Lymphoma ?

RE: Lymphoma ?

Roland Bulkyn-Rackowe — Thu, 15 Oct 2015 16:51:50 GMT

Refer?

If you're to treat in house I'd think about a bisphosphonate infusion to control the hypercalcaemia. I've not seen a hypercalcaemic dog for some time, last thing I used was pamidronate and it seemed to work well. Vigorous IV fluids also. If the hypercalcaemia has not been going on too long you may recover some renal function.

I would also not really delay chemo depending on T or B cell, there are tumours of either type that may respond well or poorly. Unless you will change your therapy depending on tumour type? I think some favour lomustine in T cell lymphoma.

I often start a CHOP (madison wisconsin) and refer for the doxocubicin / epirubicin (anthracyclines). It is nice to have a baseline cardiac echo if using an anthracycline. I also try for urinalysis and full blood count before any treatment.

Agree with the above 0.7mg Vincristine / sqm to get the ball rolling but I'm no oncologist!

RE: Lymphoma ?

Robin Grimmer — Wed, 16 Sep 2015 13:48:21 GMT

[quote user="robloxley"]

[quote user="Stigen"]put on 1,5mg/kg prednisone [/quote][quote user="Stigen"]would like to deal with Pu/PD before starting chemotherapeutics[/quote]

If I was going for chemo for lymphoma I wouldn't pre-treat with steroids. You could consider alendronic acid - cheap as chips- if the pupd is due to hypercalcaemia.

[/quote]

Agreed. Although pred should get the calcium down. Other options are iv fluids (saline at 3xm) and I seem to recall frusemide from somewhere. You need to treat the hyperca though as you will get irreversible kidney damage.

RE: Lymphoma ?

Rob Loxley — Wed, 16 Sep 2015 13:42:40 GMT

[quote user="Stigen"]put on 1,5mg/kg prednisone [/quote][quote user="Stigen"]would like to deal with Pu/PD before starting chemotherapeutics[/quote]

If I was going for chemo for lymphoma I wouldn't pre-treat with steroids. You could consider alendronic acid - cheap as chips- if the pupd is due to hypercalcaemia.

RE: Lymphoma ?

Stigen — Wed, 16 Sep 2015 09:50:23 GMT

So It has a high calcium level; this was the last biochem we did; ALB        37    (25-44),
ALP       21     (20-150),
ALT      44      (10-118),
AMY    841       (200-1200),
TBIL     6       (2-10),
BUN     4,5       (2,5-8,9),
Ca        3,66**       (2.15-2.95),
PHOS    1.01       (0,94-2,13),
CRE       79      (27-124),
GLU     5,7       (3,3-6,1),
Na+      138       (138-160),
K+       4,7      (3.7-5.8),
TP        70       (54-82),
GLOB   34      (23-52),

But th ionised calcium is normal. I presume the Pu/pd is due to the high calcium, and the high calcium is due to the lymphoma(if it was hyperparathyroidism I suppose the ionised Ca would have been raised)....but how do I deal with it to stop the Pu/pd ? It was put on 1,5mg/kg prednisone and Baytril last week. 5 minute consult advice to have it hospitalised on fluids to flush out the Ca, and possibly use things like sodium bicarbonate and Mithramycin, but would this be prudent for a dog like this. The owner wants us to proceed with the chemotheraphy, but I am waiting for the T/b-cell differentiation, and would like to deal with Pu/PD before starting chemotherapeutics.

RE: Lymphoma ?

John Flynn — Fri, 11 Sep 2015 23:06:21 GMT

[quote user="Stigen"]dog might be in kidney failure[/quote]

[quote user="Stigen"]sg was 1.001[/quote]

That's not consistent with kidney failure, especially with the absence of azotaemia. The urine here looks to be actively diluted by the kidneys, thus demonstrating they are working. I'm not saying your prognosis is necessarily better... but I wouldn't be making decisions (such as drug doses etc) based on an assumption of poor kidney function as I don't think there's an indication of that.

[quote user="Stigen"]bacterial infection found[/quote]

That bug sounds suspiciously like a commensal to me, but I missed where the culture was from.

[quote user="Stigen"]Diagnosis
Lymphoma, small cell, low grade [/quote]

Your histopath sounds pretty reliable and I'm sure better than any FNA could have been. Hopefully someone can comment on preferred treatments and outlook if treatment is being pursued (I don't think you can go too wrong euthanasing a patient with confirmed lymphoma alternatively).

RE: Lymphoma ?

Stigen — Fri, 11 Sep 2015 12:50:48 GMT

[quote user="John Flynn"]

Lymphoma would be my top differential.

Lymph node biopsy should certainly tell you if it is.

Typically, I'll do a few FNA's on these.

Take a 23G 1" needle and attach a 2ml syringe and fill with air, then carefully stab a relevant lymph nodes (big popliteal would be my starting point) couple of times only, then remove needle and syringe and blow on to a slide by depressing plunger, then GENTLY set another slide on top at 90 degrees and GENTLY use this to smear (use only the weight of the slide and be careful not to crush the slides together at all as lymphoma cells are often delicate and you could esaily ruin your sample. Most common mistakes in my experience are too much material = too thick a smear OR sucking with syringe when doing the FNA = ruptured cells OR crushing the cells when doing the smear.

