Clinical conundrum: dog with lymphoma and possible HAC

RE: Clinical conundrum: dog with lymphoma and possible HAC

Martin Atkinson — Fri, 30 Nov 2018 18:26:18 GMT

[quote user="Gerry Polton"]As a rule, I still use prednisolone in canine CHOP protocols but strictly only for the first four weeks and at a reducing dose so that by the start of the third week, they are receiving a reducing dose so that they can safely have the treatment withdrawn.[/quote]

My patient is coming in on Monday to start its chemo. So do you suggest I give it just the vincristine and wait and see or should I start cyclosphosphamide and preds simultaneously? I would reduce the dose of preds to 20mg /msq alternate days after 1 week anyway. Also this dog weighs 12kg so that is 25mg cyclophosphamide alternate days, as the tablets are 50mg I would normally give one every 4th day - is this still a recommended protocol.

The only reason we suspected HAC in this dog is because it's ALP was sky high and liver function normal so we performed a urine C:CR which was elevated. Both of these could be due to the lymphoma + stress as there are no clinical signs consistent with HAC.

[quote user="Gerry Polton"]In a case with known or suspected Cushings syndrome, I don't use prednisolone. I do consider treating with trilostane but I am conservative with the doses used and I treat largely according to clinical signs rather than relying solely on blood test results to direct the trilostane treatment. (I don't know if anybody relies solely on clinical signs; forgive me if I am out of touch for writing that.)[/quote]With the scarcity of synacthen and presently tetracosactide, Dechra have advised performing a pre Vetoryl cortisol test as the best monitoring methodology.

I have certainly had a few dogs where the monitoring ambiguous, especially borderline cases like this one and tend to go on instinct with clinical signs erring on the side of caution if they seem clinically stable.

RE: Clinical conundrum: dog with lymphoma and possible HAC

Gerry Polton — Fri, 30 Nov 2018 17:04:50 GMT

I like this approach, Beats. It enables you to get the best result in the case that are going to have a good chance of responding but you don't commit dogs or owners to long term therapy when the response is likely to be poorer.

To respond to the overall question of the use of steroids in canine lymphoma, there is some evidence that the inclusion of prednisolone in a CHOP protocol adds nothing in terms of patient survival. As a rule, I still use prednisolone in canine CHOP protocols but strictly only for the first four weeks and at a reducing dose so that by the start of the third week, they are receiving a reducing dose so that they can safely have the treatment withdrawn.

In a case with known or suspected Cushings syndrome, I don't use prednisolone. I do consider treating with trilostane but I am conservative with the doses used and I treat largely according to clinical signs rather than relying solely on blood test results to direct the trilostane treatment. (I don't know if anybody relies solely on clinical signs; forgive me if I am out of touch for writing that.)

Best regards to all

Gerry

RE: Clinical conundrum: dog with lymphoma and possible HAC

Beats — Fri, 30 Nov 2018 09:51:26 GMT

I'm obviously not an oncologist, and perhaps steroids are great for lymphoma.

If you're giving vincristine, cyclophosphamed/chlorambucil or doxyrubicin though, then I'm skeptical about whether preds/methylpred/dex adds much to this in terms of chances of getting remission or longevity of that remission - it does however (at big steroid doses) appear to contribute significantly to side effects of treatment, especially urinating in the house.

For an obvious case of multisystemic lymphoma, I give a shot of vincristine at presentation (care with collies etc) and then think about options and come back in a week. Most often dog is brilliant again and LNs have disappeared - if this hasn't happened then I consider that a bad sign, but I guess I could give it some steroids then if I really thought would make a difference.

RE: Clinical conundrum: dog with lymphoma and possible HAC

Julie Innes — Fri, 30 Nov 2018 08:54:06 GMT

[quote user="Beats"]I'm going to confess to not using steroids in lymphoma cases typically. Do they really do much good?[/quote]

I've had quite a lot of cases where the owner doesn't want to do chemo, and we have used steroids alone as a palliative measure. It's amazing how well they work! (short term!) In one case they worked so well the owner was convinced we had the diagnosis wrong (until the dog went downhill again after about 6 weeks)

I describe it to the owners as the steroids being like a dam- it seems to hold the disease at bay until the dam suddenly bursts and they deteriorate rapidly, but they get a better quality of life for a few weeks first

RE: Clinical conundrum: dog with lymphoma and possible HAC

Martin Atkinson — Fri, 30 Nov 2018 08:47:44 GMT

[quote user="Beats"]I'm going to confess to not using steroids in lymphoma cases typically. Do they really do much good?[/quote]I have always been led to believe that you would get good resolution but only short term with corticosteroids alone but I confess that I have never tried this so can't vouch for it. But if it is the case then they would appear to be a useful part of the protocol.

RE: Clinical conundrum: dog with lymphoma and possible HAC

Beats — Thu, 29 Nov 2018 20:15:18 GMT

Does it actually have clinical signs of hypercortisolaemia?

I'm going to confess to not using steroids in lymphoma cases typically. Do they really do much good?

If the patient wasn't PUPD prior to treatment, then it probably isn't a problem if you do want to give steroids, even if this is high ALKP caused by hypercortisolaemia