Lymphoma Flashcards
How common is canine lymphoma?
Age-ish?
Breeds?
- VERY COMMON IN DOGS
- Breeds: Boxer, basset Hounds, St. Bernards, Scottish terriers, Airedailes, Bulldogs, Rottweillers, Golden Retrievers
- Age ~6-7 years old
Where can canine lymphoma occur, and where does it most often occur?
- Can occur anywhere
- Enlarged peripheral LNs common (~80%)
- GI and others <10%
- Leukemia
Are lymphomas in dogs more often T cell or B cell?
- MOST often B cell but depends on breed
Cytology for lymphoma
- Quite helpful
- Flow cytometry (can’t do with a smear!)
- Immunocytochemistry
- PARR assay
Histopath for lymphoma
- Immunohistochemistry
Stage I lymphoma
- Single node or organ
Stage II lymphoma
- Group of nodes on one side of the diaphragm
Stage III lymphoma
Generalized LN involvement
Stage IV lymphoma
- Spleen or liver
Stage V lymphoma
- Bone marrow, CNS, or other organs
Substage a lymphoma
- No signs
Substage b lymphoma
- Clinical signs/sick
What tests for staging lymphoma?
- CBC/Chem/UA
- Chest rads (even lymph nodes won’t make you higher than a stage III)
- Abdominal imaging
- Bone marrow aspirate
What type of imaging for the abdomen?
- Ultrasound more sensitive and specific
- Aspirate liver and spleen (I think regardless if they appear normal or not)
Importance of staging in lymphoma?
- You can’t cure lymphoma with surgery, so it’s a little tougher to know the importance
Anatomic classifications of lymphoma
- Multicentric (peripheral lymph nodes)
- GI
- Mediastinal
- Cutaneous
- Extranodel
Histo classification with lymphoma
- Likely IMPORTANT
- Not always done the same
- Cytology or flow cyometry of biopsy is important
What are the three grades of lymphoma?
- Low grade (small cell)
- Intermediate grade (diffuse large cell)
- High grade (immunoblastic)
Is staging or grading more helpful for determining tumor bheavior?
- Usually grading is more helpful
Treatment of lymphoma (general category: chemo, radiation, +/- surgery)?
- Very sensitive to chemotherapy but usually not curable
Remission rates and survival times of lymphoma
- 85-90% achieve remission with chemotherapy
- Average survival is ~ 1 year
How do you define remission?
- Whatever they detected has gone away
- Clinical remission
Factors associated with a poorer prognosis of lymphoma
- Substage b
- Stage greater than III
- T-cell
- Hypercalcemia
- Icterus
- Hypoproteinemia
- Prior prolonged treatment with glucocorticoids
Why does prior treatment with glucocorticoids lower prognosis?
- For months
- It means that you’ve lost prednisone as a drug to induce remission
Common drugs used to treat LSA
- Prednisone (corticosteroid)
- L-asparagine or Elspar (anti-metabolite enzyme)
- Vincristine (mitotic spindle interruptor)
- Cyclophosphamide (alkylator)
- Doxorubicin (antitumor antibiotic)
- Methotrexate (antimetabolite)
- Lomustine (alkylator)
Rabacfosadine (Tanovea or newer targeted prodrug for lymphoma)
Survival or duration of first remission (for worse prognosis) if NO therapy?
- ~1 month
Survival or duration of first remission (for worse prognosis) if prednisone alone (+/- chlorambucil)
~ 2 months
Survival or duration of first remission (for worse prognosis) if COP (cyclophosphamide, vincristine, prednisone)
~4-6 months
Survival or duration of first remission (for worse prognosis) if Elspar + COP
~4-6 months
Survival or duration of first remission (for worse prognosis) if CHOP protocol (cyclophosphamide, vincristine, prednisone, and Doxorubicin or Elspar)
- ~8-9 months
Best survival times?
- CHOP protocol
- COP + Elspar is not bad
Relationship between drugs in the protocol and duration of first remission?
- More drugs in the protocol = longer duration of first remission
Protocols used at WSU for lymphoma?
- COP +/- Elspar
- CHOP Protocol or the Madison-Wisconsin 6 month protocol
- Single agent would be doxorubicin
What should we factor?
- MDR1 mutant? Hard to handle? Cardiac or renal disease?
- Client factors (economic, schedule)
- Comfort level with drug administration, safety concerns
MW 6 month protocol remission rate and survival time
92% remission
- Overall survival around 400 days
Toxicity of MW 6 month protocol
- 40% dose reductions but fewer than 10% hospitalized
L-asparaginase impact on CHOP protocol?
- Did not appear to increase median survival
Steps to take if your patient relapses with canine lymphoma?
- Start protocol over (if >6 months from induction)
- Switch to a new protocol with new drugs (more common with T cell)
Length of CHOP protocol
6 months
Rescue protocols
- Lomustine +/- Elspar
- MOPP (mechlorethamine, vincristine, prednisone, procarbazine)
- Doxorubicin and DTIC
- Mitoxantrone
- Bleomycin +?
