Cat with thickened intestines and raised globulins

RE: Cat with thickened intestines and raised globulins

Martin Atkinson — Fri, 01 Apr 2016 11:00:14 GMT

[quote user="Anthony Todd"] How often has your presumed diagnosis been wrong ie how often has a cat with a thickened bowel plus/minus enlarged mesenteric LNs plus/minus diarrhoea NOT had a lymphoma??[/quote]In an old cat that is dramatically losing condition and patently unwell probably - never, or at least if its not lymphoma its another neoplastic condition. However I will by the the time I've committed to ex lap/biopsy I've eliminated likely IBD/dietary intolerance cases, especially in younger cats with food trials and other investigations. I really think age is the key here. A 15 year old cat with these symptoms is not likely to be inflammatory if its never had problems before. As said these are lymphoma until proved otherwise and I'd be happy to be proved wrong for the cat's sake.

RE: Cat with thickened intestines and raised globulins

Anthony Todd — Thu, 31 Mar 2016 23:36:29 GMT

[quote user="robloxley"]If you treat low grade alimentary lymphoma with chlorambucil and pred median remission can be over 2 years: that's not a good enough reason for you to consider reaching a diagnosis?[/quote]

And it was clear in the citation too!

Trumped and checkmated again, I must agree [one star given and deserved I'm afraid and 5 to you]

As I posted to Martin I wonder how often cats with a thickened bowel plus/minus enlarged LNs would NOT have lymphoma?

RE: Cat with thickened intestines and raised globulins

Rob Loxley — Thu, 31 Mar 2016 23:01:16 GMT

[quote user="Anthony Todd"]unless there are definite and significant advantages, which there may be in some conditions but, apparently not in this one[/quote]

If you treat low grade alimentary lymphoma with chlorambucil and pred median remission can be over 2 years: that's not a good enough reason for you to consider reaching a diagnosis?

RE: Cat with thickened intestines and raised globulins

Anthony Todd — Thu, 31 Mar 2016 22:54:11 GMT

[quote user="Martin Atkinson"]There is a risk but I've done dozens and never had a breakdown but always made a reliable diagnosis.[/quote]

[just asking] How often has your presumed diagnosis been wrong ie how often has a cat with a thickened bowel plus/minus enlarged mesenteric LNs plus/minus diarrhoea NOT had a lymphoma??

RE: Cat with thickened intestines and raised globulins

Rach — Thu, 31 Mar 2016 22:35:20 GMT

Just my two penneth worth, and I am no oncologist, but my understanding is that an FNA would likely confirm if it is lymphoma, however the protocol used is dictated by whether it is high or low grade, and that can only reliably be differentiated on histology. So I would suggest that if they would pursue chemo it is worth considering full-thickness biopsies in order to advise on prognosis and treatment.

RE: Cat with thickened intestines and raised globulins

Anthony Todd — Thu, 31 Mar 2016 22:32:05 GMT

sorry duplicated

RE: Cat with thickened intestines and raised globulins

Anthony Todd — Thu, 31 Mar 2016 22:31:06 GMT

[quote user="robloxley"] So if you want to sample enlarged lymph nodes/tissue to get a diagnosis in the 1st place it makes it harder for the pathologist to get you that diagnosis if you've zapped the cells with pred.[/quote]

Yes, I get that, but we're back putting the diagnosis ahead of the treatment. which is what I'm suggesting is the modern but retrograde way, unless there are definite and significant advantages, which there may be in some conditions but, apparently not in this one.

I'm suggesting that, as the survival times are not that different, according to your citation, better, in a 15yo cat, just to start straight away on pred or another steroid, as the survival times may well not be different.

Pity the citation doesn't match age with survival times. I can only surmise that there was no relationship.

RE: Cat with thickened intestines and raised globulins

Rob Loxley — Thu, 31 Mar 2016 18:22:29 GMT

[quote user="Anthony Todd"]

[quote user="robloxley"]If you confirm low grade (small cell) alimentary lymphoma then I would go for chlorambucil/pred and these can do really wel[/quote]

True, better than I anticipated but, cherry picking, and worth mentioning is:

Treatment of large-cell feline GI lymphoma with multiagent chemotherapy protocols has led to median remission durations of 140 to 213 days

[/quote]

As I said, high and low grade alimentary lymphomas in cats are different beasts with different treatments advocated and different outcomes achieved.

