Bright ideas - epitheliotropic lymphoma

Re: Bright ideas - epitheliotropic lymphoma

John Flynn — Fri, 17 Jan 2014 11:50:18 GMT

[quote user="Gerry Polton"]At one time in my life I tried to collect a cohort of ten of these together to report as a case series as I think they are a specific entity. I had eight or so cases that I had managed on fresh air alone (ie no teratment at all). Some of them even went into spontaneous complete remission.[/quote]

Gutting! Does go to show the need for detailed research though as if you'd treated them with anything other than thin air and then published the case series we'd all probably consider the "treatment" to have caused the remission...

[quote user="Gerry Polton"]pseudo-lymphoma[/quote]

I like it :-)

Can I bagsy pseudo-pseudo-lymphoma for those conditions which appear like pseudo-lymphoma and are considered as such but nonetheless have a sharp downward clinical outcome ;-)

Re: Bright ideas - epitheliotropic lymphoma

Yantha Smyth — Fri, 17 Jan 2014 10:24:00 GMT

Sounds good to me! But how to tell the difference other than in retrospect.... Mmmm

Re: Bright ideas - epitheliotropic lymphoma

Gerry Polton — Fri, 17 Jan 2014 10:11:40 GMT

Have we just invented a new diagnosis?.... Pseudo-lymphoma.

You heard it here first.

Re: Bright ideas - epitheliotropic lymphoma

Yantha Smyth — Fri, 17 Jan 2014 10:07:39 GMT

Last year I was doing a Locum and saw a dog with a non healing lesion of the nail bed: took a punch type biopsy that virtually removed the grossly visible lesion- came back as likely epitheliotrphic lymphoma, subsequently confirmed with immuno-histo chemistry. Went ahead and amputated digit, survey X-rays etc. the submitted digit was sent for histo with the biopsy site indicated..... No neoplasia found at all! I find it difficult to believe the punch biopsy was an effective 'excision', and started to doubt the original results....

Re: Bright ideas - epitheliotropic lymphoma

Gerry Polton — Fri, 17 Jan 2014 09:13:09 GMT

[quote user="John Flynn"]

Last couple I saw got lomustine + preds (someone must have suggested it at the time...) - is this a bit out-dated now?

[/quote]Hi John

Lomustine is a very popular treatment for epitheliotropic lymphoma. However, treating all cases that way is wrong in my opinion. You have explained why yourself with your excellent example of the low-grade lesions that appear on the gums. At one time in my life I tried to collect a cohort of ten of these together to report as a case series as I think they are a specific entity. I had eight or so cases that I had managed on fresh air alone (ie no teratment at all). Some of them even went into spontaneous complete remission. My observations even forced the question of whether these cases are truly lymphoma cases or perhaps they are some sort of pseudo-lymphoma. Anyway, sad end to the story was that I moved house and lost all the data in the move. Whether you use prednisolone with the lomustine is a small issue; I judge it the merits of the individual case.

Just to ensure that I don't give the wrong message here, I do also see cases of low-grade oral (lip) lymphoma which absolutely do require treatment because they are progressive and they have an adverse impact on the patient's well-being.

Hope that helps.

Gerry

Re: Bright ideas - epitheliotropic lymphoma

John Flynn — Thu, 16 Jan 2014 19:02:56 GMT

[quote user="Gerry Polton"]For a multifocal low-grade lesion, I would consider treatment with one of: no teatment at all, prednisolone alone, chlorambucil and prednisolone, or isotretinoin (a Vitamin A analogue).[/quote]

Thanks for all the info, Gerry - feeling a bit more educated!

Last couple I saw got lomustine + preds (someone must have suggested it at the time...) - is this a bit out-dated now?

Thoughts on the ones in the gums (low-grade, probably been there for years unrecognized, no detectable LN involvement)?

Re: Bright ideas - epitheliotropic lymphoma

Gerry Polton — Thu, 16 Jan 2014 17:49:39 GMT

Re: Bright ideas - epitheliotropic lymphoma

Miriam Lodewyks — Thu, 16 Jan 2014 17:43:55 GMT

... what Gerry said ;-)

Re: Bright ideas - epitheliotropic lymphoma

Bob Russell — Thu, 16 Jan 2014 16:56:19 GMT

Many thanks!

The histopath report suggests a high grade tumour and the intention is to refer!

Not a tumour I have much experience with so just trying to get a bit more of a feel for the options! This is not removable surgically with these dimensions without amputation!

Re: Bright ideas - epitheliotropic lymphoma

Gerry Polton — Thu, 16 Jan 2014 15:40:50 GMT

Hi Bob

That's quite a cut on the leg!

It is a frustrating reality that the diagnosis of epitheliotropic lymphoma, despite the fact that this sounds tremendously detailed, still represents a relatively eclectic collection of lymphoma types with a similarly variable mixture of possible treatment options. For these patients we need to understand the anatomic extent of the disease, the grade of the tumour and then we need to do some good old-fashioned 'well, it looks a lot like one I saw before that responded to ...' in order to make the best decision.

For the anatomic extent of disease, we need to be sure about whether there are or are not further cutaneous lesions and we need to be confident about whether the regional lymph node is affected. In some cases it is appropriate to investigate further, including by thoracic radiography and abdominal ultrasonography. We are trying to answer a simple question: is this a solitary lesion or is it a systemic disease (as far as we can tell).

For the grade of the tumour, we want to interpret the histology report or the cytomorphology. I will often take further cytology samples from these cases as we gain different information from cytology from that we obtain from histology. We broadly categorise them as low grade and high grade and there are treatment decisions that are made on the basis of these results.

So, if you have a solitary low-grade lesion, I would consider surgery. It is not expected to cure the patient. However, it is expected to achieve remission. There are not many cases, as you suggest yourself, that actually go into remission with medical therapy, so this is a good outcome. You should expect another lump or two within six months, but perhaps a further surgery could be performed, so long as the tumour remains low-grade.

For a multifocal low-grade lesion, I would consider treatment with one of: no teatment at all, prednisolone alone, chlorambucil and prednisolone, or isotretinoin (a Vitamin A analogue). Complete remission can be achieved. I have had cases live years on no treatment at all.

For high-grade or systemic disease, medical therapy is appropriate. There is unfortunately quite a list of treatment options. The most frequently reported is lomustine. Some of these cases actually respond very well to conventional COP chemotherapy. Other systemic chemotherapy strategies for lymphoma are reasonable options.

In short, referral is a good idea. I hope, however, that this provides an explanation of the options available to you.

Best wishes

Gerry