- Lomustine and Vinblastine
- Tanovea
Survival rates of rescue protocols?
- Do not give the same types of survival as the initial
- Considered successful if at least 50% got one month additional
When to do surgery with LSA?
- Only if we are sure it’s a single node/organ
When to do radiation with lymphoma?
- Selected locations
- Nasal LSA in cats (careful staging required)
- Half body radiation therapy (irradiate half the body twice)
- Whole body radiation therapy and bone marrow transplantation
Feline lymphosarcoma
- Incidence
- Breed
- Risk factors
- Age
- High incidence
- Presentation varies with age, FeLV status, and locality
- No breed predilection
- MAY be related to second hand smoke
Young cat lymphoma vs older cat lymphoma: FeLV status and locality?
- Young cat: 4-5 years, FeLV +, mediastinal
- Older cat: 9-10 years, FeLV negative, GI or abdominal
Anatomic classification of feline lymphoma
- Alimentary/GI
- Mediastinal
- Multicentric
- Nasal
- Renal
- Spinal (check bone marrow)
- Leukemia
Staging lymphoma in cats
- Multiple schemes but not as helpful as in the dog
- Anatomic classification most useful
- Single organ involvement tends to do better
Histologic classification of feline LSA
- Not well established, but small cell is considered low grade
Treatment of high grade (large cell) LSA in cats
- Same as dogs but cats more likely to experience side effects
Two protocols for feline LSA at WSU
- COP +/- Elspar (intermediate grade)
- CHOP 6 month protocol (addition of doxorubicin important for internal forms)
Radiation therapy for feline LSA
- Single node or nasal radiation therapy useful, but be sure the cat has stage I disease only
Prognosis for feline LSA compared to dog
- Generally poorer, but also more unpredictable
Survival/remission for no treatment feline LSA?
1-2 months
Survival/remission for chemo with feline LSA
3-8 months
Survival/remission for nasal LSA
18-24 months (irradiated)
Survival/remission for stage V (CNS or bone marrow)
poor
Survival/remission for FeLV (+)
6 months
MW 6 month protocol for cats vs dogs
- In cats, complete response is about half that of dogs, which is close to 90%
- Partial response in cats is higher
- Overall survival is about half in cats what it is in dogs, and same with duration of first response
Leukemia definition
- Proliferation of a neoplastic hematopoietic cell in the bone marrow
How common is leukemia in pets?
- Relatively rare
Breed/age predilection of leukemia
- No real breed or age predilection
- Younger more aggressive in general
Clinical signs of leukemias
- In general, nothing obvious
- Weakness/depression/lethargy/anorexia
- Fever
- Bleeding
- Signs of hypercalcemia
- Sometimes asymptomatic
- Other times lymphadenopathy, splenomegaly, neuro signs, ocular signs (uveitis or hyphema), bone pain, lameness joint swelling
Classifications of leukemias
- Acute (blastic) or chronic (cytic)
- Lymphocytic or non-lymphocytic (erythroid, monocytic, stem cell leukemia)
Aleukemic leukemic
- refers to a proliferation in the bone marrow without the appearance of the abnormal cells in the peripheral blood
Diagnosis of acute leukemia on CBC
- Presence of BLASTS
- May require cytochemical stains or flow cytometry to determine cell origin
Diagnosis of chronic leukemia on CBC
- Over abundance of one MATURE cell type
- Most commonly lymphocytic
Diagnosis of aleukemic leukemia on CBC
- Other abnormalities including anemia, thrombocytopenia, or pancytopenias
Bone marrow exam of leukemia
- Assists in diagnosis of cell type (lymphocytic or myelogenous)
- Also aids in estimating prognosis - shows what is still present in bone marrow
- may require IHC for definitive diagnosis
Therapy for acute lymphocytic leukemia
- Treatable but requires more aggressive tx than solid forms
- Anthracycline and Elspar +/- Cytosar
- Support therapy can be difficult if all cell lines are damaged
- Remission is shorter than for solid forms
Overall prognosis for acute lymphocytic leukemia
- Poor
Prognosis for acute non-lymphocytic leukemia
- BADNESS
- EXTREMELY POOR
Therapy for acute non-lymphocytic leukemia
- Must be aggressive and started ASAP
- Cytosine arabinoside plus anthracycline
- Support can be very difficult; no white cells, no platelets, no red cells in adequate quantities until remission is achieved
Chronic lymphocytic leukemia prognosis
- Can be quite long (1-3 years)
Chronic lymphocytic leukemia treatment
- Chronic disease in dogs, rare in cats
- Lymphocyte numbers can be quite high (30k-200k)
- Chlorambucil every other day alternating with prednisone every other day
- Survivals can be quite long
