Feline intestinal lymphoma

Re: Feline intestinal lymphoma

Martin Atkinson — Mon, 21 Jul 2014 15:46:33 GMT

[quote user="Rob Davis"]How long would you leave it post-surgery before starting chemo?[/quote]As Gerry says it depends on the severity of clinical symptoms. My most recent successful case started on cyclophosphamide and preds 7 days post enterectomy, I may have started a couple of days earlier but it took that long before the lab report came back and the client could get in to collect the meds. Initial plan was to give just these two as I perceived the client may be resistant to coming in for weekly injections and perhaps, despite my apparently gung-ho attitude towards chemotherapy, maybe I was a bit reluctant as well. Initially there was a very good response but after 2 months I could palpate enlarged mesenteric lymph nodes again. We then started vincristine as well and the cat did very well for another 7 months.

When there is a worry over delayed healing of surgical wounds there may be mileage in staging the start of the components even if you intend going for the full monty from the start.

Re: Feline intestinal lymphoma

Rob Davis — Mon, 21 Jul 2014 14:30:19 GMT

Thanks, Gerry - diamond geezer as ever!

Re: Feline intestinal lymphoma

Gerry Polton — Mon, 21 Jul 2014 09:02:55 GMT

2 weeks... ish. Certainly no more than that. I do find myself starting sooner with no problems at all sometimes, especially when the patient's clinical status appears to be deteriorating. It becomes a balance of risks.

Gerry

Re: Feline intestinal lymphoma

Rob Davis — Mon, 21 Jul 2014 08:47:14 GMT

Many thanks for all the advice - perhaps next time I will go for FNA before surgery - good to know for the future. How long would you leave it post-surgery before starting chemo?

Re: Feline intestinal lymphoma

Gerry Polton — Mon, 21 Jul 2014 08:40:43 GMT

Good morning!

I agree with pretty much everything (I am obviously in an agreeable mood this morning). As Martin said, COP is a cracking treatment plan for these cases. It is not high cost and it remains a very useful and potent treatment. Serial blood evaluations are a big part of the cost but you can use your judgement to define how often these really need to be done. I would encourage you to do them more often at first as you learn how the cat responds to the treatment whilst it is being given most frequently. After about six weeks you should have a pretty clear idea of how the cat responds, from a marrow perspective, and then you can afford to run the blood tests less often; once you know an individual patient's response, you can predict changes pretty well, you just need to ensure that there aren't chronic changes which you would then overlook.

I agree with Rory. I too don't see evidence that the addition of doxorubicin makes a meaningful difference to these cases. Maybe it makes some difference, but in my experience, not enough to justify its use across the board.

There hasn't been any published work that I know of exmaining whether cases with large masses do better with surgery plus chemo. My feeling is that they don't. There would be multiple reasons for this: chemo when it works, works sufficiently well that surgery is unnecessary; cases often are not localised to the intestine but also affect unresectable mesenteric lymph nodes; there is surgical morbidity and mortality, and so on. I advise that surgery is indicated when and only when there is complete bowel obstruction or there is a perforation.

Good luck, Rob. Do be aware that not all cases respond to chemotherapy (of course). My advice is to expect a marked response within four weeks and if you don't have it, for all but the most determined of owners, it is time to stop the chemo at that point. By all means continue the steroids, but the prognosis is likely to be poor (~16 weeks).

Gerry

My experience of the large cell high-grade versus small cell low-grade question is that only a very small number of diagnosed lymphoma cases are actually the small cell low-grade type. In normal veterinary practice, suspicion of GI lymphoma arisees due to the presence of a palpable mass. These cases are readily diagnosed by FNA, if the FNA is handled well. Sometimes the cells rupture during the samplking process. Sometimes the cells are too poorly differentiated for a diagnosis to be made by morphology alone and immunohistochemistry is needed, in which case you need a proper biopsy.

Re: Feline intestinal lymphoma

Rory Bell — Sun, 20 Jul 2014 19:51:08 GMT

Rob,

The histology reads like a fairly high grade lymphoma. I'd recommend treating it accordingly. Provided the owners were up for it, I'd go for a COP protocol. I'm not convinced that the addition of doxorubicin has contributed anything like the survival advantages to cats compared to what it has done to dogs; there are some studies that support this.

If the owners were not up for a multiagent protocol, my next choice would be lomustine (with pred). Minimal / scanty evidence regarding efficacy of this protocol though but it does appear to be fairly well tolerated..

High grade lymphoma in cats is a completely different animal (excuse the pun) to low grade lymphoma in terms of biologic behaviour and prognosis.I'd be cautioning the owners that their cat may not do so well even with the benefit of treatment.

In terms of other issues raised on the thread and in my opinion only, but FNA is a relatively reliable way of diagnosing high grade GI LSA which often takes the form of an apparently discrete mass. Fine needle aspiration is next to useless for diagnosing what is probably the most common form of GI LSA in cats - low grade lymphoma, which often takes the form of little more than slightly thickened intestines, even on ultrasound examination. This is the form of lymphoma which is difficult to distinguish from lymphoplasmacytic enteritis (IBD). Surgery - if there is a complete GI obstruction then as a life prolonging (not life saving, and diagnostic - if FNA impossible) procedure then enterectomy is indicated. You will never completely excise GI lymphoma, so surgery will never provide a definitive treatment. I'd still FNA an obstructive lesion, because if you identify a large cell lymphoma, the owner may not want to pursue invasive therapy of a disease with a poor prognosis.

