CAL: Chemotherapy

Question 1

What lymph nodes which should be palpated during your clinical examination

Answer 1

• Mandibular / Submandibular • Pre-scapular • Axillary • Popliteal • Inguinal / Superficial Inguinal

Question 2

What are causes of generalised lymphadenopathy

Answer 2

• Infection • Immune-mediated disease • Neoplasia (primary or secondary)

Question 3

What are essential diagnostic tests to run if you suspect lymphoma?

Answer 3

Serum biochemistry Urinalysis FNA

Question 4

Why is it best to avoid the submandibular LNs?

Answer 4

reactive changes due to dental disease might complicate the interpretation. (Increased numbers of immature cells can occur in a highly reactive node). It is best to sample more than one node if possible.

Question 5

What is the biggest problem from these biochemistry results (high albumin, high calcium, high urea, high creatinine, high lipase)?

Answer 5

hypercalcaemia as this can lead to renal failure, depression, vomiting, constipation, weakness, muscle twitching and dysrhythmias (bradycardia).

Question 6

Why does hypercalcaemia occur in lymphoma?

Answer 6

In lymphoma, PTHrP is released  hypercalcaemia.

Question 7

How do you correct hypercalcaemia?

Answer 7

initially administer 0.9% NaCL IV at 6ml/kg/hour. If this fluid therapy is insufficient to reduce the calcium, besides giving treatment for the underlying disease (lymphoma), there are 2 different types of drugs that you could give to help lower the calcium levels: furosemide/ fruesemide OR 2 Bisphosphonates such as pamidronate

Question 8

How does furosemide correct hypercalcaemia?

Answer 8

This diuretic stimulates renal excretion of calcium. It should only be used after making sure that the patient is fully hydrated. Cheap and effective. When lymphoma treatment is started, the calcium will usually decrease.

Question 9

How do bisphosphonates such as pamidronate correct hypercalcaemia?

Answer 9

Bisphosphonates are osteoclast inhibitors and would reduce calcium levels. They are usually only used in refractory cases of hypercalcaemia, or when there is a delay in reaching a diagnosis. When treatment for lymphoma is started the calcium will usually decrease.

Question 10

How does calcitonin correct hypercalcaemia?

Answer 10

This drug reduces calcium by antagonising the actions of PTH or PTH-rP. Usually only used in refractory cases of hypercalcaemia, or when there is a delay in reaching a diagnosis. When treatment for lymphoma is started, the calcium will usually decrease.

Question 11

How often should you monitor a chemotherapy patient?

Answer 11

every week during the induction phase to check for any adverse effects of the chemotherapy (myelosuppression).

Question 12

Does a TC or BC lymphoma have a better prognosis?

Answer 12

TC lymphoma generally has a poorer prognosis than BC lymphoma and the remission duration and survival is generally about half that of a BC lymphoma.

Question 13

Define MST

Answer 13

median survival time

Question 14

What is the MST of a canine BC lymphoma treated with COP?

Answer 14

6 - 12 months, depending on the rescue protocol(s) used

Question 15

What chemo protocol is currently being investigated to improve TC lymphoma prognosis?

Answer 15

the RVC modified LOPP protocol (lomustine, vincristine, procarbazine and prednisolone).

Question 16

What level do platelets need to be in order for there to be a clotting problem?

Answer 16

unlikely to cause a bleeding disorder unless it falls below 30-50 x10^9/l

Question 17

Why might you get a high ALP on biochemistry from a dog on COP chemo protocol?

Answer 17

not unexpected since the dog is on high dose prednisolone. There is a steroid-induced isoform of ALP.

Question 18

Tx - cyclophosphamide-induced haemorrhagic cystitis

Answer 18

Glycosaminoglycans - help cover bladder lining Oxybutinin - relieve detrusor muscle spasm

Question 19

When can you restart vincristine and another alylating agent (e.g. chlorambucil) after an episode of cyclophosphamide-induced haemorrhagic cystitis?

Answer 19

Repeat haematology and urinalysis in 3-5 days’ time. If the neutrophil count is >2.0x109/l or within normal range at this stage, restart vincristine and another alkylating agent (e.g. chlorambucil) should be introduced in place of cyclophosphamide.

Question 20

What does this show?

Answer 20

Enlarged kidney Abdominal mass

Question 21

Why is the CHOP protocol preferred over the COP protocol in feline renal lymphoma cases?

Answer 21

COP protocol would be suitable, however, with renal involvement, a COAP protocol would be preferred i.e. a protocol containing cytosine arabinoside. This is because cats with renal lymphoma sometimes develop CNS lymphoma and cytosine arabinoside (cytarabine) has good CNS penetration.

Question 22

What is one of the major concerns, shortly after starting chemotherapy for alimentary lymphoma?

Answer 22

Gut perforation can occur as the tumour starts to die, causing peritonitis and death / euthanasia.

Question 23

Outline prevalence of alimentary and mediastinal lymphoma in cats

Answer 23

Alimentary lymphoma is the most common presentation in older cats which are usually FeLV negative. Mediastinal lymphoma is more common in younger cats. In the past, many mediastinal cases were FeLV positive, however, following widespread vaccination, more FeLV negative cases occur nowadays.

Question 24

Clinical signs - mediastinal lymphoma

Answer 24

dyspnoea, tachypnoea, cough, dysphagia, reduced lung sounds, displaced heart sounds, decreased compressibility of the cranial thorax and occasionally Horner’s syndrome.