[quote user="Anthony Todd"]I know I'm thick and out of date and time but, as the 'roids seem to be part of all the therapeutic regimes, why is it so bad to give them before you start?[/quote]

Twofold: Think back to giving an animal with lymphoma preds alone as treatment - all the lymph nodes shrink after a few days due to the antineoplastic effects (that's why they're in the treatment protocol). So if you want to sample enlarged lymph nodes/tissue to get a diagnosis in the 1st place it makes it harder for the pathologist to get you that diagnosis if you've zapped the cells with pred.

There is also worry that steroid-induced expression of p-glycoprotein may increase the rate at which tumor cells develop multidrug resistance to subsequent chemotherapy, but AFAIK the evidence is not conclusive. There was a study years back that looked at dogs with generalised lymphoma pre-treated or not with pred before chemo and how well they did which suggested giving preds worsened the outcome, but it didn't consider whether tumor type was different between the groups etc.

RE: Cat with thickened intestines and raised globulins

Martin Atkinson — Thu, 31 Mar 2016 18:18:42 GMT

[quote user="Andrew Kent"]I agree this will likely get a diagnosis but the owners should be aware that it has a risk of killing the cat much quicker if the intestinal biopsy sites breakdown and I see/hear about that occurring relatively frequently.[/quote]There is a risk but I've done dozens and never had a breakdown but always made a reliable diagnosis.

[quote user="Anthony Todd"]

[quote user="Martin Atkinson"]The problem with that is that if it is lymphoma and the owners want chemo then you may reduce the response so I would lay off any more steroids until a diagnosis/decision is made.[/quote]

I know I'm thick and out of date and time but, as the 'roids seem to be part of all the therapeutic regimes, why is it so bad to give them before you start?

[/quote]Read the post again, I've already told you why! God help us!

If you want the dummy's explanation: Chemotherapy works by attacking rapidly dividing cells, if you reduce the growth rate of those cells with steroids beforehand they will not be as susceptible to the chemo drugs when you start them. The smarty's explanation is something to do with reduced mitotic indices/rates or whatever, but I'm not a smarty so you'll have to look that up for yourself!

RE: Cat with thickened intestines and raised globulins

Anthony Todd — Thu, 31 Mar 2016 16:48:16 GMT

I know I'm thick and out of date and time but, as the 'roids seem to be part of all the therapeutic regimes, why is it so bad to give them before you start?

RE: Cat with thickened intestines and raised globulins

Anthony Todd — Thu, 31 Mar 2016 14:42:23 GMT

[quote user="robloxley"]If you confirm low grade (small cell) alimentary lymphoma then I would go for chlorambucil/pred and these can do really wel[/quote]

True, better than I anticipated but, cherry picking, and worth mentioning is:

Treatment of large-cell feline GI lymphoma with multiagent chemotherapy protocols has led to median remission durations of 140 to 213 days

and, unless you do biopsies you won't know which, AFAIK

The median age at diagnosis was 13 years (range 4 to 20 years).

obviously the animal's age would influence recommendations, I'd recommend treating a 4yo, for sure, given these results, but is the response connected to age?

A median survival time of approximately 330 days was reported for nine of the cats that received prednisone with or without other chemotherapeutics.

As far as I can see survival time isn't compared with age and, given the above and the age of the OP cat, it would seem to me that steroids in one form or another mightn't be such a bad protocol in a 15yo cat, if you consider everything.

RE: Cat with thickened intestines and raised globulins

Anthony Dennison — Thu, 31 Mar 2016 14:11:17 GMT

[quote user="robloxley"]If you confirm low grade (small cell) alimentary lymphoma then I would go for chlorambucil/pred and these can do really well[/quote]

I've just started a cat with generalised lymphadenopathy and lymphoma confirmed on LN cytology on this regime - it's back in tomorrow for the 2nd chlorambucil dose, so we'll see how things are going!

[quote user="robloxley"]If enlarged lymph nodes and markedly thickened guts[/quote]

Lymph nodes not enlarged in this case, just thickened guts.

