Dog died 3 months later. Again, lovely dog and lovely owners.

Don't beat yourself up about this case. Believe me, I am the world's worst worrier and always think I've missed something or done something wrong or fret over the simplest of cases and always picture the worse-case scenario. But even I see that you've tackled this case perfectly. As everybody always seems to suggest on here, have a large glass (or three) of vino and try and get a good night's sleep. Things will always seem easier in the morning Best of luck!

Re: Canine Lymphosarcoma

Utlendigur — Wed, 20 Mar 2013 21:31:25 GMT

Common things are common .... how many golden retrievers do we see with hot spot, and how many with epitheliotrophic lymphoma? I've seen one case of epitheliotrophic lymphoma in a dog in 20 years (also a golden retriever) - and it did look like epidermal collarettes to start with - but it came back the next week covered in masses more, despite antibiotics and the lesions were very scaly and slightly thickened by this point so biopsied - but the LN were normal. Only thing I would wonder is why Rilexine and Antirobe, since they cover similar bacteria? Unless the lesions looked particularly odd or the LN were raised initially, you wouldn't really start biopsying at first presentation. You picked up the hypercalaemia, realised the significance, looked for the cause and found it - the fact that it the diagnosis is horrible isn't your fault (even though as vets we seem programmed to blame ourselves for anything not turning out well). And it always happens to the nicest dogs and owners.