Hope this helps, Gerry will probably be along shortly to sort out any confusion!

Re: Feline intestinal lymphoma

Rob Loxley — Sat, 19 Jul 2014 21:17:08 GMT

[quote user="Richard Carter"]there still seems to be some doubt whether feline lymphoma is genuine neoplasia or extreme end stage GI inflammation[/quote]

I think what we currently refer to as "feline lymphoma" (or canine, for that matter), encompasses a wide range of differing manifestations/sub-types, with different behaviours and responses.

Re: Feline intestinal lymphoma

Richard Carter — Sat, 19 Jul 2014 12:47:09 GMT

As there still seems to be some doubt whether feline lymphoma is genuine neoplasia or extreme end stage GI inflammation may explain why so many do so well on preds or depo-med every 4 - 6 weeks. Response if there is going to be any, is usually very rapid so if budget and medication are an issue, wouldn't give up just yet without trying cortisone.

Re: Feline intestinal lymphoma

Kate Richardson — Sat, 19 Jul 2014 11:14:57 GMT

[quote user="Laurence Webb"]

Because you normally get incomplete excision (lymphoma being a systemic disease) I normally FNA intestinal masses in cats rather than ex-lap. A fraction of the cost and invasiveness and normally gets a diagnosis.

After a single dose of vincristine you can often palpate a marked reduction in tumour size after a week. There is a risk that you kill off all the tumour and leave a hole in the intestines (hasn't happened to me yet) but equally I had an enterectomy that had been fine for 2 weeks post op which broke down following starting chemo.

I'd normally only do surgery if there was an obstruction, I knew it wasn't a lymphoma or FNA was non-diagnostic.

No doubt someone wiser will be along to refute my approach!

[/quote]

That would be my approach as well, however I appreciate not everyone has access to ultrasound or is confident to FNA lesions and if referral isn't an option then surgical exploration has its merits- if you can palpate a mass, another option would be to do a blind FNA. I would worry about wound breakdown of the enterectomy site if clean margins aren't achieved, but like everything its a case of weighing up your options, discussing the risks and making an informed decision.

Got me thinking though, if chemotherapy isn't an option for whatever reason, then surgical excision may be useful as a palliative treatment- but is it any better than pred alone? I don't know the answer, am just pondering.

I have just been treating a cat with intestinal lymphoma with COP protocol which did poorly (but a complicated case as in it had IBD for years treated with pred which then crossed the line and became lymphoma), the cyclophosphamide was every 3 weeks- frequency worked out according to cats body weight/surface area.

Iain Grant is a specialist oncologist who runs Chemopet oncology services www.chemopet.co.uk

He will advise on suitable protocols/options/prognosis etc and if you go ahead he will send you the doses of treatment already drawn up along with the connecting tubing etc so all you need is to place an iv catheter and administer so from a health and safety view point significantly reduces risks. And its very reasonable price wise as well.

Re: Feline intestinal lymphoma

Laurence Webb — Sat, 19 Jul 2014 11:08:32 GMT

A retrospectoscope that works in advance? That would be a fine thing to own!

Re: Feline intestinal lymphoma

Martin Atkinson — Sat, 19 Jul 2014 11:01:09 GMT

[quote user="Laurence Webb"]

I'd normally only do surgery if there was an obstruction, I knew it wasn't a lymphoma or FNA was non-diagnostic.

No doubt someone wiser will be along to refute my approach!

[/quote]No wiser, possibly more experienced though! The case I referred to in my previous post had a very large ileocaecolic obstructive mass so we felt surgery was necessary and the approach was vindicated. Another case I dealt with a month ago wasn't totally obstructive but involved even more of the intestine (half its colon and several inches of distal ileum and it didn't recover well from surgery so the owner had it PTS. I hindsight it might have been better to have biopsied then used chemo but the retrospectoscope wasn't working that day.

Re: Feline intestinal lymphoma

Laurence Webb — Sat, 19 Jul 2014 10:21:36 GMT

I'd normally only do surgery if there was an obstruction, I knew it wasn't a lymphoma or FNA was non-diagnostic.

No doubt someone wiser will be along to refute my approach!

Re: Feline intestinal lymphoma

Rob Loxley — Fri, 18 Jul 2014 23:07:48 GMT

Not a helpful tangent, but I've often wondered whether these large discrete intestinal lymphomas (as opposed to the small cell ones) do any better with surgery and chemo than chemo alone?

Re: Feline intestinal lymphoma

Martin Atkinson — Fri, 18 Jul 2014 19:30:53 GMT

I expect Gerry will be along soon but I had one on COP after enterectomy to remove the primary mass last September, there was spread all through the mesenteric lymph nodes. It responded very well and was only PTS a couple of weeks ago as much to do with old age as anything it was 19 but there was a mass in its liver by then not sure if this was related or not but could still no palpable mesenteric nodes. The cyclophosphamide was given as a 50mg tablet fortnightly otherwise as per BSAVA Formulary guidelines. The actual cost of drugs is not high ( I re-used the vicristine vials) it is the monitoring that costs depending how frequently you do it and how much you want to charge.