RE: Cat with thickened intestines and raised globulins

Rob Loxley — Thu, 31 Mar 2016 13:53:29 GMT

[quote user="Anthony Todd"]assuming it is lymphoma what is the currently predicted prognosis for a 15 yo cat with lymphoma and what would be the treatment protocol?[/quote]

If you confirm low grade (small cell) alimentary lymphoma then I would go for chlorambucil/pred and these can do really well (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3092124/ : The overall clinical response rate was 96%, with a median clinical remission duration of 786 days). If you diagnose high grade alimentary lymphoma then you'd consider COP or dox or similar and these respond more variably and for less time.

In the OP's case, if the owners would pursue chemo then pursuing a diagnosis is worthwhile (otherwise I'd go for pred/diet). If enlarged lymph nodes and markedly thickened guts then trying some FNAs - cheap, simple, lower risk - and sending to a good cytopathologist would be my 1st option. If needing biopsies full thickness are probably the way to go.

RE: Cat with thickened intestines and raised globulins

Anthony Todd — Thu, 31 Mar 2016 13:16:51 GMT

[quote user="Anthony Dennison"]Oof, low blow! (No offence Anthony Todd...)[/quote]

Nah, used to it now, I'm just thinking of the animal rather than the diagnosis.

As Chris said to his son, "go for the body".....

I just feel for a cat, or any animal, suffering, almost certainly, for the sake of a intellectual diagnosis, particularly when there is a good chance that the animal's last days can be made more comfortable so easily which doesn't seem to be the primary aim these days.

There's room for an improved "Leicester Pathway" for old animals.......??

Leicester Pathway anybody??

RE: Cat with thickened intestines and raised globulins

Anthony Dennison — Thu, 31 Mar 2016 13:00:00 GMT

[quote user="Martin Atkinson"]Must be something to do with the Christian name ;-) The problem with that is that if it is lymphoma and the owners want chemo then you may reduce the response so I would lay off any more steroids until a diagnosis/decision is made.[/quote]

Oof, low blow! (No offence Anthony Todd...)

Again, I was thinking about effects on chemotherapy etc but wasn't sure if it was that at that point until haematology came back and the cat was miserable, off his food and had diarrhoea. A single one off pick-me-up was the intention, lasting a little longer than colvasone.

I've discussed options with the owners, from trialling a GI diet for IBD up to ex-lap and intestinal biopsies. They're going to have a think about it and get back to me. Currently the cat isn't critically unwell so I'm not going to rush them in to a decision.

RE: Cat with thickened intestines and raised globulins

Andrew Kent — Thu, 31 Mar 2016 12:56:06 GMT

[quote user="Martin Atkinson"]ou can faff around with ultrasound but it won't give you a diagnosis and I'm not convinced of the practicality of FNAs of the gut in cats.[/quote]

Its not easy, and not appropriate in all cases, but if there is marked thickening then I have found it useful (and diagnostic) in a number of cases. A good proportion of these will also have enlarged abdominal lymph nodes which can be easier to aspirate than the gut.

[quote user="Martin Atkinson"]So personally I would just get on and ex lap and take several punch biopsies from gut and mesenteric lymph nodes[/quote]

I agree this will likely get a diagnosis but the owners should be aware that it has a risk of killing the cat much quicker if the intestinal biopsy sites breakdown and I see/hear about that occurring relatively frequently.

There is no one right way in these cases but the owners should be able to make an informed choice about the pros and cons of all the diagnostic options.

Andy

RE: Cat with thickened intestines and raised globulins

Anthony Todd — Thu, 31 Mar 2016 12:30:55 GMT

Well, at least someone, that's me, is thinking of the cat and the chances of recovery, taking into account of the length of procedure, the procedure itself, and the cat's quality of life whilst all this is being gone through even without any consideration of cost.

Cat's just love open-ended long diagnostic and therapeutic procedures!

Assuming you get a diagnosis, and assuming it is lymphoma what is the currently predicted prognosis for a 15 yo cat with lymphoma and what would be the treatment protocol?

RE: Cat with thickened intestines and raised globulins

Anthony Todd — Thu, 31 Mar 2016 12:22:40 GMT

[quote user="Anthony Dennison"]Gave it a shot of dexafort Q after I'd taken bloods.[/quote]

Why not use to use one with a longer action, as I suggested.