Then look at the smear (the top spreader slide is usually the better one). The appearance of lymphoglandular bodies will tell you you have correctly aspirated from a lymph node. The presence of large numbers of lymphocytes will help also ;-) Then find a few red blood cells to use as sizing and see whether the majority of the lymphocytes are all the same size, and if so, gauge this in terms of size of a rbc (e.g. most of lymphocytes 2-3 times diameter of rbc etc). If most of the lymphocytes are the same, particularly if there is a lack of small lymphocytes, and there is little by means of neutrophils are other indicators of inflammation, then I would call a presentation like you had "multicentric lymphoma" until proven otherwise. Or put another way, as a generality I look for lymphocytes to look similar in an FNA of lymphoma to indicate this is a malignancy while in many other FNA's for malignancies I'm looking for the cells to look different.

To that effect, I'd give 0.7mg/m2 vincristine iv [read about using this drug etc before giving if not done before!] and send the stained smears + a few fresh ones away to a lab for confirmation ideally (cost permitting).

You can take photos down your microscope with a little practise and pretty much any digital camera - if you upload them, I'm sure folks would be happy to comment - a couple at low/medium power to give rough idea and then half a dozen at high power to show cellular detail would probably suffice.

[/quote]

Thanks, that`s something to remember. I did exactly the mistakes you`re describing...but still managed to get my diagnosis. Lymphoma, as I thought. I have asked for a differentiation of B/t-cell lymfoma now, but may prove fruitless as dog might be in kidney failure. Dog has had extreme Pu/pd last week. Did a urinanalysis yesterday , sg was 1.001 ! and did find lymfocytes in urine, some more leucocytes. Blood sample again to check for acute kidney failure - everything on biochemistry normal,except for CAlcium which has gone from 3,2 to 3.66. Did check ionized calcium, but that was within normal range.
Not sure about the Pu/pd then, but thinking it might be related to intrabdominally enlarged lymphatics/Lnn and possibly lymfoma in kidney parenchyma, anyways not good news. Owner did want to proceed to chemotheraphy, but not sure if there`s a point in this one. Put it on 1,5mg/kg prednisilone and baytril for the bacterial infection found. Owner seem to think that the Noroclav helped a bit by decreasing the size of the lymph nodes, but I found them to be about the same size when palpting.

cytologic finding
Submitted were 3 unstained smears.
A Pappenheim-staining was performed according to the standard
operation procedure.

I Penis dorsal lump:
The smears are cell rich. Due to autolysis and artefacts, cytological
assessment of the smears is impaired.
Cytologically a population of intermediate lymphocytes with round
nuclei and small amounts of cytoplasm is seen. (cross sections of the
nuclei >2x size of an erythrocyte)
The cells show mild anisocytosis and anisokaryosis.
Lots of lymphoglandular bodies are found.

II Popliteal lymph node.
The smear is very thick and shows severe artefacts. Cytological
assessment is not possible.

evaluation
Consiedering the clinical informtaion, the cytological findings are
suspicious for malignant lymphoma.

Depending on the clinical findings and the stage of the disease,
differentiation of the tumor cells in B-lymphocytes or T-lymphocytes
by means of PARR can be useful for confirmation or exclusion of the
tentative diagnosis and more precise prognosis.

Gross description
Submitted were 4 biopsies (up to 0,5x0,2x0,2 cm) which were embedded
in toto for histological investigations.

Histological description
The following staining was performed according to standard operation
procedures: H&E.

The organspecific structures of the lymph node were lost, due to an
infiltration of a homogenous lymphoid, small cell tumor cell
population.

Up to 2x mitoses/HPF were counted.
(dog: 0-5 mitoses - low-grade; 6-10 mitoses - medium-grade;
> 10 mitoses - high-grade).

Diagnosis
Lymphoma, small cell, low grade

Comment
A lymphoma is a malignant tumor. In most cases, a systemic spread of
tumor cells has occurred at the time of diagnosis.

Histological grading of canine lymphomas is based on Valli et al.
2011 (Vet Pathol 48(1), 198-211.

The prognosis depends on the type (B-cell/T-cell lymphoma), the
clinical staging and the individual possibilities of therapy.
T-cell lymphomas in dogs and cats have a poorer prognosis than B-cell
lymphomas.
Only low malignant, small cell intestinal lymphomas in cats have a
better prognosis than other B- and T- cell lymphomas.

Chemotherapy may increase the survival time in some cases.

bacteriological examination:
moderate concentration
Stenotrophomonas maltophilia (formerly Pseudomonas maltophilia) (1)

Susceptibility test:     (1)

* Penicillin G           R
* Ampicillin             R
* Amoxicillin            R
* Amoxic.+Clavulans.     R
* Cephalexin             R
* Cefoxitin              R
* Cephoperazon           R
* Cefovecin              R
* Cefquinom              R
* Gentamicin             S
* Neomycin/Framycin      R
* Kanamycin              R
* Tobramycin             S
* Erythromycin           R
* Spiramycin             R
* Clindamycin            R
* Lincomycin             R
* Ibafloxacin            S
* Difloxacin             R
* Enrofloxacin           S
* Marbofloxacin          S
* Pradofloxacin          S
* Orbifloxacin           S
* Tetracycline           R
* Doxycyclin             R
* Chloramphenicol        S
* Fusidic acid           R
* Sulfa.+Trimethopr.     S
* Polymyxin B/Colistin   R
* Nitrofurantoin         R
* Rifampicin             R

Legend:
S= Sensitive; I= Intermediate; R= Resistent
Testing according to CLSI / EUCAST; underlying MIC values
can be requested on demand.

RE: Lymphoma ?

John Flynn — Sun, 06 Sep 2015 19:24:24 GMT

Lymphoma would be my top differential.

Lymph node biopsy should certainly tell you if it is.

Typically, I'll do a few FNA's on these.