RE: Cat with thickened intestines and raised globulins

Martin Atkinson — Thu, 31 Mar 2016 12:16:31 GMT

[quote user="Anthony Dennison"]Gave it a shot of dexafort Q after I'd taken bloods.[/quote]Must be something to do with the Christian name ;-) The problem with that is that if it is lymphoma and the owners want chemo then you may reduce the response so I would lay off any more steroids until a diagnosis/decision is made.

RE: Cat with thickened intestines and raised globulins

Anthony Dennison — Thu, 31 Mar 2016 11:58:45 GMT

[quote user="Andrew Kent"]To some degree it depends on whether finances would allow both ultrasound and surgery. It is likely that any surgery would be diagnostic rather than therapeutic, and the risk of complication of surgery with diffusely abnormal intestines is not insignificant.[/quote]

This was my train of thought. Cat is insured so costs not as much of an issue as they could be.

[quote user="Andrew Kent"]My preference would therefore be to see if a diagnosis could be achieved in a less invasive way - ultrasound guided fine needle aspiration would be my first choice, both of the intestine and any enlarged lymph nodes etc. Endoscopy might offer another possibility if available.[/quote]

If I was at our main hospital with the good scanner I would be definitely going for this. As it is, I've got an older, basic model and my guided FNA technique is minimal due to lack of practice!

[quote user="Martin Atkinson"]IMO this is intestinal lymphoma until proven otherwise. You can faff around with ultrasound but it won't give you a diagnosis and I'm not convinced of the practicality of FNAs of the gut in cats. So personally I would just get on and ex lap and take several punch biopsies from gut and mesenteric lymph nodes but if you have someone who is good with a flexible endoscope you may get biopsies that way.[/quote]

I was thinking the same thing. We do have an endoscope but it's a bit big for cats unfortunately.

[quote user="Martin Atkinson"]But don't forget never to let anything die without the benefit of the 'roids![/quote]

Gave it a shot of dexafort Q after I'd taken bloods.

Thanks for the input. I'll speak to the owners and see what they want to do.

RE: Cat with thickened intestines and raised globulins

Martin Atkinson — Thu, 31 Mar 2016 11:46:10 GMT

[quote user="Anthony Todd"]How true, ironically, and unintentionally, I'm sure.[/quote]I knew that would get you out of the woodwork Anthony! But note I did imply that the 'roids were the last resort!

RE: Cat with thickened intestines and raised globulins

Anthony Todd — Thu, 31 Mar 2016 11:30:00 GMT

[quote user="Martin Atkinson"]But don't forget never to let anything die without the benefit of the 'roids![/quote]

How true, ironically, and unintentionally, I'm sure.

Let's face it, they are the only thing that is likely to help the cat even if only in the shorter term, which is more than a possible diagnosis is going to do for an old cat, to say nothing of the GA etc etc and not to mention the cost.

I'll probably get no, or one star, but I bet the cat would give me a five!

RE: Cat with thickened intestines and raised globulins

Martin Atkinson — Thu, 31 Mar 2016 10:36:18 GMT

IMO this is intestinal lymphoma until proven otherwise. You can faff around with ultrasound but it won't give you a diagnosis and I'm not convinced of the practicality of FNAs of the gut in cats. So personally I would just get on and ex lap and take several punch biopsies from gut and mesenteric lymph nodes but if you have someone who is good with a flexible endoscope you may get biopsies that way.

You still have to ask the question if after you've done this if the owners are going to go for chemotherapy and if not whether you might be better with just a dietary trial. But don't forget never to let anything die without the benefit of the 'roids!

RE: Cat with thickened intestines and raised globulins

Andrew Kent — Thu, 31 Mar 2016 10:18:29 GMT

Hi Anthony,

To some degree it depends on whether finances would allow both ultrasound and surgery. It is likely that any surgery would be diagnostic rather than therapeutic, and the risk of complication of surgery with diffusely abnormal intestines is not insignificant.

My preference would therefore be to see if a diagnosis could be achieved in a less invasive way - ultrasound guided fine needle aspiration would be my first choice, both of the intestine and any enlarged lymph nodes etc. Endoscopy might offer another possibility if available.

Andy